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A Reference Handbook
OF
THE MEDICAL SCIENCES
EMBRACING THE ENTIRE RANGE OF
SCIENTIFIC AND PRACTICAL MEDICINE
AND
ALLIED SCIENCE
BY VARIOUS WRITERS
FIRST AND SECOND EDITIONS EDITED BY
ALBERT H. BUCK, M. D.
THIRD EDITION
COMPLETELY REVISED AND REWRITTEN
Edited by THOMAS LATHROP STEDMAN, A. M., M. D.
COMPLETE IN EIGHT VOLUMES
VOLUME ONE
ILLUSTRATED BY NUMEROUS CHROMOLITHOGRAPHS AND SIX HUNDRED
AND ELEVEN FINE HALF-TONE AND WOOD ENGRAVINGS
NEW YORK
WILLIAM WOOD AND COMPANY
MDCCCCXIII
5
Copyright, 1913
Bt WILLIAM WOOD AND COMPANY
TIIE.MAIM.B. PRESS* YORK. PA
PREFACE.
A generation since a wise and far-seeing medical publisher, the late Mr.
William H. S. Wood, and an accomplished medical editor, Dr. Albert II. Buck,
conceived the happy idea of the Reference Handbook. There were at
that time several "systems" covering special subjects in internal medicine and
surgery, but none which satisfied the needs of the profession as a whole. It
was to meet the want of a work of general information on all subjects relating
to medicine in all its branches that this encyclopedia was designed, and how well
it did so was evidenced by the cordial reception it received from the medical men
of the country. The first volume, published in 1884, was followed at regular
intervals by others until, in 1887, the eighth and final volume was delivered to
the subscribers. In 1893 a supplementary volume covering the progress made
in the preceding six years was published. During the years 1900-1904 a second
edition of the work appeared, still under the management of Dr. Buck, and met
with an equally favorable reception from the medical public. An Appendix,
treating of Anaphylaxis, Opsonin Therapy, and other new subjects, was pub-
lished, under the supervision of the present editor, in 1908.
For a third edition of a work with this history of successful endeavcr
behind it, no apology is called for, though a few words in the way of explanation
may net be amiss. Dr. Buck, to whose rare editorial skill, aided by the loyal
cooperation of over five hundred contributors, the success of the former editions
was due, was reluctant to undertake the labor of seeing a third edition through
the press, and the present editor, whose privilege it was to have assisted in the
preparation of the first edition, was invited to assume the task.
The general plan of the original work is followed in the present edition, but
the editor has profited by the fact that the old plates have been destroyed to
introduce some new features. The system of cross references has been largely
extended and here and there these references have been amplified to full defini-
tions or miniature treatises, in many cases thus affording all the information
desired by the consulter without the necessity of searching through the main
article. Considerable space has been given to the history of medicine, and in
line with this, brief biographies of the leaders in medical thought and progress
have been introduced. Most of these, signed A. H. B., have been contributed
by Dr. Buck, who in this and many other ways has manifested his continued
interest in the work. The series of amplified cross references on zoological
subjects, signed A. S. P., have been written by Professor Arthur S. Pearse of the
University of Wisconsin. The articles on the mineral springs of the United
States in the second edition of the work were written by the late Dr. James K.
Crook. These have been so thoroughly revised, in many cases entirely rewritten,
by Dr. Emma E. Walker, that her name alone is signed to the articles.
The thanks of the editor are due to the many contributors to the former
editions of this work who have revised their articles, preserving the framework
but rewriting them with the ripened experience of thirteen years of added work
in their special lines. To those also who have contributed for the first time to
this edition or have added to the number of their former contributions, the
editor desires to express his gratitude for their prized assistance. And finally
he wishes to record his obligation to the many friends who have aided him by
suggestions of articles and of writers, and especially to Dr. Buck for encourage-
ment and advice on many points. The Publishers, by their ready acceptance of
his suggestions, sometimes involving greatly increased expense, have lightened
his labors in no small measure.
T. L. S.
iii
Authority to use for comment the Pharmacopeia of the United States of America, eighth
decennial revision, in this volume, has been granted by the Board of Trustees of the United
States Pharmacopeial Convention, which Board of Trustees is in no way responsible for the
accuracy of any translations of the official weights and measures, or for any statement as
to the strength of official preparations.
LIST OF CONTRIBUTORS TO VOLUME I.
LEONARD W. BACON, M.D., New Haven, Conn.
Instructor in Operative Surgery, Medical Depart-
ment, Yale University.
JAMES B. BAIRD, M.D Atlanta, Ga.
Formerly Professor of Clinical Medicine, Southern
Medical College; Attending Physician, Grady
Hospital.
FRANK BAKER, M.D., Ph.D., Washington, D. C.
Professor of Anatomy, Georgetown University
School of Medicine, Washington, D. C; Supt.,
National Zoological Park, Smithsonian Institu-
tion.
EDWARD R. BALDWIN, M.D.. .Saranac Lake,
N. Y.
Assistant, Saranac Laboratory; Examiner, Adiron-
dack Cottage Sanitarium; Director, Reception
Hospital.
WALTER A. BASTEDO, M.D.. .New York, N. Y.
Associate in Pharmacology and Therapeutics,
Columbia University; Assistant Attending Phy-
sician, St. Luke's Hospital, New York; Consulting
Physician, St. Vincent's Hospital, Staten Island;
Fifth Vice President, National Convention for
the Revision of the Pharmacopoeia.
A. L. BENEDICT, A.M., M.D.. .. Buffalo, N. Y.
Editor of The Buffalo Medical Journal; Consultant
in Digestive Diseases, City and Columbus Hos-
pitals; Attendant, Mercy Hospital; Author of
"Golden Rules of Dietetics"; Charter Member
of the American Gastroenterological Association.
ROBERT PAYNE BIGELOW, Ph.D Boston.
Assistant Professor of Zoology and Parasitology,
Massachusetts Institute of Technology.
ALBERT N. BLODGETT, M.D.. .. Boston, Mass.
PERCIVAL R. BOLTON, M.D... New York, N. Y.
Formerly Instructor in Surgery, Cornell University
Medical College in New York City.
JOHN T. BOWEN, M.D Boston, Mass.
Edward Wigglesworth Professor of Dermatology,
Emeritus, Harvard University; Chief of Service,
Department, of Dermatology, Massachusetts
General Hospital; Consulting Physician, Chil-
dren's and Infants' Hospitals, Boston.
ALBERT H. BUCK, M.D New York, N. Y.
C. N. B. CAMAC, M.D New York, N. Y.
Assistant Professor of Clinical Medicine, College of
Physicians and Surgeons, Columbia University;
Physician to New York City Hospital; Formerly
Professor of Clinical Medicine, Cornell University
Medical College in New York City.
W. B. CANNON, A.M., M.D Boston, Mass.
George Higginson Professor of Physiology, Harvard
University.
RAYMOND C. COBURN, M.A., M.D New
York, N. Y.
Anesthetist, City Hospital; Consulting Anesthetist,
Beth Israel Hospital, New York City.
BENSON AMBROSE COIIOE, B.A., M. B. (Tor.),
Pittsburgh, Pa.
Late Professor of Anatomy, LTniversity of Pitts-
burgh; Associate Professor of Therapeutics,
University of Pittsburgh; Attending Physician,
St. Francis Hospital, Pittsburgh.
THOMAS D. COLEMAN, A.M., M.D Augusta,
( i \.
Professor of Principles and Practice of Medicine,
Medical Department of the University of Georgia;
Attending Physician, Augusta City and Lamar
Hospitals.
W. J. CONKLIN, M.D Dayton, O.
Formerly Professor of Diseases of Children, Star-
ling Medical College; Consulting Physician to St.
Elizabeth's and Miami Valley Hospitals.
LUZERNE COVILLE, M.D Ithaca, N. Y.
Formerly Lecturer and Demonstrator in Anatomy,
Cornell University at Ithaca.
MONTGOMERY A. CROCKETT, M.D. . . Bedford
City, Va.
Formerly Adjunct Professor of Obstetrics and
Gynecology, University of Buffalo Medical
School.
EDWARD CURTIS, M.D New York, N. Y.
Late Emeritus Professor of Materia Medica and
Therapeutics, College of Physicians and Surgeons,
Columbia University.
CHARLES TOWNSHEND DADE, M.D New
York, N. Y.
Consulting Dermatologist, Roosevelt Hospital,
Englewood Hospital, N. J., and Vassar Brothers
Hospital, Poughkeepsie, N. Y.; Dermatologist,
St. Luke's Hospital Clinic.
CHARLES L. DANA, M.D New York, N. Y.
Professor of Diseases of the Nervous System,
Cornell University Medical College in New York
City; Physician to Bellevue Hospital; Neurologist
to the Montefiore Homo; Ex-president N. Y.
Academy of Medicine; President New York
Psychiatrical Society.
ROBERT H. S. DAWBARN, M.D. . .New York.
Senior Attending Surgeon, City Hospital; Professor
of Surgery, Fordham University Medical School;
Emeritus Professor of Surgery, New York
Polyclinic Medical School; Consulting Surgeon,
New York Polyclinic Hospital.
UEORGE V. N. DEARBORN, A.M., M.D., Ph.D.,
Boston, Mass.
Professor of Physiology, Tufts Medical and Dental
Schools, Boston; Professor of the Philosophy of
Physical Education, Sargent Normal School,
Cambridge; Author of "The Emotion of Joy,"
"A Textbook of Human Physiology," "Moto-
sensory Development," etc.
D. BRYSON DELAVAN, M.D. . .New York, N. Y.
Professor of Laryngology, New York Polyclinic
Medical School: Consulting Laryngologist, Gen-
eral Memorial Hospital, Hospital for Ruptured
and Crippled and Vassar Brothers Hospital,
Poughkeepsie; Surgeon, New York Polyclinic;
Consulting Physician, Stony Wold Sanatorium.
LIST OF CONTRIBUTORS TO VOLUME I.
FRANCIS X. DERCUM, M.D. .Philadelphia, Pa.
Professor of Nervous and Mental Diseases, Jefferson
Medical College; Consulting Neurologist to the
Philadelphia General Hospital; Foreign Corre-
sponding Member of the Neurological Society of
Paris, and Corresponding Member of the Psychia-
tric and Neurological Society of Vienna.
WILLIAM A. NEWMAN DORLAND, M. D. . . .Chi-
cago, III.
Professor of Obstetrics, Medical Department,
Loyoia University; Visiting Obstetrician, Cook
County Hospital; Visiting Obstetrician and Gyne-
cologist, Jefferson Park Hospital; First Lieu-
tenant Medical Reserve Corps, U. S. A.; Member
Committee on Nomenclature and Classification
of Diseases of the American Medical Association.
HENRY DUFFY, ESQ Baltimore, Md.
Lately State's Attorney.
ISADORE DYER, Ph.B., M.D. .New Orleans, La.
Dean and Professor of Diseases of the Skin, Medical
Department, Tulane University of Louisiana;
Editor New Orleans Medical and Surgical Jour-
nal, etc.
R. G. ECCLES, M.D., Ph.D Brooklyn, N. Y.
Ex-Dean Brooklyn College of Pharmacy; ex-
Chairman Section of Active Principles of Com-
mittee of Revision U. S. Pharmacopoeia.
MAX EINHORN, M.D New York, N. Y.
Professor of Medicine, New York Post-Graduate
Medical School; Visiting Physician, German
Hospital; Consulting Physician, White Plains
and Hackensack Hospitals.
GEORGE THOMSON ELLIOT, M.D..New York.
Clinical Professor of Dermatology, Cornell Univer-
sity Medical College in New York City; Consulting
Dermatologist, St. Luke's, Columbus, and New
York Lying-in Hospitals, and New York Eye and
Ear Infirmary.
LEONARD W. ELY, M.D Denver, Colo.
Orthopedic Surgeon to the County, Children's, and
St. Joseph's Hospitals.
L. W. FAMULENER, M.D New York, N. Y.
Assistant Director, Research Laboratory, Depart-
ment of Health, New York City.
FREDERICK G. FINLEY, M.D Montreal,
Canada.
Professor of Medicine, McGill University; Physician
to the Montreal General Hospital.
JOHN ADDISON FORDYCE, A.M., M.D New
York, N. Y.
Professor of Dermatology and Syphilology, The
University and Bellevue Hospital Medical Col-
lege; Visiting Dermatologist, City Hospital.
WILLIAM WHITWORTH GANNETT, M.D.. Bos-
ton, Mass.
Formerly Instructor in Clinical Medicine, Harvard
University Medical School.
JOHN H. GIBBON, M.D Philadelphia, Pa.
Professor of Surgery, Jefferson Medical College;
Surgeon to the Pennsylvania and Bryn Mawr
Hospitals; Consulting Surgeon to the Woman's
Hospital.
CHARLES L. GIBSON, M. D.. . .New York, N. Y.
Adjunct Professor of Surgery, Cornell University;
Surgeon to St. Luke's Hospital; Consulting Sur-
geon to the City Hospital.
A. II. CORDON, M.D Montreal, Canada.
Demonstrator of Clinical Medicine, McGill Univer-
sity; Out-patient Physician, Montreal General
11" ipital.
JOHN GREEN, M.D St. Louis, Mo.
Emeritus Professor of Ophthalmology, Medical
Department of Washington University, St. Louis.
ARTHUR R. GUERARD, M.A., B.S., M.D... Flat
Rock, N. C.
Formerly Instructor in Therapeutics, The Univer-
sity and Bellevue Hospital Medical College, and
Assistant Bacteriologist, New York City Health
Department.
LEWIS WENDELL HACKETT, M.D.... Boston.
Assistant, Department of Preventive Medicine and
Hygiene, Harvard Medical School.
ALLAN McLANE HAMILTON, M.D., LL.D., F.R.S
(Edin.), New York, N. Y.
Consulting Neurologist to the Manhattan State
Hospital for the Insane; Formerly Professor of
Clinical Psychiatry at Cornell University Medical
College and Consulting Neurologist to the Hos-
pital for Ruptured and Crippled; Author of "A
System of Legal Medicine."
H. F. HANSELL, A.M., M.D.. .Philadelphia, Pa.
Professor of Ophthalmology, Jefferson Medical
College; Emeritus Professor Diseases of the Eye,
Philadelphia Polyclinic; Attending Ophthal-
mologist, Philadelphia General Hospital.
WILLIAM A. HARDAWAY, M.D.. . St. Louis, Mo.
Honorary Member of the American Dermatological
Association.
LUDVIG HEKTOEN, M.D Chicago, III.
Director of the Memorial Institute for Infectious
Diseases; Professor of Pathology, University of
Chicago and Rush Medical College.
FREDERICK P. HENRY, A.M., M.D Phila-
delphia, Pa.
Professor of the Principles and Practice of Medicine
in the Women's Medical College of Pennsylvania;
Attending Physician, Philadelphia Hospital;
Consulting Physician, Woman's Hospital of
Philadelphia.
CHARLES ADAMS HOLDER, M.D Phila-
delphia, Pa.
Formerly Assistant in Therapeutics, Jefferson
Medical College.
JOHN HOWLAND, M.D Baltimore, Md.
Professor of Pediatrics, Johns Hopkins University.
JOHN B. HUBER, A.M., M.D..New York, N. Y.
Professor of Pulmonary Diseases, Fordham Uni-
versity Medical School; Visiting Physician, St.
Joseph's Hospital for Consumptives.
GEORGE THOMAS JACKSON, M.D New
York, N. Y.
Professor of Dermatology, College of Physicians
and Surgeons, Columbia University; Consulting
Dermatologist, Presbyterian Hospital and the
New York Infirmary for Women and Children.
SMITH ELY JELLIFFE, A.M., M.D., Ph.D. . .New
York, N. Y.
Professor Clinical Psychiatry, Fordham University;
Adjunct Professor Diseases of the Nervous Sys-
tem, Post-Graduate Medical School; Visiting Neu-
rologist, City Hospital; Physician, Neurological
Hospital, New York.
JEFFERSON R. KEAN, M.D United States
Army.
Lieutenant-Colonel, Medical Corps, U. S. Army;
Assistant to the Surgeon-General.
OTTO KILIANI, M.D New York, N. Y.
Professor of Clinical Surgery, Columbia University;
Surgeon to the German Hospital.
LIST OF CONTRIBUTORS TO VOLUME I.
CHARLES LESTER LEONARD, M.D. .. .Phila-
delphia, Pa.
Professor of Roentgenology, Philadelphia Poly-
clinic; Ex-President, American Roentgen Ray
Society.
J. F. LEYS, M.I) United States N wy.
Formerly Superintendent Colon Hospital, Isthmian
Canal Commission, and President Medical Asso-
ciation of the Canal Zone.
GEORGE BURGESS MAGRATH, M.D.. Boston.
Formerly Assistant in Pathology, Harvard Uni-
versity Medical School.
MATTHEW D. MANN, M.D Buffalo, N. Y.
Emeritus Professor of Obstetrics and Gynecology,
Medical Department, University of Buffalo;
Consulting Gynecologist, Buffalo General and
Erie County Hospitals.
CHARLES F. MARTIN, M.D. Montreal, Canada.
Professor of Medicine and Clinical Medicine, McGill
University; Physician Royal Victoria Hospital.
PHILIP MARVEL. M.D Atlantic City, X. J.
WILLY MEYER, M.D New Yobk, X. Y.
Professor of Surgery, N. Y. Post-Graduate Medica
School; Surgeon to the German and Post-Gradu-
ate Hospitals; Consulting Surgeon, X. Y. Infir-
mary for Women and Children, Skin and Cancer
Hospital, Har Moriah Hospital, and Hospital for
Deformities and Joint Diseases.
BENJAMIN MICHAILOVSKY, B.S., M.D... New
York, N. Y r .
Deputy Physician, New York Hospital, O.P.D.
T. WESLEY MILLS, M.A., M.D., L.R.C.P. (Lond.),
London, England.
Emeritus Professor of Physiology, McGill Univer-
sity, Montreal, Canada.
WILLIAM OLIVER MOORE, M.D., LL.B...New
York, N. Y.
Professor Emeritus of Diseases of the Eye and Ear,
New York Post-Graduate Medical School; Oph-
thalmic Surgeon to the Protestant Orphans'
Home and Asylum; Consulting Ophthalmic
Surgeon, Flushing Hospital.
. Montreal,
WILLIAM S. MORROW, M.D.
Canada.
EDWARD L. MUNSON, M.D United States
Army.
Major, Medical Corps, U. S. Army; Director, Field
Service School for Medical < (fficers, Army Service
Schools, Fort Leavenworth, Kansas.
RICHARD COLE NEWTON, M.D Montclaih,
N. J.
Consulting Physician, Mountainside Hospital,
Montclair; Member New Jersey State Board of
Health.
JOHN BENJAMIN NICHOLS, M.D Wash-
ington, D. C.
Lecturer on Dietetics, George Washington Uni-
versity; Pathologist, Episcopal Hospital; At-
tending Physician, Freedmen's Hospital.
FREDERICK G. NOVY, Sc.D., M.D. Ann Arbor,
Mich.
Professor of Bacteriology and Director of the
Hygienic Laboratory, University of Michigan.
THOMAS A. OLNEY, M.D South Bend,
Indiana.
Surgeon to St. Joseph Hospital.
I W.I VER T. OSBORNE, M.A., M.D New
Haven, Conn.
Professor of Therapeutics, Medical Department,
Yale University; Member of the Revision Com-
mittee of the United states Pharmacopoeia;
Member of t he ( 'oiineil on Pharmacy and ( Ihemis-
try of the American Medical Association.
EDWARD 0. OTIS. M. D Boston, Mass,
Professor of Pulmonary Diseases and Climatology,
Tufts College Medical School; Late Visiting and
Consulting Physician to the Massachusetts State
Sanatorium; Ex-President, of the American
Climatological Association; Physician to the
Department of Tuberculosis of the Lungs,
Boston Dispensary.
WILLIAM H. PARK, M.D New York, N. Y.
Professor of Bacteriology and Hygiene, The Uni-
versity and Bellevue Hospital Medical College;
Director of the Research Laboratories of the
Department of Health of the City of New York.
RICHARD MILLS PEARCE, M.D .. Philadelphia.
Professor of Research Medicine, University of
Pennsylvania.
ARTHUR S. PEARSE, Ph.D Madison, Wis.
Assistant Professor of Zoology, University of Wis-
consin; Instructor in Zoology, Marine Biological
Laboratory, Woods Hole, Mass.
JULIUS POHLMAN, M.D Buffalo, N. Y.
Late Professor of Physiology, Medical Department,
University of Buffalo.
SIOMUND POLLITZER, M.D..New York, N. Y.
Professor of Dermatology, New York Post-Graduate
Medical School; Physician to the German Dis-
pensary, Class of Skin Diseases.
EDWARD PREBLE, M.D New Y'ork, N. Y.
ROBERT B. PREBLE, M.D Chicago, III.
Professor of Medicine, Northwestern L T niversity
Medical School; Attending Physician, Cook
County and German Hospitals, Chicago.
JOSEPH RANSOHOFF, M.D., F.R.C.S. (Eng.),
Cincinnati, O.
Professor of Surgery, University of Cincinnati.
ANDREW ROSE ROBINSON, M.D.New York.
Professor of Dermatology, New York Polyclinic;
Attending Physician, New York Polyclinic
Hospital; Consulting Dermatologist, Perth
Amboy Hospital.
HENRY H. RUSBY, M.D Newark, N. J.
Dean and Professor of Botany, Physiology, and
Materia Medica, New York College of Pharmacy;
Pharmacognosist at the Port of New York for the
U. S. Department of Agriculture; Chairman
Scientific Directors, N. Y. Botanical Garden.
T. E. SATTERTHWAITE, A.B., M.D., LL.D.,
Sc.D., New York, N. Y.
Consulting Physician, Post-Graduate, Manhattan
State, Orthopaedic, Babies', and Champlain Val-
ley Hospitals; First Lieutenant, U. S. A. (Medical
Reserve Corps).
OTTO SCHULTZE, M.D New York, N. Y.
Professor of Medicolegal Pathology and Assistant
Professor of Pathological Anatomy, Cornell Uni-
versity Medical College in New York City; Coro-
ner's Physician in the Borough of Manhattan,
New York City.
R. J. E. SCOTT, M.D New York, N. Y.
Formerly Gynecologist, Demilt Dispensary; and
\i lending' Physician, Out-Patient Department,
Bellevue Hospital, New York.
vn
LIST OF CONTRIBUTORS TO VOLUME I.
FRANCIS J. SHEPHERD, M.D., LL.D., F.R.C.S.
(Ed.), Montreal, Canada.
Professor of Anatomy, Medical Department,
McGill University; Senior Surgeon, The Montreal
General Hospital; Consulting Surgeon to the
Royal Victoria Hospital.
J. G. SHERRILL, M.D Louisville, Ky.
Professor of Surgery, University of Louisville;
Visiting Surgeon, Louisville City Hospital.
CHAXXING C. SIMMONS, M.D. .. Boston, Mass.
Surgeon to Out-Patients, .Massachusetts General
Hospital; Assistant in Surgery, Harvard Medical
School.
H. BEAUMONT SMALL, M.D . . Ottawa, Canada.
Attending Physician, St. Luke's Hospital, Ottawa;
Late Examiner in Materia Mediea, College of
Physicians and Surgeons, Ontario.
EDMOND SOUCHON, M.D... New Orleans, La.
Formerly Professor of Anatomy and Clinical Sur-
gery, Medical Department, Tulane University of
Louisiana; Curator Souchon Museum of Anatomy.
ALEXANDER SPINGARN, A.M., M.D.. Brook-.
lyn, N. Y.
Assistant Editor, Medical Record; Attending Pedi-
atrist to the Bushwick and East Brooklyn and
Jewish Hospital Dispensaries.
HEIXRICH STERX, M.D New York, N. Y.
Visiting Physician, St. Mark's Hospital and the
.Methodist Deaconess' Home; Consulting Physi-
cian, Methodist Episcopal (Seney) Hospital,
Central Islip State Hospital, Portchester Hos-
pital, and Glens Falls Hospital; Editor, Archives
of Diagnosis.
RALPH G. STILLMAN, M.D... New York, N. Y.
Clinical Pathologist, Attending Physician for Con-
tagious Diseases, First Deputy Attending Physi-
cian to the Out-Patient Department, New York
Hospital; Attending Physician, Seton Hospital;
Instructor in Clinical Medicine, Cornell Univer-
sity Medical College in New York City.
LEWIS A. STIMSON, M.D., LL.D... New York.
Professor of Surgery, Cornell University Medical
College in New York City; Consulting Surgeon,
New York and Bellevue Hospitals.
E. W. TAYLOR, A.M., M.D Boston, Mass.
Assistant Professor of Neurology, Harvard Medical
School; Chief-of-Service, Neurological Depart-
ment, Massachusetts General Hospital; Visiting
Neurologist, Long Island Hospital, Boston.
WILLIAM H. THOMSON, M.D New York.
Visiting Physician, Roosevelt Hospital.
PAUL THORNDYKE, M.D Boston, Mass.
Surgeon-in-Chief, Boston City Hospital; Assistant
Professor of Genito-Urinary Surgery Harvard
Medical School.
FRANK P. UNDERHILL, Ph.D., New Haven, Conn.
Assistant Professor of Physiological Chemistry,
Sheffield Scientific School of Yale University;
Professor of Pathological Chemistry, Department
of Medicine, Yale University; Chemist to the
New Haven Hospital.
CARL VON RUCK, M.D Asheville, N. C.
Consulting Physician to the Winyah Sanatorium;
Director of the von Ruck Research Laboratory
for Tuberculosis.
EMMA ELIZABETH WALKER, M.D New
York, N. Y.
Assistant Surgeon, Hospital for the Relief of the
Ruptured and Crippled.
HENRY BALDWIN WARD, Ph.D., Urbana, III.
Professor of Zoology and Chief of the Research
Laboratory of Parasitology, University of Illinois;
Formerly Dean of the College of Medicine and
Professor of Zoology, University of Nebraska,
and Zoologist to the State Board" of Agriculture.
JOHN COLLINS WARREN, M.D., LL.D., Hon.
F.R.C.S., Boston, Mass.
Professor of Surgery Emeritus, Harvard University
Medical School; Consulting Surgeon, Massa-
chusetts General Hospital.
ALDRED SCOTT WARTHIN, Ph.D., M.D Ann
Arbor, Mich.
Professor of Pathology and Director of the Patho-
logical Laboratories, University of Michigan.
II. GIDEON WELLS, M.D Chicago, III.
Associate Professor of Pathology, University of
Chicago.
WILLIAM A. WHITE, M.D., Washington, D. C.
Superintendent, Government Hospital for the In-
sane; Professor of Nervous and Mental Diseases,
George Washington University Medical College
and Georgetown University Medical College;
Lecturer on Insanity, U. S. Army and U. S.
Navy Medical Schools.
H. AUGUSTUS WILSON, M.D... Philadelphia, Pa.
Professor of Orthopedic Surgery, Jefferson Medical
College; Orthopedic Surgeon to St. Agnes
Hospital and to the Philadelphia General Hos-
pital; Consulting Orthopedic Surgeon, Kensing-
ton Hospital for Women and the Philadelphia
Lying-in Charity.
CHARLES F. WITHINGTON, M.D Boston.
Visiting Physician, Boston City Hospital; Formerly
Instructor in Clinical Medicine, Harvard Medical
School.
C. G. L. WOLF, B.A., M.D., CM., New York, N. Y.
Formerly Instructor in Physiological Chemistry,
Cornell University Medical College.
JAMES HOMER WRIGHT, A.M., M.D., S.D., Bos-
ton, Mass.
Director of the Pathological Laboratory, Massa-
chusetts General Hospital; Assistant Professorof
Pathology, Harvard University Medical School.
A REFERENCE HANDBOOK
OF
THE MEDICAL SCIENCES
Aachen
Abdomen
Aachen. — See Aix-la-Chapelle.
Abdomen, Surgical Anatomy of the. — Theabdomenis
the region of the body lying between the thorax and the
pelvis. It includes theabdominal wall, theabdominal cav-
ity, and its contents, the latter comprising almost the
whole of the digestive apparatus andapart of theurinary.
Above, theabdominal \vallisseparated from the thorax by
the costal arch. Below, it is continued into the pelvis
and thighs, the line of separation on either side being the
iliac crest (crista iliaca) laterally and Poupart's ligament
(ligamentum inguinale) mesially. These superficial
boundaries of the wall are not coextensive with those
of the cavity, for it extends above into the vault of the
diaphragm, corresponding superficially to the fourth
intercostal space on the right side and the fifth on the left.
Below, it passes into the pelvic cavity, the line of sep-
aration between abdomen and pelvis being the linea
iliopectinea. Here the lower limit is the upper surface
of the levator ani and coccygeus muscles.
The form and external appearance of the abdomen
van- with sex. age, and the condition of the abdominal
wall and underlying organs. In infancy, as the pelvis
is undeveloped and the organs in the upper part of the
cavity are relatively large, the abdomen is cone-shaped,
the apex of the cone being directed downward. In
adult males the region is cylindrical and slightly
flattened from before backward. In females it is again
cone-shaped, but the apex of the cone is above, as the
diameter of the lower circumference of the thorax is
always less than that of the pelvis.
The abdominal wall presents anterolateral and
posterior aspects. It differs from the walls of other
cavities in being, for the most part, devoid of skeleton,
which, with the elastic character of the tissues com-
posing it, allows the cavity to vary in capacity accord-
ing to the size of the contained viscera. At "all times
it exerts upon them a gentle pressure, supporting them,
and causing the more solid to impress the softer. This
pressure may be appreciated in any laparotomy
wound, when the omentum and more movable intes-
tines are retained with difficulty. The anterolateral
wall is composed of the following layers of tissue,
which must be considered in detail:
Skin,
Superficial fascia {^^^
External oblique muscle,
Internal oblique muscle,
Transversalis muscle,
Rectus muscle,
Transversalis fascia,
Preperitoneal tissue,
Parietal peritoneum.
In addition to this general description, certain regions
which are commonly the seat of hernia must receive
especial study. These are:
The inguinal region,
The inguinofemoral region.
Vol. I.— 1
The Skin of the abdominal wall is thin and movable
except in the region of the navel, where it is attached to
the underlying tissue. Corresponding to the linea alba
is a furrow which indicates the space between the recti
muscles. Two transverse flexion folds are usually
present, one at the level of the umbilicus, a second, one
inch above the pubis. This latter marks the summit
of the moderately distended bladder. In pregnancy,
or during the growth of large intraabdominal tumors,
the stretching of the skin may give rise to a series of
longitudinal lines, called stria? gravidarum.
Superficial Fascia. — Of this there are two layers.
The superficial layer varies in thickness according to
the amount of fat deposited in it. Both above and
below- it is continuous with the corresponding layer of
tissue in adjacent regions. In the pubic region it
passes into the scrotum, losing the fat, and, joining the
deep layer, it assists in the formation of the dartos.
At the posterior border of the scrotum it becomes con-
tinuous with the same layer of the perineum. The
amount of fat deposited in this layer, together with
that in the omentum and mesenteries, is the principal
factor in determining the external appearance of the
abdomen. Accordingly, all gradations occur, from
the thin concave abdomen of the emaciated to the
thick pendulous one of the obese. These variations
become of importance in examinations of abdominal
organs or in operations upon them. The thick wall
renders the task more difficult.
The deep layer is thin and more fibrous in structure.
It can be separated distinctly only in the lower half of
the wall; above, it is lost in the superficial layer.
Below, externally, it is connected with the iliac crests:
anteriorly, it passes over Poupart's ligaments, to be
attached to the fascia lata half an inch below them.
In the pubic region, together with the superficial layer
it passes into the scrotum to form the dartos. At the
posterior border of the scrotum the layers again
separate, the deeper one forming the corresponding
fascia of the perineum. This latter fascia is attached
on each side to the rami of the pubis and ischium, and
turning around the posterior border of the transverse
perineal muscles, it becomes continuous with the deep
perineal fascia. It is beneath this layer of tissue that
urine or an infection is guided from the perineum
through the scrotum upon the abdomen. The attach-
ment of the fascia to the bony margin of the pelvis
prevents the spread into the thighs on their inner sides,
while the attachment to the fascia lata prevents a
similar spread from in front. The deep superficial
fascia is separated from the aponeurosis of the external
oblique by loose areolar tissue except along the linea
alba, where the attachment is more intimate.
External Oblique Muscle (musculus obliquus externus
abdominis) (Figs. 1 and 2). — This, the strongest and
most superficial of the abdominal muscles, arises by
fleshy digitations from the eight lower ribs, interdigi-
tating in the upper half with the serratus magnus, in
the lower with the latissimus dorsi. The fibers are
Abdomen, Surscical Anatomy
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
ir:
m I
\
k
Fig. 1. — On the Left Side, the External Oblique and the Anterior
Layer of the Rectus Sheath are Removed; on the Right Side, the
External and Internal Oblique and the Lower Half of the Rectus.
The deep epigastric artery is shown through the wall. (Joessel.)
a. Rectus abdominis; b, inseriptio tendinea; c, external oblique;
d, linea alba; c, internal oblique; /, fascia transversalis; (7, internal
abdominal ring; h, Poupart's ligament; £, anterior crural nerve;
3, femoral artery; k, femoral vein; I, spermatic cord;;m, fossa ovalis;
n, deep epigastric artery, shown through abdominal wall; o, trans-
versalis muscle; p, linea semilunaris; q, semilunar fold of Douglas.
directed downward, forward, and inward,
those from the last two ribs almost verti-
cally downward to their insertion in the
anterior two-thirds of the external lip of the
iliac crest. The remaining fibers, more
oblique in direction, terminate in a broad
aponeurosis, which at the mid-line joins with
the aponeurosis of the remaining muscles in
the linea alba. The following structures in
the aponeurosis of the external oblique re-
quire especial mention:
Poupart's Ligament (ligamentum in-
guinale), formed by the thickened lower
border of the aponeurosis, stretched be-
tween the anterior superior iliac spine and
the pubic spine. Attached to it below is the
fascia lata, which gives to the ligament an
outline, convex downward. The flexor mus-
cles of the thigh, the femoral vessels, and
the anterior crural nerve pass behind the
ligament in their course downward.
(iimli, ■nml's Ligament (ligamentum lacu-
nare) (Fig. 5). — Reflected from the pubic
end nf Poupart's ligament to the linea iliopec-
tinea for about three-quarters of an inch, is
a triangular layer of fibrous tissue termed
Gimbernat's ligament. It has upper and
lower free surfaces, and a concave external
border, bounding the femoral ring internally.
External Abdominal or Inguinal Ring (an-
nulus inguinalis subcutaneus) (Fig. 2). —
Situated in the lower and inner part of the
aponeurosis is an oval opening, formed by
the separation of the fibers composing this
part of the aponeurosis from the fibers of
m-t
Poupart's ligament. The long axis of the ring corre-
sponds in direction to that of the fibers of the aponeu-
rosis. Its base is formed by the pubic crest, its sides
by the diverging fibers, which are called the pillars of
the ring. The superior or internal pillar, thin and flat,
is attached to the anterior surface of the symphysis
pubis, while the inferior or external, thick and pris-
matic, essentially the inner end of Poupart's ligament,
curves inward to terminate at the pubic spine. Further
facts concerning the external ring will be mentioned
in the special description of the inguinal region.
Inter columnar Fascia (fibras intererurales). — Binding
together the fibers of the aponeurosis above the
inguinal opening is a set of fibers which arch trans-
versely inward from the outer half of Poupart's liga-
ment, thus closing the angular interval left between
the diverging pillars. At the margins of the opening
these fibers are continued over the spermatic cord
and testicle as a fine fascia, the intercolumnar or
spermatic fascia.
Internal Oblique Muscle (musculus obliquus interims
abdominis) (Fig. 1). — The general direction of the
fibers composing this muscle is the opposite of that of
the external oblique. It arises below from the outer
half or two-thirds of Poupart's ligament, from the
anterior two-thirds of the middle lip of the crest of the
ilium, and from the lumbar fascia in the angle between
the crest of the ilium and the outer border of the erector
spinoe muscle. From this origin the fibers ascend over
the side of the abdomen to be disposed of as follows:
the most posterior fibers pass upward to be inserted
into the outer surfaces of the three lower ribs; those
from the crest anteriorly, the spine, and Poupart's
ligament end in a broad aponeurosis which extends
from the thorax to the pubis, and at the outer border
of the rectus divides into two layers, to enclose this
muscle, uniting again at the linea alba. The anterior
layer is inseparably united with the aponeurosis of the
external oblique, the posterior with that of the trans-
versalis, and above with the seventh and eighth costal
cartilages and the ensiform process. This arrangement
obtains only in the upper two-thirds of the aponeurosis.
Fig. 2. — On theLeftSide, the Aponeurosis of the External Oblique and the
Course of the Deep Epigastric Artery on the Rear Surface of the Abdominal
Wall are Shown; on the Right, the External Oblique is Removed, Opening the
Inguinal Canal. (Joessel.) a, Poupart's ligament; 6, spermatic cord; c,
anterior crural nerve; d, free edge of iliac portion of fascia lata; e, femoral
artery;/, femoral vein; g, saphenous vein; Ji. fossa ovalis; i, reflected portion
nf Gimbernat's ligament; /, fascia transversalis; /,-, lymph gland in femoral
canal; I, fascia lata; m, pubic portion of fascia lata; n, cremaster muscle;
o, internal oblique; p, external oblique; q, deep epigastric vessels; r, superior
pillar of tin- external ring; s, inferior pillar of the external ring; t, inter-
columar fascia.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
MmIoiikm, Surgical Anatomy
In (he lower third there is no division into layers, l»>ih
internal oblique and transversalis passing in front of
the rectus wiih the external oblique. The deficiency
resulting in the; sheath of the rectus is marked above
by a semilunar edge, known as the semilunar fold of
Douglas (linea semicircularis). The lowest fibers
which arise from I'oupart's ligament arch downward
and inward, and, joining similar libers from the
transversalis, form the conjoined tendon of these two
muscles, by which they are inserted into the anterior
surface of the pubis and the inner part of the ilio-
peetineal line, behind (iimbernat's ligament.
The Transversalis Muscle (musculus transversus
abdominis) (Fig. 1), situated beneath the internal
oblique, arises from the inner surfaces of the six lower
ribs, from the transverse processes of the lumbar
vertebnE by an aponeurosis, and from the anterior
two-thirds of the inner lip of the crest of the ilium.
Passing horizontally inward, the fibers terminate in an
aponeurosis about an inch external to the border of
the rectus, except at
the upper extremity,
where the fibers pass
behind the rectus al-
most to the middle
line. The arrange-
ment of the aponeuro-
sis was described with
that of the internal
oblique.
Rectus Abdominis
Muscle (musculus rec-
tus abdominis) (Fig.
1). — This muscle con-
sists of vertical fibers
lying within the sheath
formed by the internal
oblique as described
above. Situated on
either side of the mid-
line of the abdomen,
it arises from the an-
terior surface and crest
of the pubis. Expand-
ing and becoming thin-
ner as it ascends, it is
inserted into the carti-
lages of the fifth, sixth,
and seventh ribs, as
well as the bone of the
fifth. The fibers of the
muscle are interrupted
by three or more ten-
dinous intersections
(inscriptiones tendi-
nece) placed, the first
at the umbilicus, the second at the lower end of the
ensiform process, the third midway between them.
They are confined chiefly to its anterior fibers and
are firmly united to the anterior wall of the muscle
sheath. When additional transverse lines occur, they
are usually incomplete and are placed below the
umbilicus.
The Linea Alba, formed by the union of the aponeu-
roses of the two oblique and transverse muscles, extends
in the mid-line from the ensiform process to the pubis.
A little below the middle it is widened into a circular
space, in the center of which is the umbilicus. Above
the umbilicus the recti muscles diverge and the linea
alba broadens. Below the umbilicus the recti muscles
converge and the linea becomes narrower and passes
in front of the conjoined inner heads of the recti
muscles to the pubis. Passing from the linea, behind
the conjoined heads, is a small band of longitudinal
fibers, the adminiculum linea? alb*, which spreads out
below into a triangular expansion attached to the
upper border of the pubis behind the external head of
the rectus. During pregnancy, or when the abdomen
Fig. 3 —
(Jurssi'l )
d, middle
ff, bladder
inguinal fossa;
h, wis deferens;
h t anterior crural nerve; l t iliac muscle;
hypogastrica; o, plica urachi ; p, peritoneum.
is distended by disease, the linea alba is much increased
in breadth.
The Linea Semilunaris, situated along the outer
border of the rectus muscle, is a curved linear depre ton
Corresponding to the narrow portion of the aponeurosis
of the internal oblique, between the termination of the
muscular liber- and tie- division of the aponeurosis to
form the rectus sheath.
Fascia Transversalis. — This thin layer of fascia
lines the posterior surface of the transversalis muscle
and is continued on to the under surface of the dia-
phragm. Above the umbilical line it is exceedingly
thin, but below, especially in the inguinal region, it is
more strongly developed and is attached to I'oupart's
ligament. Laterally, it is attached to the inner lip of
the crest of the ilium and is continuous with the iliac
fascia. An opening in the transversalis, the internal
abdominal ring, will be described below.
Preperitoneal Tissue and Parietal Peritoneum. — The
properitoneal tissue is a variable layer which is situated
between the transver-
salis fascia and the
peritoneum, and is
more highly developed
in the inguinal regions.
Farther up on the ab-
dominal wall it is fre-
quently absent. In
this layer are situated
the most important
blood-vessels of the
abdominal wall. The
parietal peritoneum
will be more especially
noted below. For the
most part it is sepa-
rated from the fascia
transversalis by the
properitoneal tissue,
but along the linea
alba and the umbilical
region the two are
united.
Blood-vessels of the
Anterior Abdominal
Wall. — The Arteries of
the abdominal wall are
in two sets, superficial
and deep. The super-
ficial vessels are situ-
ated in the superficial
fascia. They are the
superficial epigastric
and the superficial
circumflex iliac, de-
rived from the femoral.
The deep set comprises the six lower intercostals, the
lumbar, the deep circumflex iliac, the superior epigas-
tric, and the deep epigastric artery (arteria epigastrica
inferior). Of these, the latter requires especial
description.
Arising from the distal end of the external iliac, the
deep epigastric artery passes upward and inward across
the rear wall of the inguinal canal to the posterior sur-
face of the rectus; entering the sheath of the rectus it
continues its course upward to anastomose with the
superior epigastric, a branch of the internal mammary.
It lies between the fascia transversalis and the parietal
peritoneum in the properitoneal tissue. In the begin-
ning of its course it encircles the lower and internal
boundaries of the internal inguinal ring.
Two small branches arise from the deep epigastric
artery: the cremasteric, which accompanies the sper-
matic cord, and the pubic branch, which ramifies on the
superior surface of Gimbernat's ligament and the
posterior surface of the pubic bone. On the surface of
the abdomen the course of the artery may be indicated
by a line drawn from the junction of the inner third
Rear View of the Anterior Abdominal Wall in the Inguinal Region.
a, Poupart's ligament; b, external inguinal fossa; c, femoral fossa;
internal inguinal fossa; /, umbilical artery ;
i, external iliac vein; ;, external iliac artery;
plica epigastrica;
plica
Abdomen, Sureical Anatomy
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
with the outer two-thirds of Poupart's ligament,
obliquely upward to the umbilicus.
The veins are likewise divisible into a superficial and
a deep set. The superficial include the superficial
epigastric, the superficial circumflex iliac, and the vena
tegumentosa. The latter connects the axillary with
either the superficial epigastric or the femoral veins.
The deep veins accompany the corresponding arteries
and are double. They anastomose with one another,
and also with the superficial veins on one side and with
the portal system on the other, through the para-
umbilical veins which run in the falciform ligament of
the liver. In pathological states which interfere with
the circulation in either the vena cava inferior or the
porta] system, the superficial veins may be much more
prominent than is usual. In the former ease, the blood
current is upward, toward the umbilicus, the veins
assisting in the formation of a collateral circulation.
In the latter case the
current is downward,
away from the umbil-
icus, and the dilata-
tion is due to direct
stasis.
Above the umbilicus
the superficial lymph-
atics empty into the
axillary glands; below
it, into the inguinal
glands. The deep
lymphatic vessels
empty into the sternal
glands above and into
the iliac glands below.
Nerves. — The ab-
dominal muscles are
supplied by the six
lower intercostal
nerves; the skin of the
abdomen, by cutane-
ous branches of the
same together with the
ilio-hypogastric and
the ilio-inguinal from
the first lumbar. The
nerves are situated be-
tween the transver-
salis and the internal
oblique, and pursue a,
course corresponding
to the intercostal
space, from which
they emerge as far as
the sheath of the rec-
tus, which they pierce
to become cutaneous.
Laterally, between the
origins of the external
oblique, the latissimus
dorsi, and the serratus magnus, arises a series of lateral
cutaneous branches which supply the skin of the lateral
aspect of the abdomen.
In this connection it is interesting to note the rela-
tionship existing between the nerve supply of the
abdominal wall on the one hand, and that of the abdom-
inal viscera and peritoneum on the other. The viscera
derive their principal nerve supply from the three
splanchnics, which are formed by the union of the
rami communicantcs of the six lower intercostals.
Therefore the abdominal viscera and the abdominal
walls are all connected with the same segments of the
central nervous system.
In disease these nerve connections may serve to
explain many of the symptoms and signs, such as
reflected pains and rigid abdominal muscles in acute
inflammatory stairs.
The surgeon is frequently called upon to open the
Fig. 4. — Rear View of Anterior Abdominal Wall, the Peritoneum having
been Removed. (Joessel.) a, Anterior crural nerve; b, external iliac
artery; c, external iliac vein; d, obturator artery; e, obturator nerve; /,
umbilical artery; q, ureter; h, seminal vesicle; 7, bladder; j, adminiculura
linear alb®; k, vas deferens; I, spermatic vessels; m, transversalis fascia;
n, iliacus; o, Poupart's ligament; p, semilunar fold of Douglas; q, obliterated
umbilical arterv: r, urachus; s, suspensory ligament of liver; t, rectus muscle;
u, deep epigastric vessels; v, internal abdominal ring.
abdominal cavity through the anterolateral wall. The
incisions should be carefully planned, first, to give
ample room for the necessary intraabdominal manipu-
lations; second, to do the least possible injury to the
abdominal wall, thus reducing to a minimum the
liability of a subsequent ventral hernia.
The most common line of incision is through the linea
alba, this route being chosen in most pelvic operations,
in those upon the intestines in general, and in many of
those upon the stomach. The line is easily followed
above the umbilicus, where the linea alba is broad, but
below, where it is narrow, the line is followed with
difficulty. In incisions above the umbilicus the
position of the falciform ligament of the liver should be
remembered.
Many surgeons prefer an incision slightly to one side
of the linea — one which opens the sheath "of the rectus
muscle and separates its fibers. They believe that
such a wound heals
more solidly than one
s that divides the linea
alba, formed as it is
by the interlacement
of numerous aponeu-
rotic layers. Certainly
the linea has but one
possible advantage,
that is, nonvascu-
lar! ty. The rectus
should be separated
only in its inner half,
because of the position
of the nerve trunks in
its outer half. For
this reason a trans-
verse incision will do
less damage than a
longitudinal one in the
outer half of the rec-
tus.
In lateral incisions
three points must be
borne in mind: (l)The
direction of muscular
or aponeurotic fibers;
(2) the course of
nerves; (3) the course
of blood-vessels.
All longitudinal or
oblique incisions will
divide one or more
layers of muscular
fibers which, in many
instances, it is impos-
sible to avoid. How-
ever, when possible
the plan of McBurney
should be followed — ■
namely, that of sepa-
rating each aponeurotic layer in the direction of its
fibers. When the fibers of all the layers cannot be
separated in this manner, it is advisable to separate
those of the external oblique and divide the remaining
layers. The separation of the fibers possesses many
advantages — it is almost bloodless, no large nerves are
injured, and the edges of the wound, instead of tending
to separate, tend to approximate. It has the dis-
advantage of requiring a larger number of assistants
and of not giving as free an opening as direct incision.
When it becomes necessary to incise the entire thick-
ness of the abdominal wall, the incision should be
planned with due regard to the nerves, remembering
that they are continued forward from the intercostal
spaces between the transversalis and the internal
oblique. For this reason, lateral longitudinal incisions
along the rectus are objectionable, division of the nerves
being followed by more or less paralysis, which is an
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Abdomen, Surgical Anatomy
important predisposing factor in the development of a
hernia.
Transverse incisions in the lower abdominal region
must avoid the deep epigastric artery the course of
which is indicated above. In the upper half they must
avoid the superior epigastric artery, which, however,
i~ of less importance than the deep vessel.
The inguinal region is bounded below by Pouparl 's
ligament, internally by the median line indicated by
the lineaalba, and above by a horizontal line extending
from the anterior superior iliac spine to the median line.
The tissue layers composing the wall are the same as
those of the abdominal wall in general.
Piercing the region in an oblique direction from
behind forward, downward, and inward is the sper-
matic cord (funiculus spermaticus) in the male and the
round ligament (ligamentum teres uteri) in the female.
The track which the spermatic cord pursues in the
abdominal wall is known as the inguinal canal, but it
must be understood that a true canal exists only in a
pathological state.
The canal presents
for description an ex-
ternal opening, an in-
ternal opening, and
four walls. As men-
tioned, the external
opening (annulus in-
guinalis subcutaneus)
is formed by the sepa-
ration of the lower and
the inner fibers of the
aponeurosis of the ex-
ternal oblique. The
ring is closed by the
intercolumnar fascia
(libra' intercrurales)
which is continued
over the cord and
testicle and must be
teased from the cord
before the ring is
plainly visible. At
the upper angle, it
binds the columns to-
gether, thus strength-
ening the ring above.
The externa! ring
varies in size, depend-
ing upon the develop-
ment of the intercol-
umnar fibers. Nor-
mally, the opening will
admit the end of the
finger, but this is
modified by the posi-
tion of the body. ~
Fk:. 5. — On the Right Side arc Shown the Location and Relations of an
External Inguinal Hernia; on the Left Side, those of a Femoral Hernia. The
obturator artery is shown arising from the deep epigastric. Us course
along the free edge of Gimbemat's ligament is diagrammatically shown
on the left side. (Joessel.) a. Deep circumflex iliac artery; o, external
iliac artery and vein; c, lymphatic glands; ) infundibuliform fascia; (4) the preperitoneal
tissue and peritoneum composing the hernial sac. In
Fig. 6. — Rear View of Internal Inguinal Hernia. (Joessel.)
a, Rectus; 6, sac of internal inguinal hernia: c, bladder; d, vas
deferens; e, seminal vesicle; f, obturator foramen; g, Poupart'g
ligament; h, external iliac artery and vein; i, obliterated umbilical
artery; ;', spermatic vessels; /.■, crural nerve; I, iliac muscle; m, deep
circumflex iliac vessels; n, transversalis fascia; o, internal abdominal
ring; p, deep epigastric vessels.
congenital hernia this is the processus vaginalis perito-
nei, and may be distinguished from the acquired peri-
toneal coat by its relation to the testicle, the testicle
being within the sac, and its firm adherence to the fascia
propria. The acquired sac is easily separated from the
fascia propria, while the congenital is separated with
difficulty. The aci [uired hernial sac, like the congenital,
lies directly in front of and in contact with the vessels of
the spermatic cord, but does not pass below the testicle.
Two additional forms of acquired external inguinal
hernia are described, and though both are associated
with incomplete obliteration of the processus vaginalis
peritonei, they are not provided with a congenital sac.
The first is the infantile variety, in which the processus
vaginalis peritonei is obliterated only at the internal
ring, leaving a large tunica vaginalis testis, behind
which the newly formed hernial sac descends.
In the second form, that of encysted hernia, the con-
dition of the processus vaginalis peritonei is the same;
but the septum which is undergoing obliteration yields,
and, passing down into the tunica vaginalis testis,
invests the new sac. In a dissection of the first, three
layers of peritoneum must be divided; in a dissection of
the latter only two, before the hernial contents are
exposed.
Internal inguinal hernia is of much less frequent
occurrence and differs from the oblique variety, (1) in
passing through the abdominal wall in the floor of the
6
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Abdomen, Surgical Anatomy
middle or internal inguinal fossa, and consequently
always lying on the inner side of the deep epigastric
artery; ('-') in not passing along the entire canal; (3) in
external appearance, being smaller and more globular
in form; (4) in being situated over the os pubis and not
in the course of the inguinal canal. The most valuable
differential point is the position of the dee]) epigastric
artery. The floor of the middle inguinal fossa is The
rear wall of the inguinal canal. It is divisible into two
parts: An inner part, the conjoined tendon of the inter-
nal oblique and transversalis; an outer part, the trans-
versalis fascia. The conjoined tendon (falx inguinalis)
varies greatly in its development. In many cases it is
slight and scarcely discernible, while in others it is
strongly developed, especially in its deeper portion
which is derived from the transversalis muscle, and
which may bound the canal as far outward as the
internal ring.
There are two forms of internal hernia which pass out
through the middle fossa. The first and most common
form protrudes in the inner part of the fossa, either
separating or pushing before it the conjoined tendon.
It traverses only the lower end of the canal, to emerge
at the external ring. The coverings of this variety,
from within outward, are the peritoneum and subperi-
toneal tissue, the fascia transversalis, and the conjoined
tendon, except in those cases in which the sac passes
between the fibers of the tendon, the intercolumnar
fascia, the superficial fascia, and the skin. The sper-
matic cord, placed behind and on the outer side, is not
in contact with the sac, the cremasteric and the infun-
dibuliform fascia being interposed.
The second form of internal hernia passes into the
inguinal canal through the outer portion of the rear _
wall, and lies between the conjoined tendon internally
and the deep epigastric artery externally. It passes for
a considerable distance along the canal, which gives it
a certain degree of obliquity. The coverings of this
hernia are the same as those of the first variety, with
the exception of the conjoined tendon, which is replaced
by a layer derived from the cremasteric fascia.
The Inguinofemoral Region. — Upon removing
the skin of the inguinofemoral region the superficial
fascia of the thigh is exposed, ascending as a continuous
layer upon the abdomen, descending upon the thighs,
and internally passing into the dartos of the scrotum
and the superficial fascia of the perineum. A deep
layer of superficial fascia, thin and membranous, can
also be distinguished. It is this layer which is attached
to the margins of the saphenous opening, closing it and
receiving in this locality the special name of cribriform
fascia. Between the two layers are the superficial
blood-vessels and the lymphatics of the thigh.
The deep fascia of the thigh, the fascia lata, strong
and aponeurotic, concerns us only in its anterior and
upper regions, where it is described as consisting of
two portions, the iliac and the pubic. The iliac portion,
attached throughout to Poupart's ligament, lies in
front of the femoral sheath, and, at the inner end of
Poupart's ligament, terminates in a free edge, which,
passing downward and outward and then inward, in
the angle between the internal saphenous and femoral
veins, becomes continuous with the pubic portion.
The pubic portion, continued upward behind the
femoral sheath to which it is attached, ends at the linea
iliopectinea.
Thus is formed the saphenous opening through which
the internal saphenous vein passes to join the femoral
vein. Its upper extremity lies about an inch external
to the pubic spine. Its vertical diameter is about an
inch and a half or two inches. Only the outer side of
the opening is well marked, where the free edge of
the iliac portion of the fascia forms a distinct falciform
border, ending above and below in superior and
inferior cornua. On the inner side, the pubic portion
does not form a well-marked edge, but, after covering
the pectineus muscle, passes upward behind the
femoral sheath to which it is connected, to the linea
iliopectiiH-a where ii is ci nit ii ii with the iliac fascia.
The deep layer of the superficial fascia is attached to
the margin of the opening which it closes, and, becau e
it is perforated by the internal saphenous vein and
numerous small arteries and veins, is known as the
cribriform fascia.
Poupart's Ligament (ligamentum inguinale). — The
defect in the anterior wall of the pelvis between the
anterior superior spine of the ilium and the spine of the
pubis is bridged over by Poupart's ligament. The
space between the ligament and the pelvic bones serves
for the passage of certain structures from the abdomen
into the thigh, and is divided into three compartments
by the fascia 1 investing them.
The first or iliac compartment, situated externally, is
formed anteriorly by Poupart's ligament and the iliac
fascia, posteriorly by the ilium, and internally is sepa-
rated from the second or pectineal compartment by an
intermuscular septum. This compartment transmits
the iliopsoas muscle and anterior crural nerve.
Fig. 7. — Rear View of Femoral Hernia, Showing Normal Obturator
Artery. (Joessel.) a, Rectus muscle; b, transversalis fascia;
c, deep circumflex iliac artery; d, deep epigastric artery; ft, cre-
masteric artery; /, Poupart's ligament; g, pubic branch of deep
epigastric; h, hernial sac; i, Gimbernat's ligament ; ;', pubic branch
of obturator artery; k, abnormal obturator artery; I, obturator
nerve; m, external iliac vein; n, external iliac artery: o, psoas
muscle; p, anterior crural nerve; q, iliac muscle; r, iliac fascia.
The second or pectineal compartment, lodging the
upper end of the pectineus muscle, does not communi-
cate with the abdomen, but corresponds to the space
between the pubic portion of the fascia lata and the
pectineal surface of the os pubis.
The third or vascular compartment is the most
important. It is situated in front of the other two,
being bounded anteriorly by Poupart's ligament, and
posteriorly by the continuous iliac and pectineal
fascia?. It transmits into the thigh the external iliac
vessels and the crural branch of the genitocrural nerve.
Femoral Sheath. — As the external iliac vessels become
the femoral, they are enclosed within the femoral or
crural sheath, which accompanies them into the thigh.
The anterior wall of the sheath is derived from the
transversalis fascia, the posterior wall from the iliac
fascia. On the outer side of the artery the two layers
are continuous and closely embrace it; but on the inner
side, while they are continuous, a space is left between
them and the vein. Furthermore, both the anterior
and posterior walls are attached to the iliac and pubic
portions of the fascia lata, respectively.
Within the sheath the artery lies external to the vein,
and is separated from it by a thin septum stretched
Abdomen, Surgical Anatomy
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
from the anterior to the posterior wall. A second
septum completes, on the inner side, the compartment
for the vein, and cuts off a third space, about one-half
inch in length, between the vein and the inner wall of
the sheath. This is the funnel-shaped crural canal,
through which a femoral hernia descends. Thus each
vessel has its separate compartment, and there remains
a small internal compartment containing only areolar
and lymphatic tissue.
The Femoral or Crural Canal (canalis femoralis). —
The size of the femoral canal varies in different persons,
being larger in the female than in the male. Like the
external abdominal ring, the size of the femoral canal
and the degree of tension of its orifices are markedly
influenced by the position of the thigh. Extension,
abduction, and external rotation contract the opening,
while flexion, adduction, and internal rotation relax
the femoral canal and its orifice; consequently this
latter position should be used in the application of
taxis to a femoral hernia.
The four walls of this canal will be understood from
the above description. Below, it terminates beneath
the saphenous opening (fossa ovalis), while above, it
opens on the anterior abdominal wall by an aperture
known as the femoral or crural ring (annulus femoralis).
This aperture is oval, and is larger in the female; its
long diameter, directed transversely, is about one-half
inch.
The ring, covered by the parietal peritoneum, shows
a slight depression, which, if not visible, can easily be
felt. Beneath the peritoneum is a thin layer of con-
densed properitoneal tissue, the septum crurale, which
closes the ring. The ring is bounded anteriorly by
Poupart's ligament and the deep crural arch; posteri-
orly, by the os pubis, covered by the pectineus muscle
and the pubic portion of the fascia lata; externally, by
the external iliac vein. Internally to the ring are
the sharp margins of Gimbernat's ligament, the con-
joined tendon, and the deep femoral arch. With the
exception of the external, the boundaries of the ring
arc formed by very unyielding structures.
Relations. — The position of the external iliac vein has
been noted. The deep epigastric vessels cross the supe-
rior and external angle. A small communicating
branch between the deep epigastric and obturator
arteries is usually found on the superior aspect of
Gimbernat's ligament.
Obturator Artery. — In two out of every five subjects,
the obturator arises from the deep epigastric on one
or both sides. It then turns backward into the pelvis
to reach the thyroid foramen. In doing so it may
pursue one of two courses: First, it may turn backward
close to the external iliac vein, and will then be on the
outer side of the femoral ring; second, it may first run
inward, then arch backward along the free edga of
Gimbernat's ligament, and will then be on the inner
side of the ring. This inner position is more frequent
in males than in females, though the epigastric origin on
the whole is somewhat more common in females than
in males.
These anomalies can be detected in a given case only
by palpation of the artery through the femoral canal.
" Femoral hernia is rare as compared with the inguinal
variety. It occurs more frequently in females, and is
always acquired. Entering through the femoral ring,
it passes vertically downward along the femoral canal
as far as the end, carrying before it a sac of peritoneum
and the septum crurale. Having reached this point,
the hernia turns forward through the saphenous open-
ins, where it derives a covering from the cribriform
fascia, and then ascends beneath the superficial fascia
of the groin as far as, or above, Poupart's ligament.
The fascia propria is composed of the septum crurale
and the femora] sheath, but at times, instead of dis-
tending the sheath, it passes through an opening in it.
Within the canal the hernia is small, as it is sur-
rounded by unyielding structures; but having passed the
saphenous opening, it rapidly enlarges. The direction
of a femoral hernia and the position of the body should
be borne in mind during attempts at reduction by
taxis. Thus the lower limb should be flexed, adducted,
and rotated inward. The pressure should be first
downward, then backward, and finally upward.
A femoral hernia may be strangulated at any part
of the canal or at the saphenous opening, the most
frequent point being the femoral ring. In all cases the
stricture may be safely divided in an upward direction.
At the femoral ring, the least damage will be done by
dividing Gimbernat's ligament, except in cases of
anomalous obturator artery.
The coverings of a femoral hernia, from without
inward, are the skin, the superficial fascia, the cribri-
form fascia, the fascia propria, consisting of the femoral
sheath and the septum crurale, and the peritoneum.
The Posterior Abdominal Wall. — The posterior
abdominal wall is of simpler construction and of less
extent than the anterolateral. In its center is the
portion of the spinal column composed of the five lum-
bar vertebra with their connecting ligaments and carti-
lages. On each side are arranged the muscles — ilio-
psoas, quadratus lumborum, and erector spina 1 —
enclosed within sheaths of fascia, that of the ilio-
psoas muscle being of especial importance. This
fascia is attached to the spinal column about the origin
of the muscle; to the ligamentum arcuatum internum
and to the anterior layer of the lumbar aponeurosis
along the outer border of the muscle. Below, it
firmly binds the iliac portion of the muscle into the
false pelvis, being attached about its entire circum-
ference, with the exception of the space where it passes
beneath Poupart's ligament to form the posterior wall
of the femoral sheath. It follows the tendon of the
iliopsoas to its insertion, and ends by blending with
the fascia lata. Beneath this fascia collections of pus
resulting from caries of the spine or of the ilium may
be guided into the thigh, to appear just below the groin
on the outer side of the femoral vessels. These
collections of purulent fluid should be distinguished
from those situated beneath the transversalis fascia or
in the subperitoneal tissue. In the first instance, the
pus can spread no farther backward than the outer
edge of the psoas, and no farther downward than the
iliac crest and Poupart's ligament; internally, it is
arrested at the mid-line. In the second instance, an
abscess is in close contact with the cecum or sigmoid
flexure, and may open into one of them; or it may
follow the iliac blood-vessels into the thigh. In any
case the typical picture may be lost should an abscess
penetrate the layer of fascia beneath which it originally
developed.
The incisions through the posterior abdominal wall
are made to expose the kidney and colon. They are
noted in the article on Abdominal Organs.
Thomas A. Olnet.
Abdominal Injuries. — The abdominal viscera, un-
like those of the cranium and thorax, are contained
within a cavity whose walls are composed chiefly of
soft tissues and to a relatively slight extent of bony
and cartilaginous structures. The viscera of the
upper abdomen are protected in some degree by the
lower ribs and their cartilages, and those of the lower
abdomen by the pelvic bones, while posteriorly there
is the lumbar spine.
The muscular wall of the abdomen, too, varies in
thickness, and hence in its protecting properties, in
different regions, being heavy and solid in the loins,
and relatively thin at the sides and front. These
defences are more apparent than real, for while
viscera may be shielded by them from the effects of
violence acting in certain directions, practically all the
abdominal contents are exposed to violence acting
from in front.
The dangers of abdominal injuries depend also in no
small measure upon the character of some of the viscera
themselves.
8
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Abdominal Injuries
The gastrointestinal canal, although its mobility
within the abdomen unquestionably enables it in
many instances to escape the effects of violence, yet
contains matter in a high degree infect ions, which,
finding its way into the peritoneum, regularly excites
a dangerous and usually fatal peritonitis.
Distention of the hollow viscera also favors injury
of them, for not only is there thus a larger mark for
violence to act upon, but the increased tension of
their walls facilitates the rupturing effect of violence.
Others of the viscera, as the liver, spleen, kidney.
and great vessels, are practically fixed and immovable,
and therefore are subject to injury from a degree of
violence sometimes comparatively slight.
The abdominal walls are lined by, and the viscera
wholly or partially covered by, the peritoneum. This
membrane, by rendering the movements of the abdom-
inal organs upon one another and beneath the abdom-
inal walls easy, no doubt often facilitates their escape
from the results of violence which would otherwise
inevitably produce injury of them, and thus it be-
comes a conservative agent.
On the other hand, peritonitis, however produced,
is the most dangerous and oftenest fatal of the 'con-
sequences of abdominal injuries.
Peritonitis developing as the consequence of inju-
ries assumes one or other of three types. First, it
results in the formation of adhesions between con-
tiguous peritoneal surfaces, without pockets contain-
ing fluid of any kind; or, second, the adhesions form
pockets shutting in collections of pus of greater or
less size. In both of these types the peritonitis is
confined to some particular region of the abdomen and
involves only a part of the peritoneum, the rest of it
remaining uninflamed. Such types are distinctly
conservative.
In contrast to them there is a third type in which the
inflammation, instead of being circumscribed, spreads
quickly and soon involves the whole peritoneum.
Such a type of peritonitis is usually fatal, while the
first two are by no means necessarily so.
Peritonitis is invariably the result of infection by
pus-producing bacteria either from without, through
lesions of the abdominal walls, or from within, through
lesions of the viscera, particularly of the gastrointesti-
nal canal.
Why, in different instances, different forms of
peritonitis are produced, does not as yet seem evident.
We have not the means for determining what is the
role of the peritoneal cells and other defensive factors
in combating infection. Several facts are apparent,
however. Numerous experiments and observations
have shown that the development of peritonitis is
greatly promoted by the presence of blood in the
peritoneal cavity; it is known also that infection by
the contents of the intestine high up is milder than
when escape of the contents of the colon occurs; and,
finally, it is known that small fecal extravasations
may be encapsulated, while large ones are usually
followed by a general peritonitis.
Bile in moderate quantities may cause only an
adhesive peritonitis; less frequently a general periton-
itis follows. The same is true of perfectly normal
urine; but decomposing urine, or urine containing
inflammatory products or contaminated by unclean
instruments — all of which are conditions implying
the presence of bacteria — quickly excites a septic
peritonitis.
Abdominal Wall. — It is convenient to classify in-
juries of the abdomen into two groups: (1) The sub-
cutaneous, including contusions; (2) the open wound-.
Subcutaneous injuries may be confined to the ab-
dominal wall, or there may be lesions of the viscera also.
The open injuries may be confined to the abdominal
wall without penetrating it, or they may simply
penetrate the abdomen without injuring any of the
viscera, or there may be a prolapse or a wound of
the viscera.
Subcutaneous injuries of the abdominal wall result
from the infliction of direct violence by blows, kicks,
falls against, obstructions, spent balls, pas-age across
the abdomen of wheels, crushing by machinery, etc.
In this group, too, are included those cases of over-
exertion in which muscles are ruptured. This acci-
dent is api to occur in the recti, the diaphragm, or the
elector spina', particularly in the presence of degenera-
tive changes in these muscle
Blood is extra vy ated bet ween the retracted ends of
the muscle torn by overact ion or crushed by direct
force; and after its absorption, repair occurs by
cicatricial tissue, which may occasionally yield to
intraabdominal pressure and become the site of hernia.
Ecchymosis also occurs over wide areas beneath the
skin or in the subserous connective tissue.
Wounds of the abdominal wall which do not pene-
trate are not in themselves peculiar injuries. With
proper treatment they heal readily; but care must be
exercised in the accurate approximation of the cut
muscles to prevent the subsequent development of
hernia.
Another condition and one totally different pre-
sents itself the moment the peritoneum is penetrated;
then the wound becomes a grave injury, with the
possibility of peritoneal infection and septic perito-
nitis; but the dangers of such wounds depend upon
their size, upon the implement by which they are
inflicted, and upon the presence or absence of foreign
bodies.
Small wounds inflicted by narrow, sharp blades are
relatively innocuous and are usually recovered from;
the visceral peritoneum, especially the omentum,
becomes adherent to the abdominal wall in the region
of the wound, the general cavity is shut off, and heal-
ing occurs without incident. In the case of larger
wounds in which there is more or less gaping, or in
those inflicted by dirty implements or complicated
by the presence of foreign bodies, so great a surface
of peritoneum is infected that no adequate adhesion
occurs and a septic peritonitis follows. This may be
prevented, however, in a certain proportion of cases
at any rate, by proper wound treatment.
Through wounds of the abdominal wall, even if of
small or moderate size, and almost certainly through
those of any considerable dimensions, prolapse of
one or other viscus, or of parts of viscera, is apt to
occur. The omentum is most apt to escape; next the
small intestine; and, when separated from their
attachments, parts of the liver and the whole or
portions of the spleen and kidney have been known to
undergo a prolapse.
The viscus, especially if prolapsed through a small
wound, soon becomes congested and edematous, and
adherent at the margins of the wound; it may
then remain fixed there, or become wholly or partly
necrotic.
Occasionally, as in the case of the omentum, the
wound is plugged and permanently sealed; or a
peritonitis spreads from the wound and destroys the
patient's life.
The dangers which prolapse of viscera thus adds to
those inherent in the penetrating wound of the abdo-
men, are the increased risk of peritonitis, unavoidable
from the necessity of returning a prolapsed area of
peritoneum almost certainly infected, and the likeli-
hood of injury or of strangulation of the prolapsed
viscera.
The Liver and Its Ducts. — While the liver is
protected within certain limits by its position beneath
the ribs and their cartilages, its relative fixity renders
traumatic lesions fairly frequent.
Subcutaneous injuries are oftenest the result of
crushing violence or of blows inflicted directly over
the liver, and are not infrequently associated with
fractures of the ribs, under which circumstances the
bony fragments may be the agents by which the liver
lesion is produced.
Abdominal Injuries
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
The lesion varies from slight subperitoneal lacera-
tion to fissures of some depth and extent, or even
pulpification of the affected region or separation of
masses of liver tissue.
The lesion occurs oftener in the right lobe than
elsewhere.
Open injuries of the liver are usually the result of
bullet or stab wounds, and the lesion itself varies
from a small puncture to a large incision or hole.
In all these lesions, except those which are subperi-
toneal, bleeding is free and often profuse, and consti-
tutes the main danger to life. Healing of the injured
liver tissue occurs readily; but it may be interfered
with by infection conveyed by the blood current or
introduced from without.
The prognosis is modified in great measure by the
presence or absence of associated injuries of other
viscera. The mortality is reckoned by Edler at
So. 7 per cent, for contusions, 55 per cent, for gunshot
wounds, 04. S per cent, for stab wounds — average, 66.S
per cent.; for uncomplicated injuries, 5-1.6 per cent.
With or without injury of the liver itself the gall
bladder or the ducts may be injured, and this may be
followed by the escape of bile into the peritoneum in
quantities more or less great.
Peritonitis regularly follows, but there are on record
a considerable number of cases which are exceptions.
In them, in subcutaneous injuries, the extravasated
bile has been encapsulated, and the patient has been
saved by repeated aspirations; or the bile has escaped
externally through fistuke formed in the tract of
wounds, the flow gradually diminishing as these
closed.
Treatment of injuries of the liver is directed chiefly
to the control of the bleeding from them, and ought
not to be delayed if the symptoms of loss of blood are
increasing. It should be undertaken before exsan-
guination has proceeded far enough to make the addi-
tional shock of the necessary operative procedures a
source of serious danger.
Hemorrhage from the liver may be stopped by
gauze packing or by deep sutures; the cautery is
useless.
The liver and its ducts are most accessible through
incisions of the abdominal wall, made parallel with
the margin of the costal cartilages; but it may be
necessary to cut through the latter, or even to approach
the liver through the pleural cavity and diaphragm.
Wounds of the gall-bladder are to be sutured; in
only the rarest cases is extirpation indicated. Incom-
plete divisions of any of the ducts should be closed as
far as possible by suture, and in any case adequate
provision for the escape of bile should be made by
means of gauze packing.
In a case of complete division of the common duct,
if approximation of the severed ends by suture seems
impracticable, anastomosis between the gall-bladder
and intestine is clearly necessary.
The Spleen. — The deep-seated position of the
spleen in the abdomen makes injuries of this organ
relatively rare. Its injuries are the result of much
the same sorts of violence as produce lesions of the
liver. OfEdler's 1 ICO cases, S3 were subcutaneous,
42 were bullet wounds, and 35 were stabs.
It goes without saying that an enlarged spleen is
much more liable to damage than one of normal size.
The intimate relation of the spleen to other abdom-
inal (and thoracic) viscera makes associated injuries
of these organs of frequent occurrence.
The great danger in injury of the spleen itself is
from hemorrhage.
Suppuration and abscess of the spleen have been
known to follow even subcutaneous injuries of the
organ.
The prognosis is therefore grave. Of the subcu-
taneous injuries, Edler e.-timates that S6.7 per cent,
are fatal; of the shot, wounds, 83.3 per cent. The
presence of associated injuries adds greatly to the
dangers qf the situation and increases the mortality.
The treatment of injuries of the spleen is chiefly
directed to the control of hemorrhage. It should there-
fore be carried out at the earliest possible moment.
The spleen is easily reached through an incision carried
from the free border of the costal cartilages vertically
downward through the outer margin of the rectus
muscle. For relatively small wounds or ruptures of
the spleen deep sutures may be used to stop the bleed-
ing, but for more extensive injuries one should proceed
without delay to extirpation.
_ The Kidneys and Ureters. — Contusions of the
kidney may occur as the result of violence acting upon
the loins in the form of kicks, blows, and falls. The
lesion, in the mildest cases, consists in small subcap-
sular lacerations or in more extensive tears, particu-
larly at the bases of the pyramids, while in the most
severe cases the kidney is ruptured, split into two or
more fragments, or reduced to pulp.
Lacerations without open wound are rare. [Bell 2
states that in the Royal Victoria Hospital, Montreal,
9,920 surgical cases were treated in the years 1903 to
1910, and among them were only seven cases of lacera-
tion of the kidney without open wound.]
Bleeding from the torn kidney tissue is apt to be
profuse, and the extravasated blood infiltrates the
retroperitoneal tissue or finds its way into the peri-
toneum if rents of this membrane are also present.
Wounds of the kidney are rare in civil practice,
but they present in themselves no anatomical peculi-
arities that distinguish them from the subcutaneous
injuries.
Repair of traumatic lesions of the kidney occurs
with great readiness and completeness. Rarely,
cysts persist at the site of injury or the kidney goes
on to atrophy.
< The danger to life in injury of the kidney lies first
in the hemorrhage and then in suppuration. But
the close relation of this organ to other viscera makes
associated injuries of one or other of them of frequent
occurrence, and thus the prognosis may be greatly
modified.
Of 10S cases of contusion of the kidney collected
by Grawitz, 3 50, or 46.3 per cent.., were fatal. Of
these 50 cases, IS were complicated by injury of more
important viscera; in 17, suppuration occurred, with
7 deaths. Of the 32 uncomplicated cases, 14 died of
the primary hemorrhage, S of secondary hemorrhage,
7 of suppuration, and 3 of urinary retention.
Of 50 cases of stab wound of the kidney, 15 were
complicated by injuries of other viscera, 35 were
uncomplicated. Of the 35 uncomplicated cases, 11
patients died — 1 from primary bleeding, 1 from sec-
ondary hemorrhage, 6 from suppurative nephritis of
the injured kidney, 2 from suppuration of the uninjured
kidney, 1 not stated. Of the 15 complicated cases,
3 were complicated by injury of the spine, and all
were fatal; 1 by laceration of the peritoneum, fatal;
2 by injury of the liver, both patients died; 3 by
injury of the intestine, 2 died; 6 by injury of the
chest, 4 died; thus 12 died and 3 recovered.
Of 50 bullet wounds of the kidney collected by
Edler, 22 resulted fatally. Of the 50, but 20 were
uncomplicated by injuries of other viscera, and of
these only 3 were fatal.
Injuries of the ureter occur infrequently, most
often perhaps as accidents in operations upon the
pelvic viscera. Extravasated urine collects behind
the peritoneum, exciting a cellulitis there, or it enters
the peritoneal cavity and produces a fatal peritonitis.
The treatment of injuries of the kidney turns upon
the control of bleeding, upon the provision for the
escape of extravasated urine, and upon the avoidance
of infection.
In contusions, therefore, if catheterism is practised
at all, it must be done with every care to avoid intro-
ducing infection. For the less severe cases rest in
bed is all that is required. For the more severe cases
10
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Abdominal Injuries
no delay is to be allowed in temporizing with urinary
astringents, cold enemata, etc.; the kidney should
be exposed and the bleeding controlled by suture,
by gauze packing, or by partial or total nephrectomy.
The external wound must be freely drained.
The Bladder. — The position of the bladder behind
the symphysis renders injuries of this viscus fairly
infrequent. Whether the wound be subcutaneous
or open, the presence of the peritoneum over a portion
of the bladder wall is of capital importance, and it is
convenient therefore to divide injuries of the bladder
into two groups — extra- and intraperitoneal.
Of the intraperitoneal injuries of the bladder,
wounds may occur in any position, while the sub-
cutaneous injuries or ruptures are usually transverse
or oblique, of variable size, and occur oftenest Low
down in the posterior wall, and least often at the
summit. They are usually due to blows or falls upon
the hypogastrium, especially when the bladder is
distended and the abdominal walls are lax.
There is free bleeding from the bladder lesion and
escape of urine into the peritoneum; and sooner or
later, generally within two or three days, a peritonitis
is produced that, once established, has no tendency
to remain circumscribed, but spreads and is regularly
fatal. The promptness with which peritonitis devel-
ops depends in great measure upon the character of
the extravasated urine and upon the presence or
absence of infection introduced from without by
instrumentation.
The extraperitoneal injuries occur in the anterior
wall of the bladder, and vary in size from mere punc-
tures to considerable rents. They are due to much
the same sort of accidents that cause intraperitoneal
injuries, and are not infrequently the result of fracture
of the pubic bones, in which accident fragments are
displaced and perforate the bladder wall.
In these cases there is also free bleeding and an
escape of urine into the cellular tissue of the prevesical
space and into the subserous connective tissue; and,
as a result of this, cellulitis develops in these tissues,
and is practically always fatal.
As to the relative frequency of extra- and intra-
peritoneal ruptures of the bladder, the latter are
much more numerous, being estimated by Fenwick*
at SS per cent., as against 12 per cent, for the former.
[Ferguson 5 states that of 109 cases collected from the
literature, in only 49 was the rupture extraperitoneal.]
The prognosis of injuries of the bladder, even if
uncomplicated by injuries of other viscera, is always
most grave. Bartel collected 504 cases with a general
mortality of 45 per cent. Of these, 373 were extra-
peritoneal, with a mortality of 20 per cent., and 131
intraperitoneal, with a mortality of 99.2 per cent.
Arranged according to the presence or absence of
an external wound, 169 eases were subcutaneous
injuries and 90 per cent, died, while 335 were open
injuries and 22.7 per cent. died. Of the 109 subcuta-
neous injuries, 131 were intraperitoneal, with a
mortality of 99.2 per cent.; 3S were extraperitoneal,
with a mortality of 58 per cent. Of the 335 open
injuries, 50 were stab wounds, with a mortality of
22 per cent. ; 285 were bullet wounds, with a mortality
of 24.5 per cent.
But these figures do not indicate the present mor-
tality rate, which has undergone marked improve-
ment with the advance of aseptic technic and the
general adoption of earlier operative interference.
Thus Schlange has collected 32 cases, with 15 deaths
and 17 recoveries. Of these, 22 were intraperitoneal
with 10 recoveries, and 10 extraperitoneal with 7
recoveries.
The treatment of injuries of the bladder is designed
to provide for the escape of urine and to close the
bladder lesion itself, thus preventing infiltration of
urine and the development of those inflammations
which otherwise follow, and which are the immediate
cause of death.
Suprapubic cystotomy, then, should be done at the
earliest moment possible. In extraperitoneal injuries
the lesion should be closed by suture, wholly or in part,
Retzius' space should be thoroughly drained by gauze
(lacking, and the bladder itself should be drained by
a perineal t ube.
In a case of intraperitoneal injury the abdomen
should be entered just above the bladder, and thor-
oughly flushed, and the bladder itself should be closed
by appropriate suture; a Mikulicz drain being passed
into the depth of the pelvis and the bladder being
drained by perineal tube.
If the ureter has been severed the divided ends may
be brought together by the method of Hochenegg
or of Kelly, or the kidney may be removed. Implan-
tation of the ureter into the intestine is a hazardous
expedient, as is also implantation into the bladder.
Tin; Gastrointestinal Tract. — Injuries of the
stomach occur less often than those of the intestine,
and injuries of the large intestine are less frequent
than tliose of the small. They may be single or
multiple. Such injuries vary in extent, being either
incomplete (involving only one or two of the layers
of the tract) or complete (involving all of them).
The former group includes those cases in which the
mucous membrane is lacerated by foreign bodies
passing through the canal; those in which the intes-
tinal wall is contused by violence acting from without,
and in which the injury is accompanied by hemor-
rhage between the component layers of the intestine,
and those in which there is laceration of the peritoneal
or peritoncomuscular layers.
Such injuries are relatively unimportant. Per-
foration may be a consequence but it probably occurs
very infrequently. The complete lacerations are the
important ones. They are of variable extent. In
the stomach the lesion may be a minute perforation
or a tear several inches in length; in the intestine also
the injury may be a small puncture or a total trans-
verse division of the bowel. There is more or less
hemorrhage from the margins of the injured spot
into the canal and into the peritoneum, and, most
important, there is likely to be an escape of the con-
tents of the intestine, the amount varying according
to the dimensions of the opening.
The consequence may be either a peritonitis of
small and limited extent, resulting substantially in
nothing more than adhesions; or a circumscribed
peritonitis, with abscess of greater or less size; or a
generalized septic peritonitis.
In the smaller lesions, at least, extravasation of
intestinal contents does not occur at once on the inflic-
tion of the injury, for one commonly finds, in opera-
tions done for bullet wounds of the intestine, that for
some hours the opening is occupied and practically
occluded by prolapsed mucous membrane. The
mechanism of this occlusion was studied by Griffith,
who found that in transverse wounds of one-third of
an inch in length, the mucous membrane is extruded
by the contraction of the longitudinal fibers of the
intestine, and that in small longitudinal wounds the
contraction of the circular fibers causes the margins
of the wound to roll in, expresses the mucous mem-
brane, and produces the same occlusion. Such ob-
struction to the escape of intestinal contents is best
seen in the small intestine, as it does not occur in the
relatively thinner-walled parts of the colon.
Injuries of the gastrointestinal tract result from
contusions of the abdomen due to blows, falls, kicks,
etc., which crush the intestine against the spine; arid
if this part of the canal happens to be distended when
the injury is inflicted, an actual bursting of its walls
may result. Penetrating bullet and stab wounds of
the abdomen are a common cause of injuries of the
intestines, and the latter may also result from the
passage of a foreign body through the intestinal tract.
The prognosis is always grave and the chief danger
is peritonitis. But the development of peritonitis
11
Alnl.iiniii.il Injuries
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
varies with the extent of the lesion, with the ability of
the patient to circumscribe peritoneal infection by
forming adhesions, and with the promptness with
which surgical intervention is undertaken.
According to Petry, of 199 cases of rupture of the
intestine, 4.8 per cent, recovered through the develop-
ment of adhesions to neighboring structures; in 8.5
per cent, a circumscribed fecal abscess formed. The
general mortality of ruptures of the intestine was
SG per cent.; of rupture of the stomach, 80 per cent.
The seriousness of wounds of the gastrointestinal
canal will appear more clearly when I state that they
are specially apt to be multiple and that other organs
an- apt to be w-ounded at the same time. Of 4,958
cases grouped by Coley,' the mortality was SI per
cent. Of 105 cases treated bj r operation the mortal-
ity was (17. 2 per cent.; and of these, 81 concerned the
small intestine (mortality. 67.5 percent.) ; 24 the stom-
ach (mortality, 75 per cent.); 36 the colon (mortality,
66.0 per cent.).
The treatment should be undertaken at the earliest
moment. But here there is not the positive indica-
tion for instant operation that exists when the control
of hemorrhage is the object in view. Nevertheless
there should be no unnecessary delay in intervention,
and the guide to the time of operation lies in the degree
of shock present. The rule should be to operate the
moment the general condition of the patient will
admit of the procedures necessary, and before periton-
itis has developed. In fact, after a peritonitis is
under way and is spreading, no surgical measure is
likely to be of avail in any but the most exceptional
cases.
The lesions are to be sought systematically, and any
existing tears should be closed by some one of the
recognized forms of intestinal suture; or the intestine
should be resected, or anastomoses should be made.
Then the neighboring peritoneum should be cleaned:
or the entire peritoneal cavity should be flushed until
it is perfectly clean ami then should be sponged dry.
In most cases the judicious placing of gauze drains
will be advantageous.
The Mesentery axd Great Blood-vessels. — In-
juries of these structures are exceedingly uncommon
in subcutaneous injuries of the abdomen, but they
occur with some frequency as the consequence of penc-
trating wounds. The great danger entailed is from
hemorrhage, which is considerable in wounds of the
me 'ntery even of small size, while in those inflicted
at the root of this structure or involving one or other
of the named brandies of the aorta or vena cava, the
bleeding is profuse and usually quickly fatal.
Treatment, if available at all, is practically so only
in those cases in which the wound involves the smaller
vessels, which may be clamped and ligatured, or sur-
rounded by suture, and so closed.
Symptoms of Abdominal Injuries. — To arrive at
the proper conclusion in estimating the consequences
of abdominal injuries it is essential to study the in-
dividual case from every point of view, beginning
with the history of the injury itself, the degree of vio-
lence exercised, the attitude of the patient at the
time of the occurrence, and the state of his abdominal
viscera — empty or full, normal or diseased. Tien,
besides, one must note the sequence of symptoms,
both the addition and the disappearance of local evi-
dences, and the general condition of the individual
considered as a whole.
()f the general symptoms, shock is apparent from
the beginning in most cases of abdominal injury,
although it varies in degree. It is most profound
after severe contusions, and may be but slightly
developed in a considerable number of cases of pene-
trating wounds of the abdomen, so that the absence
of very marked shock should not be construed to mean
absence of visceral lesions of serious or even fatal
character; although profound shock must usually be
interpreted to be indicative of grave injury.
The symptoms of hemorrhage are practically
identical with those of shock, but they are gradually
developed; and very often the similarity of the symp-
toms of the two conditions makes their distinction
impossible, at least with any degree of certainty.
Peritonitis at its outset, which may occur within a
few hours of the reception of an injury, sometimes
closely resembles shock or hemorhage in its symp-
toms, but when fully established it can hardly be
mistaken for any other condition.
There are certain local symptoms which appear
after injuries of any of several viscera, and there are
others which are peculiar to lesions of special viscera
alone.
Hemorrhage in any volume from the liver, spleen,
or kidney — extraperitoneal or intraperitoneal — or
from the mesentery, is accompanied by great pain, by
distention of the abdomen, by great rigidity of its
walls, by dulness in the flanks in some cases; but by no
means all of these symptoms are present in every case
in marked degree, and often one or more of them are
absent altogether.
The presence of gas in the peritoneal cavity is indi-
cated by loss of liver dulness and by a peculiar, non-
resistant feeling of the abdominal wall on palpation
and percussion. Here, again, exceptions are numer-
ous in both the positive and the negative sense. Per-
forations of the intestine occur without loss of liver
dulness, and liver dulness may be absent without per-
foration of the intestine.
Distention of the abdomen following injury is
usually evidence of peritonitis.
Pain is often experienced at the site of injur3 r , but
is a better index of the location of injuries of the
abdominal wall than of visceral injuries; it may be
entirely absent or may be referred to another region,
and is of little value in determining any of the
features of visceral lesions.
Tenderness, on the other hand, is of great value,
and as a rule is felt only in the region injured, and is
thus often an accurate guide to the location of the
intraabdominal trouble.
With injuries of the liver there is a history of wound
or contusion in the region of the liver, followed by
the local and general symptoms of hemorrhage.
With injuries of the spleen there is a history of
wound or contusion in the region of the spleen,
followed by the local and general symptoms of
hemorrhage.
With injuries of the stomach there is a history of
wound or contusion in the region of the stomach, or
of the ingestion of a foreign body, followed by loss of
liver dulness, by hematemesis, and by peritonitis.
With injuries of the intestine there is a history of a
wound or contusion of the abdomen followed by loss
of liver dulness, by bloody stools in some cases, and
by peritonitis.
With injuries of the kidney there is a history of a
wound or contusion in the region of the kidney,
followed by evacuation of bloody urine, probably by
tumefaction in the loin, and very often by the symp-
toms of suppurative nephritis and perirenal cellulitis.
With injuries of the bladder there is a history of a
wound or contusion in the region of this organ. The
symptoms and the conditions observed are the follow-
ing: The bladder is very often, although not always,
empty, and this condition is associated with apparent
suppression of urine, with tenesmus, with evacuation
of small amounts of blood through the catheter, with
non-distensibility of the bladder by means of injec-
tions or with the return of smaller volumes than those
injected, and, finally, with perivesical cellulitis or
with peritonitis.
With injuries of the mesentery there is a history of
a wound or contusion of the central region of the
abdomen, followed by the local and general symp-
toms of hemorrhage or of intestinal obstruction and
peritonitis.
12
REFERENCE HANDBOOK OF Til 10 MEDICAL SCIENCES
Abdominal Injuries
Willi injury of any of the good-sized vessels of the
abdomen there are the symptoms of hemorrhage.
Diagnosis. — In most instances it is practically
impossible to make a correct diagnosis of the viscera
injured, and of the extent of the lesions present ill
consequence of injuries of the abdomen. It com-
paratively rarely happens that such injuries are
confined to a single viscus, and in the combination
of symptoms thai regularly ensue, some are over-
shadowed by others. This fact, together with the
unreliability of many of the symptoms which should
be pathognomonic of special injuries, renders the
diagnosis always one of probability. Nevertheless,
in a considerable number of cases the lesions probably
present may be estimated with a fair degree of
accuracy, and in a small number the diagnosis may
be made with certainty; but it should be emphasized
that this number is small, and that in these particular
cases the injuries present are relatively slight. All
the factors possible must be duly considered: the
character of the violence; its degree and the par-
ticular region which it affects; the viscera present in
this region and their condition at the time of injury ;
and both the immediate and the later symptoms
produced. To all of these features proper value must
be assigned before the final conclusion can safely be
formulated.
Prognosis and Complications. — For the same
reasons any statement in regard to the prognosis of
abdominal injuries must be made with great caution.
It may be said, however, that of those cases that re-
cover after abdominal injuries, there are some in
which the recovery is complete, and others in which
it is incomplete (through the persistence of fistulas
or of peritoneal adhesions, or through the development
of hernia;).
Of the complications of abdominal injuries, hemor-
rhage is perhaps the most important. It may accom-
pany almost any of the visceral injuries.
Peritonitis is an almost equally grave complication.
It is particularly apt to accompany injuries of the
gastrointestinal tract, the bladder, and the biliary
ducts.
Later complications, as mentioned under prognosis,
are: fistula? communicating with the alimentary canal,
the biliary passages, and the kidney; adhesions which
possibly give rise to functional disturbances of the
viscera and especially to intestinal obstruction;
herniae due to yielding of cicatrices of the abdominal
wall; and, finally, the protrusion of one or other or
several of the abdominal organs.
Treatment. — The treatment of patients suffering
from the results of abdominal injuries is of a twofold
character: it comprises the treatment of the general
symptoms — those of shock, hemorrhage, or peritonitis
— and the treatment of the local lesions present.
So far as the treatment of shock is concerned, the
Eatient should be placed in bed and the foot of the
ed should be elevated. He should be warmly
covered, and artificial heat should be applied exter-
nally by hot bottles, etc. Heart action is to be
stimulated by the application of heat or mustard
paste over the precordium, by subcutaneous in-
jections of strychnine, of morphine, of atropine, or of
whiskey, and by enemata of hot water, fluid extract
of coffee, and whiskey. In many cases, and in those
particularly in which the symptoms are due to hem-
orrhage, the infusion of the patient with from forty to
sixty ounces of physiological salt solution is of the
greatest possible service; but it should be borne in mind
that the effect of the infusion will subside in about
four hours, and that then the injection may have to
be repeated.
All that it is necessary to say in this place in regard
to the treatment of peritonitis has reference to its
prevention, and this end is best served by the rigid
observance of the rules which have been formulated
for the aseptic or antiseptic treatment of wounds.
In the ease of a wound of the abdominal wall,
whether penetrating or not, the object of the local
treatment is to secure union in the shortest time
possible and in such a way that hernial protrusions
are least, likely to OCCUT. For this purpose surgeons
are fairly agreed that suturing must be done in layers,
that is, thai identical structures in each margin of
the wound are to !«■ united again; further, that such
union is best accomplished by buried absorbable
suture material, namely, catgut. But since catgul
is absorbed within a few days, some other more
enduring suture material must be used to preserve
the apposition and beginning union, started between
structures brought together by catgut. For this
purpose, then, it is conventional to use deep suture-,
embracing all the layers except the peritoneum,
composed of silk, of silkworm gut, or of silver wire,
Finally, accurate union along the skin incision is
obtained by a continuous suture of fine silk.
For subcutaneous injuries of the abdominal wall in
which no rupture of muscle occurs, no special treat-
ment is required beyond promoting the disappearance
of extravasated blood by massage or aspiration.
When rupture of muscle occurs the overlying skin
is to be incised and the injury treated as a wound by
successive tiers of sutures.
When injury of one or of several of the abdominal
viscera is certain or seems probable, no delay in
instituting active treatment is permissible. It is far
and away the better scheme to make explorative
incisions through the abdominal wall, to render the
diagnosis certain, than to subject the patient to the
dangers of peritonitis or fatal exsanguination by
waiting for a confirmation of the diagnosis of some
doubtful or probable lesion by the development of
positive symptoms. Many patients have without
doubt been saved in consequence of this practice,
and it is equally evident that many have been lost
through hesitation in carrying out this scheme.
There is little or no risk involved in the simple incision
itself.
But no operative procedure may be undertaken in
states of profound shock or in cases in which the
injuries are so extensive or so complicated as to make
their treatment practically impossible; nor should
interference be resorted to in the presence of well-
marked peritonitis. On the other hand, in the pres-
ence of a beginning peritonitis there still remains some
possibility of success.
If decided shock is present, energetic measures for
its relief are called for, and only when the patient has
begun to rally, that is, when the pulse becomes slower
and stronger and the temperature begins to approach
normal, may an operation be contemplated. The
exception to this rule is met with in those cases in
which the symptoms of apparent shock are due to
hemorrhage. In such cases no substantial im-
provement is likely to result from stimulation, and
the patient's best if not only hope lies in immediate
intervention, during which active stimulation should
be carried on.
For the treatment of any visceral lesion that is a
consequence of a non-penetrating injury of the abdo-
men it is necessary to incise the abdominal wall, the
position, direction, and extent of the incision being
determined by the viscus to be reached.
To expose the liver and biliary ducts, an oblique
incision parallel with the free border of the ribs, with
its center about opposite the tenth cartilage, is con-
ventional, while a similar incision on the left side
exposes the stomach. But for either purpose a ver-
tical incision through the outer part of the rectus
downward, for variable distances from the free border
of the ribs, serves equally well, and has the advantage
that on the right side the kidney may be explored and
attacked through it, while on the left side the spleen
may also, if necessary, be reached.
To expose the kidney by the transperitoneal route,
13
Abdominal Injuries
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
the incision just described is the best; but for general
purposes the Konig incision of the loin is much to be
preferred in every way, since in itself it is extra-
peritoneal, but at the same time it allows the perito-
neal cavity to be entered very readily by extending
the incision forward but a short distance.
For the purpose of reaching the bladder an incision
carried upward from the symphysis between the
rectus muscles for the necessary distance, with the
patient in the Trendelenburg position, exposes this
organ perfectly; and, in order still further to enlarge
the working space, the insertions of the recti into the
symphysis may be divided for a short distance. Then,
by the aid of retractors placed so as to draw the mar-
gins of the wound apart, one may obtain a perfect
view of the bladder, and ample room may be gained for
any suturing operation.
To gain access to the intestine and mesentery a
median incision through the linea alba, of variable
length and carried around the left side of the umbilicus
will answer the purpose best. In this way the small
intestine and mesentery, the rectum, and the sigmoid
flexure may readily be reached, and by use of vigorous
retraction the rest of the colon may be exposed, as well
as the first and second parts of the duodenum.
In making incisions through the abdominal wall, no
time should be lost in using a director. The incision
should be rapidly carried through the skin, the super-
ficial and deep layers of fascia, and the muscles —
clamps being applied to all bleeding points — until the
transversalis fascia is reached. This is to be nicked
with the knife and then divided along the length of the
wound by scissors, thus exposing the peritoneum.
The latter in turn is then to be pinched up by two
pairs of forceps, a nick is to be made between them,
and the membrane is then to be divided by scissors on
a finger thrust beneath it through the small primary
opening. It is optional whether bleeding points are
to be tied before entering the cavity or whether
clamps are to be left in situ.
In the operative treatment of ■penetrating wounds of
the abdominal wall it is best to enlarge the wound of
entrance with the same precautions that are usually
observed in formally opening the abdomen. Having
done so, one should inspect the subjacent viscera, and
then upon ascertaining the extent and character of
the lesions to be treated, should, if necessary, make
additional incisions through the abdominal wall in
one or other of the positions, and in the manner just
described, orthe wound should be still further enlarged.
The treatment of the injuries of different viscera has
been referred to under the description of their lesions.
Here it is proper to indicate (he method of caring
for prolapse of viscera, and for blood and foreign
material which may be present in the peritoneal
cavity.
Almost any of the viscera, whether injured or not,
may prolapse through wounds of the abdominal wall,
and then be injured, or infected, or become strangu-
lated; and the procedure to be adopted depends upon
which of these events has occurred.
In general terms, for purposes of treatment, it is
always to be assumed that prolapsed viscera are
infected; and whether a given viscus is to be returned
or not will be decided by the possibility of rendering
it practically aseptic or not, of repairing injuries pres-
ent in it, or of restoring its circulation.
Prolapsed omentum should in any case be tied off
and removed.
Prolapsed intestine, if strangulated, may be sutured
in situ, or may be opened in such a manner as to
form a fecal fistula which is to be closed subsequently,
or it may be resected at once. If it has become in-
fected it is to be subjected to very thorough mechan-
ical cleansing with 0.5-per-cent. salt solution, and
then returned after any injuries possibly present in it
have been repaired.
Prolapse of the spleen calls for its removal if stran-
gulated or irreparably injured, or for its return if it
can be thoroughly cleaned and repaired.
Prolapsed portions of the liver are to be removed.
Prolapse of the kidney should be managed by
removal if it is necrotic or very greatly injured; by
mechanical cleansing, repair, and replacement of the
organ if it be possible. However, in any case ample
drainage must be provided by gauze leading from the
site of the returned viscus to the surface.
Blood is to be completely removed from the ab-
dominal cavity. This is done by scooping out clots
with the hand and sponge, and by copious douch-
ings with hot salt solution. Provision for subse-
quent drainage need not necessarily be supplied.
The entrance of foreign bodies from without or
from the intestine, or the entrance of intestinal con-
tents into the peritoneal cavity, is a fruitful source
of peritonitis, and measures should be taken to pre-
vent its occurrence. But once they have invaded the
cavity and infected it, no time is to be lost in remov-
ing them and in neutralizing their conseqences.
Intestinal contents are to be removed by scooping
and sponging, and then not only the visibly soiled
areas of peritoneum must be cleansed by the liberal
use of salt solution, but the same procedure must be
carried out with regard to the whole peritoneum,
especially if considerable quantities of foreign ma-
terial have escaped; and, if necessary, evisceration
must be resorted to. Drainage must of course be
provided in every case.
Drainage of areas of the peritoneum is best accom-
plished by the use of gauze — ordinary absorbent
gauze sterilized, or gauze impregnated with iodoform.
Gauze has the advantage over tubes of various kinds
in several respects. Besides the perfect manner in
which it enables all exudate to be carried to the sur-
face, it decidedly promotes the formation of adhesions
about itself, and consequently about the region
drained, which is often infected, and further oozing
is best checked by the pressure exerted by the gauze
packing.
Gauze introduced for drainage purposes is used in
ribbons, one or more of which are so placed as to lead
from the area drained; or larger pieces of gauze may
be packed into the region to be drained and brought
out of the abdominal wound; or the Mikulicz dressing
may be used. This consists of a piece of iodoform
gauze about fifteen inches square, doubled back from
its center like an umbrella, and containing strips of
gauze so arranged that one after another can be
withdrawn without disturbing the enveloping skirt,
which is last to be removed.
The period for withdrawing drains varies somewhat
with the purpose for which they have been intro-
duced; gauze placed to stop oozing should be removed
in from twenty-four to forty-eight hours, while
that used to drain infected or inflamed areas is allowed
to remain in place some days longer.
The treatment of the sequeUe of injuries, as fistula?,
ventral hernia, etc., does not naturally come under
the present title. Pebcival R. Bolton.
References.
1. Edler: Langenbeck's Archiv, vol. xxxiv.
2. Bell: American Practice of Surgery, vol. viii, 1911.
3. Grawitz: Archiv fur klinische Chirurgie, No. 2, 18S7.
■1. Fenwick: Quoted in Traite de Chirurgie, Duplay et Reclus,
vol. vii., p. 686.
.">. Ferguson: American Practice of Surgery, vol. viii, 1911.
6. Bartel: Deutsche Chirurgie. Lieferung 52, p. 67.
7. Coley: Am. Journal of the Medical Sciences, March, IS91.
Abdominal Organs, Regional and Surgical Anatomy
of the. — The abdominal cavity is arbitrarily divided
into nine regions by two horizontal and two vertical
lines. The superior horizontal line extends between
the cartilaginous ends of the tenth ribs, the inferior
between the anterior superior iliac spines. These two
lines divide the cavity into three zones, epigastric,
14
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Abdominal Organs! Regional
Anatomy
nasogastric, and hypogastric, each of which is sub-
divided into three regions by vertical lines passing
upward from the ilio-pcctineal eminences to the higher
horizontal line. The epigastric zone contains, in order,
the right hypochondrium, epigastrium, and left
hypochondrium. The nasogastric zone contains the
right lumbar, umbilical, and left lumbar regions. The
hypogastric zone contains the right iliac, hypogastric,
and left iliac regions. The boundaries of I he several
zones according to the B.N. A. nomenclature differ
somewhat from those. The two may be compared by
reference to Figs. S and 9.
Fig. S. — Regions of the Abdomen in the Old Nomenclature.
The viscera situated in each region are shown in the
following table:
Right Hypochon-
Epigastrium.
Left Hypochun-
drium.
drium.
Liver.
Liver.
Stomach.
Right kidney.
Stomach.
Spleen.
Hepatic flexure.
Gal] bladder.
Left kidney.
Colon.
Duodenum.
Splenic flexure.
Pancreas.
Colon.
Right Lumbar.
Umbilical.
Left "Lumbar.
Right kidney.
Transverse colon.
Small part of left
Ascending colon.
Duodenum and .small
kidney.
Ileum.
intestines.
Descending colon.
< Ireat omentum.
Small intestines.
Right Iliac.
Hypogastric.
Left Iliac.
Cecum.
Small intestines.
Sigmoid colon.
Appendix.
Bladder in children.
Small intestines.
Laal .oil of ileum.
Distended bladder in
adults.
Pregnant uterus.
Sigmoid colon.
Liver (hepar). — The liver occupies the right hypo-
chondriac region and part of the epigastric, and extends
into the left hypochondriac region as far as the mam-
millary line; at times it descends into the right lumbar
region. With the exception of a small part of the
right and left lobes, which come in contact with the
anterior abdominal wall in the subcostal angle, it lies
behind the ribs and costal cartilages.
Surface Outline. — The outlil f the liver may be
indicated on die surface of the body as follows: Supe-
riorly, a line beginning in the mammillary line in the
fifth lefl intercostal space, extending toward the right,
through the lower end of the sternum, gradually rising
to the fourth right interspace just inside the nipple line,
then sloping downward behind the iifth and sixth ribs,
where the superior surface is continuous with the right
surface. Interiorly, beginning on the right side at the
upper border of the third lumbar vertebra, the line
runs directly to the costal arch, which it follows as far
upward as the tip of the ninth costal cartilage. Here
Fig. 9. — Regions of the Adbomen, in the Basle Anatomical
Nomenclature.
it crosses the subcostal angle to the eighth left cartilage,
then gradually rises to terminate at the beginning of
the superior line. The right surface, lying behind the
seventh, eighth, ninth, and tenth ribs, is separated
from them only by the thin edge of the lung, the
diaphragm, and the pleura. It is thus apparent that
I he lower border is most accessible to examination, and
especially that part of it which lies across the subcostal
angle. Here it usually reaches a point midway between
the end of the sternum and the umbilicus. When the
lower border in the remainder of its extent is easily
palpable, the liver is either displaced or enlarged. The
superior extent can be determined only by percussion,
but the line of .absolute dulness does not correspond to
the line above given, for the reason that the anterior,
right, and posterior surfaces are considerably over-
lapped by the lower edge of the lung. This line in the
mid-line falls at the end of the sternum, in the right
nipple line at the sixth rib, in the mid-axillary line at
the eighth rib, and in the scapular line at the tenth rib.
When the border of the liver can be palpated this
method of determining its lower limit will be found more
accurate than that by means of percussion.
Relations. — The liver presents superior, anterior, pos-
terior, inferior, and right surfaces.
The superior surface is accurately moulded to the dia-
phragm, which separates it from the pleura?, lungs, peri-
cardium, and heart.
The anterior surface, also in contact with the dia-
phragm, with the exception of the small region coming
in contact with the abdominal wall in the subcostal
15
Abdominal Organs, Regional
Anatomy
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
angle, lies behind the fifth to the ninth costal cartilages
and adjacent portions of the ribs. In its upper part it
is overlapped by the lower margin of the lung.
The posterior surface, also in contact with the dia-
phragm and overlapped by the lung, covers in turn the
right suprarenal capsule, the vena cava, the thoracic
duct, and the esophagus.
The inferior surface is plainly impressed by the fol-
lowing organs: Beginning at the right, in front, the
hepatic flexure of the colon; behind, the right kidney,
immediately to the left of which is the impression of the
duodenum, and to the left of both the impression of the
gall bladder. The succeeding part of the liver is the
quadrate lobe, lying in front of the lesser omentum.
Finally, the under surface of the left lobe overlaps the
lesser curvature and upper part of the anterior surface
of the stomach.
Regions of the Abdomen, Posterior View. (Joessel.)
The right surface lies internal to the seventh, eighth,
ninth, tenth, and eleventh ribs, being separated from
them by the diaphragm, and being overlapped above by
the lung. Many clinical facts of importance can be
learned by a close study of these relations. In gunshot
and stab wounds of the lower part of the thoracic wall,
lung, pleura, diaphragm, peritoneum, and liver may all
be involved. The end of a fractured rib may penetrate
the liver. Abscesses of the liver may extend through
the diaphragm and open into the pleural cavity, or,
u hen this is obliterated by adhesions, into the lung, and
a bronchus. Behind, an enlargement of tne liver may
retard the circulation in the aorta, the vena cava, or the
thoracic duel. Below, the close relations of the stom-
ach, duodenum, and colon explain the ease with which
adhesions develop between these organs, and disease
spreads from one to the others.
16
During inspiration, the liver descends about the
breadth of one intercostal space. The lower border is
more easily palpable in the erect posture than in the
recumbent, as in the latter it recedes somewhat behind
the costal arch. These changes in position, especially
the first, may serve to distinguish a tumor or swelling of
the liver from one of the stomach, kidney, adrenal gland,
or pancreas. The peritoneal relations of the liver are
extensive and important. For the most part its surface
looks into the general peritoneal cavity, and the reflec-
tions of the peritoneum from the abdominal wall and
diaphragm are the principal agents in supporting, or
rather suspending, the organ. A small part of its
posterior surface is not visible from the greater cavity,
as it looks into the lesser. This corresponds in extent
to the Spigelian lobe. A second area of the posterior
surface, between the layers of the right coronary liga-
ments, is not covered by peritoneum; it lies in contact
with the diaphragm. This locality is the favorite seat
of subphrenic abscesses, and here they most easily
spread to the pleura and lung.
Blood-vessels. — The artery of the liver is the hepatic
branch of the celiac axis. It reaches the organ be-
tween the layers of the lesser omentum, and entering
at the transverse fissure its branches accompany those
of the portal vein.
The portal vein, formed behind the head of the pan-
creas by the union of the superior mesenteric, splenic,
inferior mesenteric, and the veins of the stomach, also
ascends in the lesser omentum to the transverse fissure.
In the substance of the liver its branches are situated
within the portal spaces, i.e. outside the lobules, before
entering the intralobular capillaries. They are dis-
tinguished by their relatively thick walls and collapsed
state on cross section. An infective thrombophlebitis
in a distant part of the abdomen or pelvis may be fol-
lowed by a metastatic abscess or abscesses in the liver,
a phenomenon explained by the anatomy of the portal
circulation.
The hepatic veins are remarkable for their thin walls,
which, closely connected with the surrounding liver
substance, stand widely open on section. Consequently
a rupture or incised wound of the liver bleeds with
great freedom and the bleeding has little tendency to
cease spontaneously. The hepatic veins emerge on the
posterior surface of the liver, entering immediately the
inferior vena cava within half an inch to an inch "from
its termination in the right auricle. They have no
valves; consequently the circulation in them is easily
impeded. In some forms of valvular heart lesions —
e.g. tricuspid insufficiency — the pulsation of the heart
may be transmitted through them to the liver.
The excretory apparatus of the liver consists of the
hepatic duct (ductus hepaticus), the cystic duct (ductus
eysticus), and gall bladder (vesica fellea), and the
common duct (ductus choledochus). The gall bladder,
three or four inches in length and with a capacity of
from one to two ounces, is held in position on the under
surface of the liver by the peritoneum. As a rule, it is
closely applied to the liver substance, lying in a dis-
tinct fossa; but it may hang free, completely invested
by peritoneum and suspended by a mesentery. Its
fundus projects beyond the lower border of the liver
opposite the ninth costal cartilage. It is directed
downward, forward, and to the right, while the neck is
in the opposite direction. Immediately below it are
the transverse colon, duodenum, and sometimes the
pylorus of the stomach. The relation to the colon is
most constant and important. An artificial opening is
sometimes formed between the two organs, and through
it gall stones may be passed.
The ducts are all situated between the layers of the
lesser omentum, and can be easily exposed by removal
of its anterior layer. The portal vein, hepatic artery
and hepatic nerves are found in the same space, but the
ducts are anterior to them, and occupy the right free
edge of the omentum. In making a dissection, or in an
operation, the foramen of Winslow should first be
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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Abdominal Organs, Regional
Anatomy
located, and, with the fingers of the left hand in it for a
guide, an exposure can be easily accomplished. The
cystic duct, arising at the neck of the gall bladder, is an
inch and a half in length. It is directed downward,
backward, and to the left, to join the hepatic duct at an
acute angle. The hepatic duct, about two inches in
length, is directed downward, backward, and to the
right. It arises at the liver by two main branches.
The common bile duct, formed by the union of these
two, continues the direction of the hepatic along the
right free edge of the lesser omentum on the anterior
surface of the portal vein, and to the right of the hepatic
artery. Approaching the duodenum, the vein tends
to the left, the duct to the right. This relation of the
vein to the duct is remarkably constant, but the hepatic
artery and its branches are subject to frequent varia-
tions which should be guarded against. As the com-
mon duct reaches the duodenum, it passes behind its
first portion, then downward, between the second por-
tion and the head of the pancreas; or it is embedded in
the latter, from which point onward it accompanies the
pancreatic duct into the lower part of the second por-
tion of the duodenum. The duodenal orifice is mark-
edly constricted, but just proximal to it the duct is
dilated, forming a well-marked diverticulum. Conse-
quently a calculus may successfully pass the entire duct,
to be arrested at the terminal orifice. To cause a
jaundice, calculi must be situated in either the hepatic
or the common duct, for any number may occupy the
gall-bladder or the cystic duct, yet give rise to few or no
symptoms as long as they remain there and the gall
bladder is not infected. Not all cases of obstructive
jaundice are due to gallstones. Enlarged lymphatic
glands in the lesser omentum, tumors of adjacent
organs, especially of the head of the pancreas, hydatids,
ascaris, adhesions producing flexures of the ducts, and
many other causes have been noted.
Stomach (ventrieulus). — This varies in position and
relations according to the degree of distention. When
empty, it lies in the left hypochondrium and left half of
the epigastrium, the cardiac orifice being four to five
inches posterior to the interval between the seventh left
costal cartilage and the ensiform process, on a level
with the eleventh or twelfth dorsal vertebra. This is
the most fixed portion of the stomach, and participates
only slightly in any changes of position. The pylorus
is in or near the mid-line, at the level of the last dorsal
or first lumbar vertebra. It looks toward the right,
and is the most movable portion of the stomach. Thus
a tumor of the pylorus may be found in the central or
lower part of the abdomen. The anterior and posterior
surfaces are separated by sharp borders, and the entire
viscus recedes from the anterior abdominal wall behind
the liver.
When distended, the fundus fills the left cupola of
the diaphragm, impinging upon the liver and heart.
The great curvature comes in contact with the anterior
abdominal wall in the subcostal angle, and may enter
the left lumbar and umbilical regions. Immediately
below it is the transverse colon. The pylorus moves to
the right as much as two or three inches, and rotates so
that it is directed backward, being concealed from in
front by the dilated lesser cul-de-sac.
Relations. — The anterior surface is divisible into two
regions; the upper and right region, which includes the
pylorus and cardia, and is overlapped by the right and
left lobes of the liver; and the lower and left region, which
may be subdivided into two, viz., the small triangular
portion in contact with the anterior abdominal wall,
and above this the portion lying behind the costal arch
and diaphragm. The fundus is also overlapped by the
lung and pleura in the fifth and sixth intercostal spaces.
Here, again, a wound may involve both thoracic and
abdominal viscera. Posteriorly, the stomach is in
relation with the diaphragm, spleen, left kidney and
capsule, pancreas, and the splenic flexure of the colon,
all of which taken together form for it a concave bed.
The peritoneal relations of the stomach are compli-
cated. Its anterior surface faces the greater peritoneal
cavity, but the posterior surface is concealed behind
the great oment uin, which hangs from its greater curva-
ture. Furthermore, joined to the posterior surface of
the omentum are the transverse colon and the meso-
colon. When the omentum is raised these structures
are carried with it. Only by passing the finger through
the foramen of Winslow can the posterior surface of the
stomach be reached. In a dissection, however, one of
two routes may be chosen. The first lies between the
greater curvature and the transverse colon; the second
passes through the transverse mesocolon. A periton-
itis arising from perforation of the posterior wall of
the stomach, whether due to trauma or to disease, will
at first involve the lesser cavity only and may be limited
entirely to it. In operating for wounds of the stomach,
the posterior surface should always be examined in the
manner indicated. The lesser omentum is attached to
the entire lesser curvature, while the gastrosplenic and
gn ■: 1 1 er omenta are continued from the greater curvature.
The arteries of the stomach are derived from the three
branches of the celiac axis, and reach the organ between
the layers of the omenta. On the lesser curvature an
inch is formed by the gastric and pyloric branches of the
hepatic; on the greater, a similar arch is formed by the
gastroepiploica dextra and sinistra. From these arches
transversely directed branches arise which anastomose
near the center of the surfaces. Incisions in the stom-
ach wall are best made in the direction of the transverse
branches, with the exception of the central region where
the sets anastomose.
Small Intestine (intestinum tenue). — With the ex-
ception of the duodenum, the small intestines are sur-
rounded throughout by peritoneum, and are suspended
from the posterior abdominal wall by a mesentery.
The line of attachment of the mesentery extends from
the left side of the second lumbar vertebra obliquely
across the vertebral column, aorta, vena cava, and third
portion of the duodenum to the right sacroiliac articula-
tion. Although this line is only six or eight inches in
length, and the average width of the mesentery is eight
or ten inches, it reaches at its convex intestinal edge a
length of some twenty feet. The middle or lower
intestinal loops have the widest mesentery and are
therefore most likely to enter a hernia. Between the
layers of the mesentery are the blood-vessels, lymph-
atics, and nerves of the intestine.
The duodenum is for the most part situated behind
the peritoneum, a position which it acquired when the
large intestine of the embryo crossed the small. Up to
this time it possessed a mesentery, which then fused
with the posterior body wall. The first portion of the
duodenum is movable except at its distal end. With
an empty stomach it is directed transversely; with a
distended stomach, anteroposteriorly. Above, it is in
relation with the liver and gall bladder; below, with the
pancreas; behind, with the portal vein and common bile
duct. Beneath the neck of the gall bladder, at a point
opposite the first lumbar vertebra, it turns downward
as far as the fourth vertebra, in front of the right kidney
and vena cava, being crossed anteriorly by the meso-
colon, above and below which it is covered by visceral
peritoneum. Internally is the head of the pancreas,
whose duct opens with the bile duct into the lower
portion of the duodenum. This constitutes the second
portion, at the end of which the duodenum turns to
the left across the spinal column and great vessels to
ascend a short distance and end in the jejunum
opposite the first or second lumbar vertebra. Note its
relations to surrounding organs in connection with the
spread of disease. It may be involved and the peri-
toneal cavity may escape. Wounds are serious because
of its inaccessibility and its fixed position. With the
exception of the first part, it cannot be raised into a
laparotomy wound. Its arteries, forming an arch
within the concavity, may be opened in a duodenal
ulcer and may allow a fatal hemorrhage.
The jejunum and ileum include the remainder of the
Vol. 1—2
17
Abdominal Organs, Regional
Anatomy
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
small intestine, called intestinum tenue mesenterfale —
two-fifths jejunum, three-fifths ileum. Although there
is no distinct line separating them, each has distinctive
characteristics. The walls of the jejunum are thicker
and more vascular, the valvulae conniventes are
numerous and perfectly developed, and the caliber is
greater. Peyer's patches are larger and more numer-
ous in the ileum. The coils of the small intestines
have no fixed position, but one may expect to find
jejunum in the umbilical, left lumbar, and left iliac
regions, while the ileum tends more to the right side,
toward the hypogastric region and toward the pelvis.
Because of their wide extent and exposed position
the small intestines are frequently injured. The
degree of injury may vary from slight contusion to
complete rupture, and is greater the nearer it ap-
proaches the stomach and the more distended the coils
happen to b». The extent to which the abdominal
wall is injured does not indicate the severity of the
visceral injury, for the most extensive laceration may
follow a blow which scarcely leaves a mark upon the
skin. The great dangers are hemorrhage and fecal
extravasation, especially the latter. It occurs more
rapidly from distended coils, and they are the ones
most frequently injured. A longitudinal wound gapes
more widely than a transverse, the edges being sepa-
rated by the strong circular muscular fibers. A small
penetrating wound may be plugged by everted mucous
membrane. A wound in the mesenteric border is most
difficult to repair. A gunshot wound in the lower left
quarter of the abdomen will certainly inflict multiple
intestinal injuries. As a rule, however, they will be
found in a comparatively short loop of intestine, with
a few scattered in distant coils.
Large Intestine (intestinum crassum). — Of this
there are the following divisions: cecum, ascending,
transverse, and descending colon, sigmoid flexure,
and rectum.
It is distinguished from the small intestine by its
larger size, by its more fixed position, and by the appen-
dices epiploic®. Furthermore, the longitudinal muscu-
lar fibers which are spread in an even layer over the
small intestine are gathered into three well-marked
bundles on the surface of the colon. These are about
one-half the length of the remaining colon layers, and so
throw it into sacculations separated by transverse
constrictions, which project into the lumen of the bowel
as plicae or valvulae sigmoidse. The length of the large
intestine is five or six feet; its capacity is about one
gallon.
The cecum — that part of the large intestine below
the ileocolic opening — is situated in the right iliac
fossa, upon the iliopsoas muscle. Anteriorly, it is
in contact with the anterior abdominal wall above the
outer half of Poupart's ligament, except when the
omentum is interposed. Its exact position depends
upon its peritoneal relations. As a rule, it is completely
invested by peritoneum, though it has no mesocecum.
In a small percentage of cases the upper part of the pos-
terior surface is not covered by peritoneum, and so
comes in contact with the areolar tissue of the posterior
abdominal wall. It may be long and movable, its free
extremity hanging into the pelvis or projecting across
the mid-line to the opposite side of the body. Or it may
be situated at any point between the iliac fossa and a
position immediately beneath the liver, this bcint; its
location in the embryo of three months. The latter
variation occurs in consequence of an arrest of its nor-
mal descent into the false pelvis. When the posterior
wall of the cecum is not entirely covered by peritoneum,
an infection readily travels from it to the areolar tissue
about the right kidney.
The appendix vermiform is (processus vermiformis)
originally arose from the apex of the cecum, but, as the
right half of the hitler exceeds the left in development,
tin- iiluli appendix arises from its inner and posterior
surface a little below the ileocolic opening. Its average
length is between three and four inches, but it may vary
18
from one to nine. Its cavity, lined by mucous membrane
continuous with that of the cecum, tends to undergo
obliteration with advancing age. The lumen is narrow-
est at the orifice, which is guarded by a valve of mucous
membrane. It is enveloped by peritoneum throughout,
and is provided with a triangular mesentery derived
from that of the small intestines. The mesentery is
rarely complete, allowing the end to hang free. Within
the mesentery is a branch of the ileocolic artery, fur-
nishing its blood supply. The exact position of the
appendix is variable, but it will always be found by
following one of the longitudinal bands of muscular
fibers seen on the surface of the colon. Two main posi-
tions are observed. In one, the appendix is truly an
intraperitoneal organ hanging free from the cecum. It
may be directed inward and upward, or downward; it
may be curled on the brim of the pelvis or may hang
into the pelvic cavity; or it may occupy one of the
fossae about the cecum. In the second position the
appendix is practically an extraperitoneal organ, lying
between the posterior surface of the cecum and the
colon. The base of the appendix, as indicated by
McBurney's point, lies two inches from the spine of the
ilium on a line drawn from the spine to the umbilicus.
Colon. — The ascending colon (colon ascendens)
reaches from the cecum to the under surface of the
liver, passing through the right lumbar region into the
hypochondrium. Here it turns to the left forming the
hepatic flexure (flexura coli dextra) and becomes the
transverse colon (colon transversum). As a rule, it has
no mesentery, being held in position by the peritoneum
which covers its anterior surface and sides. Behind, it is
separated by loose areolar tissue from the quadratus
lumborum and transversalis muscles and the lower and
inner part of the right kidney. In front it is in contact
with the anterior abdominal wall, omentum, and a few
coils of the small intestines. The relation to the ante-
rior surface of the kidney is most important. An ab-
scess of the kidney or a perinephritic abscess may open
into it without involving the peritoneum. A kidney
enlarged from infection or a tumor carries the colon
forward on its anterior surface. This may be deter-
mined by inflation of the colon.
The transverse colon suspended by a mesocolon is
deeply placed at its ends, but comes in close contact
with the anterior abdominal wall in the remainder of
its course. As a rule, it lies along the subcostal line,
but may descend as far as the pelvis. Above, it is
first close to the fundus of the gall bladder; adhesions
between the two are common, and calculi may ulcerate
into it from this viscus. The greater curvature of
the stomach and the lower end of the spleen lie above
in the remainder of its course.
The descending colon (colon descendens) begins at
the splenic flexure (flexura coli sinistra), at which point
it is situated deeply in the left hypochondrium. From
here it descends through the left lumbar region along
the outer border of the kidney. Its peritoneal relations
resemble those of the ascending colon. A relation
worthy of not ice is that to the kidney. The left kidney
lies more internal to the descending colon than the
right does to the ascending colon. Anteriorly, the
descending colon is more constantly covered by omen-
tum and small intestine than is the ascending.
Fecal matter may accumulate in the colon in any
part to such an extent as to simulate a true tumor;
consequently colonic flushing is always a wise procedure
in the examination of an intraabdominal growth.
The sigmoid flexure (colon sigmoideum), continuing
the descending colon, extends from the iliac crest to the
third sacral vertebra, at which point it becomes the rec-
tum (intestinum rectum). It is provided with a mes-
entery attached transversely in front of the psoas muscle.
Its length and position are variable. It may form a per-
fect loop occupying the pelvis, or, when the bladder and
rectum are distended, lying near the umbilicus. At times
it tests in the left iliac fossa. It is this loop which sur-
geons open in a left inguinal colostomy. In the descend-
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Abdominal Orcans, Regional
Anatomy
ing colon, the opening may be through the posterior ab-
dominal wall without exposing the peritoneal cavity,
but as the position of the artificial anus is an awkward
one for the patient the operation has been abandoned.
The remaining portion of the large intestine is the
rectum, situated within the true pelvis, with which
it is usually described.
The spleen (lien) is situated obliquely behind the
stomach in the epigastric and left hypochondriac regions.
It lies beneath the eighth, ninth, tenth, and eleventh
ribs; its long axis, measuring five or six inches, corre-
sponds in direction with the tenth rib. It is separated
fn mi these ribs above by the lower border of the lung
and pleura, and throughout by the peritoneum and
diaphragm. A normal spleen cannot be palpated.
The enlarged spleen appears beneath the costal arch at
the level of the tenth and eleventh ribs. It may be
distinguished by the notches, one or two, in it< anterior
border and by its respiratory movement. Unlike the
movement of the liver, which is vertical, the movement
of the spleen is oblique, that is, toward the umbilicus.
The dulness of the spleen as outlined by percussion is
an oval area extending from the ninth to the eleventh
rib in the posterior axillary line. Four surfaces are
described on the organ, each indicating a relation to a
neighboring viscus. The phrenic surface is in contact
with the diaphragm. The renal surface, directed
downward and inward, is in contact with the left
kidney. The gastric surface faces forward and in-
ward and is iii contact with the posterior surface of
the stomach; on this surface is the hilum. Finally,
the lower blunt end is the basal surface upon the splenic
flexure of the colon and the tail of the pancreas.
The peritoneal relations of the spleen are extensive.
With the exception of the small region corresponding to
the hilum it is covered by the visceral peritoneum of
the greater sac. The blood-vessels and nerves reach
the organ between the layers of the gastrosplenic
omentum.
Wounds of the spleen are accompanied by severe
hemorrhage. When it is extreme it may become
necessary to remove the organ for this reason.
The pancreas, situated behind the stomach, in front
of the first and second lumbar vertebrae, reaches from
the concavity of the duodenum on the right to the
spleen on the left. On the surface of the abdomen its
position is from two and one-half to five inches above
the umbilicus. To expose the pancreas the lesser
peritoneal cavity must be opened. It is then seen
lying behind the posterior layer of this cavity. It can
be palpated only when pathologically enlarged, as by a
carcinoma or cyst. The organ -does not move with
respiration.
The anterior surface of the pancreas is in contact
with the posterior surface of the stomach, while the
posterior surface lies in front of the aorta, the superior
mesenteric artery, the splenic vein, and the left kidney
with its vessels. The head is encircled by the duo-
denum. The pancreatic duct crosses the gland from
left to right, and is buried in its substance close to the
posterior surface. Its course is straight until it reaches
the head, at which point it turns obliquely downward
to enter the second portion of the duodenum, close to
or in common with the bile duct. Retention cysts of
the duct or of some of its smaller branches occur, and
may attain a large size. In general appearance such
a cyst resembles a solid or a. cystic tumor of the kidney,
the differential diagnosis being at times impossible.
Kidneys (renes) . — For the greater part the kidneys
are situated deeply in the hypochondriac regions, their
lower ends, however, extending into the adjacent
lumbar and umbilical regions. In consequence of the
position of the liver on the right side, the right kidney
is somewhat lower than the left. As regards the
vertebral column, the kidneys are opposite the twelfth
dorsal, the first and second, and sometimes the third
lumbar vertebra?. The upper end of the right kidney
reaches a line drawn transversely outward from the
tip of the spine of the eleventh dorsal vertebra. Its
lower border reaches a similar line drawn from the
lower edge of the spine of the second lumbar vertebra.
This line is usually about an inch and a half above the
iliac crest. Its upper end is nearer the spinal column
than the lower. The pelvis of the organ is opposite
the transverse process of the second lumbar vertebra.
A'i laiimix. -The posterior surfaces are similar, but the
anterior surfaces differ on the two sides. Posteriorly,
the kidneys are not covered by peritoneum, being con-
nected by areolar tissue with the diaphragm, the
anterior layer of the lumbar aponeurosis covering the
quadratus lumborum, and, more internally, the psoas
magnus muscles. Above, the relation to the dia-
phragm is important, as this structure separates the
kidney from the twelfth rib, and sometimes, on the
hit side, from the eleventh. An inspection of Plate 1
will show that the pleura descends over the inner ends
of these ribs, and so lies between the upper ends of the
kidneys and the surface of the body. Notice especially
that the pleura does not descend below the angle formed
by the lower border of the twelfth rib and the outer
edge of the quadratus lumborum muscle. However,
the development of the twelfth rib is not constant, it
being incompletely developed or entirely absent in
many cases. The individual cases can be recognized
only by counting the ribs. On the other hand, the
lower limit of the pleura and its relation to the kidney
are constant, and in a case of anomalous twelfth rib the
pleura will lie unprotected by rib in this locality. The
importance of this condition will be appreciated later.
Anteriorly, the right kidney has the following rela-
tions: At the extreme upper end is a small non-peri-
toneal surface in contact with the suprarenal capsule,
below and external to which is a large peritoneal surface
in contact with the liver. The area about the hilum
is non-peritoneal and is in contact with the descending
portion of the duodenum. Below this region and
internal to the liver area are two regions: an outer non- •
peritoneal covered by the colon, and an inner peritoneal
covered by coils of small intestine.
The anterior surface of the left kidney is crossed just
above its center by the pancreas, no peritoneum inter-
vening. Above the pancreatic surface three organs are
in relation with the kidney: the suprarenal capsule, the
stomach, and the spleen — the first being the only organ
not separated by peritoneum. Below the pancreas the
surface is largely covered by peritoneum and small in-
testine, the exception being the outer border, which
lies behind the colon. From the description of the
situation and relations of the kidney a number of
practical points are evident. As a general rule, it is
safe to say that a palpable kidney is enlarged or dis-
placed. Only in very favorable subjects, especially
thin women, in whom the organ is frequently lower
than normal, can we certainly feel the normal kidney,
and then only the lower third, as the upper two-thirds
lie behind the lower ribs. Bimanual palpation should
be used, the hand placed in the loin being depended
upon to lift the kidney against its fellow which presses
upon the abdomen. In this connection note the posi-
tion of the colon; it is nearly over the center of the right
kidney, but to the left of or outside the left kidney.
The kidney has no respiratory movement. It is
recognized by its characteristic shape, and by the
large artery which enters the hilum. The kidney may
be reached through the loin or by way of the perit-
oneal cavity. In the former method various incisions
are employed. The most important landmarks are the
outer edge of the quadratus lumborum muscle and
the twelfth rib. In all incisions it should be remem-
bered that the pleural cavity is near, and it should be
avoided. As indicated above, when the twelfth rib is
of normal development, an incision may be carried
closely into the angle between this muscle and the
ribs. When the rib is short or absent, which is to be
determined only by careful examination, then the
location of the normal rib should be borne in mind,
19
Abdominal Organs, Regional
Anatomy
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
and the incision should be carried no farther than
the normal angle. The attachment of the quadratus
to the eleventh rib in these cases should not mislead
one.
The ureters occupy a position in the hilum pos-
terior to the artery and vein. Their average length
is seventeen inches. Beginning as a well-marked
dilatation, called the pelvis of the kidney, the ureter
passes downward on the psoas magnus as far as the
brim of the true pelvis, which it enters by crossing
either the common or the external iliac artery. It is
accompanied by the spermatic vessels in the male, and
by the ovarian in the female. This portion of the ureter
may be reached through the postperitoneal space.
In searching for it the operator must raise the parietal
layer of the peritoneum, to which structure it will be
found adherent.
The peritoneum is a closed serous sac with the excep-
tion of the tubal openings in the female. It appears as
though placed within the abdominal cavity in front of
the viscera, the anterior or parietal layer of the sac
lining the posterior surface of the anterolateral wall,
while the posterior or visceral layer is tucked about the
viscera, enclosing them more or less completely, and
attaching them to the abdominal walls. The exact
relations of the membrane to the individual viscera
have been noted in the descriptions of the latter , and
are of importance in the spread of disease from viscera to
peritoneum. Many injuries and diseases of the abdom-
inal viscera are dangerous only as they involve the
peritoneum. It is a well-known fact that an infection
approaching the membrane from its outer surface is of
_ . , , D ■. Outline of Diaphragm
Parietal Peritoneum , 6
Gastro-hepatic Omentum
Transverse Meso-colon
Great Omentum
Parietal Peritoneu
Vesicula Seminalis
Fin. 11. — Diagram of the Peritoneum in the Adult Male
(vertical .section). S, stomach; P, pancreas; D, duodenum:
H, urinary bladder; A', rectum; Tt\ transverse colon; .S7, small
intestine; the arrow is through the foramen of Winslow.
(Buchanan.)
much less danger lhan one approaching from the inner.
The former is soon localized and results in the formation
tit an abscess; absorption of toxins is slight. When the
inner surface is infected, the tendency of the disease is
to spread rapidly, and the absorption of septic toxins
is intense. These phenomena are explained by the
microscopical structure of the peritoneum. It consists
e entially of two layers. The outer layer is composed
of fibrous ami elastic tissue. It supports the inner
layer, which is composed of flat endothelial cells.
Between the margins of the cells are numerous openings
of lymphatic vessels, stomata, which are the active
absorbents of the peritoneum. Some regions, as those
of the diaphragm and small intestines, are especially
rich in lymphatic vessels, while in others, as the
omentum, the number is small. For this reason a
peritonitis is more dangerous in certain localities than
in others.
When the anterolateral abdominal wall is opened,
the peritoneal cavity is also opened. In the living
body, however, no cavity exists, parietal and visceral
layers being held in contact by muscular action and
Visceral Pentone
■hepaiic Omentum
Hepatic Aitery
Vena Porta:
^\<
SV\ Common Bile-duct
Fir,. 12.-
-Diagram of the Peritoneum at the head of the Foramen
of Winslow (transverse section;. tBuchauan )
atmospheric pressure. The great omentum is seen
hanging from the greater curvature of the stomach,
covering more or less completely the viscera in the
lower half of the cavity. Normally it should do so
quite completely, but it may be found collected in a
roll about some organ or loop of intestine. This is
especially the case when there has been a former
peritonitis. The omentum serves to protect the in-
testines, and also as a storehouse for fat, but its most
important function is that of limiting an infection. It
readily contracts adhesions about organs, such as an
inflamed appendix or a perforated intestinal coil, and
so prevents infection of the general peritoneal cavity.
In extensive pelvic suppuration, the omentum may
completely exclude the pelvic from the general abdom-
inal cavity. Behind the omentum are the small
intestines, and, on either side of the posterior wall, the
ascending and descending colon.
The mesentery of the transverse colon is raised with
the great omentum. As it is attached transversely
across the posterior abdominal wall, it divides the
cavity into two compartments. The upper contains
the liver, stomach, and spleen. It also includes the
lesser peritoneal cavity. The lower compartment con-
tains the small intestines and the colon. It is sub-
divided by the mesentery into an upper right and a
lower left portion. The upper portion ends below in
the right iliac fossa. Consequently a fluid effused in
this region or on the upper surface of the mesentery
will gravitate into the right iliac region. The left and
lower portion passes to the pelvis, into which cavity
fluid will descend when it originates below and to the
left of the mesentery.
The relations of the lesser peritoneal cavity are de-
scribed with those of the stomach.
Thomas A. Olney.
Abdominal Section. — The large number of abdom-
inal operations permit of a selection of the incision
best suited for the purpose. A good incision must
possess the following requisites.
1. It must give the best possible access to the
region to be operated on.
2. It must injure least other organs.
3. It must promise the strongest possible scar for
the prevention of hernia.
3)
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
\inii.iiiiii.ii Section
4. In woman, at least, the cosmetic effect of the
scar is to be considered to a certain extent.
There are other desiderata to be fulfilled. For
instance, in certain operations, like appendicitis,
gall-bladder operations, and so on, one may wish to
make a smaller incision which will suffice only if the
case does not prove too difficult. If difficulties arise,
and a larger incision is needed, the selected incision
must permit of this enlargement to obtain free access
without sacrificing any of the tissues so far saved.
The incision must also permit of subsequent drainage,
if necessary, in any of its parts, without too much
probability of the formation of a hernia.
There are certain abdominal affections in which
there is no choice as regards the situation, at least, of
the incision, as, for instance, in the case of solid immov-
able tumors, abscesses, hernias, fistulas, and so on.
Then only the direction of the incision will have to be
considered.
For all other operations there was a time when
laparotomy as such meant the median incision, be-
cause that gives access to practically every region of the
abdomen, inflicts practically no injury on the tissues,
and is attended with the least possible hemorrhage.
The conditio sine qua non for a sound scar, to
prevent hernia, is primary union; but it has been
found that even where such was the case, quite a
large percentage (some statistics claim as many as
ten per cent.) of hernias resulted from a median inci-
sion. This is especially true in cases of older women,
who have borne children, with a resulting diastasis
of the rectus muscles. The reason for this is appar-
ent. The median incision severs practically only one
layer of tissue, that is, the aponeurosis, which is
poorly nourished by vessels, like all tendinous tissues
of the body. And thus its very simplicity is its
disadvantage; namely, that the whole abdominal
wall at this part of the body consists of only one layer.
In any other part of the abdomen the operator has to
go through several layers which, as modern surgery
has taught us, are to be united by separate sutures in
layers.
For this reason, chiefly in all abdominal gyneco-
logical operations, the median incision has been aban-
doned entirely by a great many of the best operators.
Special incisions have been advised for a number of
typical operations, as diseases of the appendix, gall
bladder, stomach, spleen, and so on. So that the
median incision, either above or below the navel, is
employed practically only in so-called exploratory
operations, where either the nature of the disease
cannot be diagnosed with sufficient certainty before
the operation, or where its exact location cannot be
ascertained, as in ileus, volvulus, and like conditions.
The preparation of the patient for abdominal sec-
tion has become extremely simple. I will omit, of
course, all special preparations which may be neces-
sitated by the nature of the disease for which the
patient is to be operated on, and will mention only
those preparations that are essential for abdominal
section as such.
The preparation of the operative field is now done
almost entirely by simply painting the skin of the
abdomen (after the same has been shaved) with a
ten per cent, tincture of iodine. Care should be
taken that the skin is absolutely dry when the tinc-
ture is applied. This is achieved by rubbing the
skin either with ether or with iodine benzine. A
great many operators apply this one and only coat of
iodine immediately before the operation, when the
patient is on the operating table, without any other
preparation at all, while others first have the patient
bathe, after which the skin is well dried, and then the
evening before the operation a good coat of iodine is
applied; this is repeated the next day on the operat-
ing table. It has been found, however, that the one
single application of iodine is sufficient. Care has to
be taken not to bring the peritoneal covering of
internal organs, especially intestines, into contact
with the iodinized skin as this is liable lo produce
adhesions. If intestines or other organs have to be
brought out of the abdominal cavity and laid for a
while on the abdominal wall, the skin should be
covered u it h ei! her rubber I issue or gauze pads which
are attached with Mikulicz, or Michel clamps to I lie
peril oneal edge.
The simple preparation of the skin of the field of
operation being i lpleted, I lie patient is either left
in the horizontal position on tin- table or put into
Trendelenburg's <>r any other position, according to
the nature of t he operation. A Her I he en I ire patient,
with the except ion of the immediate field of opera! ion.
has been covered in the usual v. ay by sterile sheets and
towels, thi' actual incision is made by the operator.
I ii-t the skin and the underlying tissue are severed
down to the aponeurosis in one or several strokes
according to the thickness of fat. The further details
of the incision vary in accordance with the type of
incision selected, and will be described presently.
The last step, incision of the peritoneum, is again
alike in all types of incisions; it should be made by
catching the peritoneum and lifting it up by two
surgical forceps or clamps, between which the incision
is made. Thus any injury of the underlying intes-
tines is avoided. The free edges are at once caught
by Mikulicz clamps, which are applied on each side
as the incision in the peritoneum is enlarged with
scissors over the introduced finger as a guide, or over
one of the peritoneal spoons. After this retractors
are introduced and the exposed viscera covered by an
abdominal pad of large flat layers of gauze, hemmed
together. To avoid losing any of these pads in
the abdominal cavity, many surgeons have a tape
(about twelve inches long), sewed into one of the
corners of the pad ; the free end of the tape is grasped
by a clamp which remains outside the wound.
I shall now describe the different methods of inci-
sions for different operations.
Probatory or Exploratory Laparotomy. — Incisions
4 and 6 of Plate II, Fig. 1 show the median incision,
either epigastric or hypogastric. Either can be
lengthened, if necessary. In the latter case the navel
is to be passed around on the left side, or even
excised, as some operators prefer.
Appendicitis Operation. — Two incisions are chiefly
known and practised in this country — the McBurney
and what is commonly known as the Kammerer
incision. The former is seen in Plate II., Fig. 2,
incision 5, the latter in Fig. 1, incision 5. The Mc-
Burney incision is doubtless, physiologically, abso-
lutely proper. It is, technically, not very easy, and
gives exceedingly little room after it has been com-
pleted. While it suffices in simple interval eases, it
is absolutely impracticable even when only adhesions
are found, and especially if other difficulties arise,
like the retrocecal situation of the appendix, very
dense adhesions, or unsuspected encapsulated old
abscesses. To gain enough room, then, one has either
to destroy the carefully prepared gridiron by incisions
across the fibers of the muscles, or one has to follow
the advice of Sprengel, and cut across the anterior
sheath of the rectus, retract the rectus muscle with
the epigastric vessels toward the median line, and
then incise the peritoneum, plus transverse fascia.
There is no trouble in uniting such an incision, and
drainage in any of the corners of the wound can easily
be carried out if necessary.
In the other incision, known as Kammerer's, the
anterior sheath of the rectus is divided, and the muscle
itself, together with the vessels, drawn toward the
median line. Before incising the posterior sheath
with the attached peritoneum, the nerve branch which
appears in the wound, is also drawn aside in the
median direction by a blunt hook. In order to do
this, one usually has to liberate the nerve by scratch-
ing along its edge with a sharp-pointed knife. This
21
Abdominal Section
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
incision gives good access. If difficulties arise, the
incision can easily be lengthened to any desired
degree. Its closure — of course in layers — is easy;
it permits drainage in either angle of the wound.
In the very latest literature a great deal of objection
has been raised against this incision on account of its
not being physiological, and also by reason of the fact
that it necessitates severing the nerves supplying the
different parts of the rectus muscle. In those cases
where the nerve or nerves, according to the length of
the incision, had been severed, paralysis of that part
of the rectus muscle has been observed, with a hernia
as a result. But this can happen only when, on ac-
count of unusual difficulties arising during the opera-
tion, the incision has to be lengthened unduly. Other.
\\ ise, the results of this incision are very good indeed-
Fig. 13. — Lines of Abdominal Incisions. 1, Sprengel's gas-
trotomy incision; the same, when on the right side, is
Bakes's gall-bladder incision. 2, Sprengel's incision for major
operations on the stomach, also for operations on the transverse
colon. 3, For operations on the spleen. 4, Bakes's incision for
liver operations. 5, Bakes's new plastic kidney incision. 6, Rep-
resents Mackenrodt's incision of the sigmoid flexure and trans-
peritoneal operations on the rectum. 7, Resection of the cecum.
8, Pfannenstiel's incison for gynecological abdominal operations.
(Figure after Bakes.)
Operations on Gall Bladder and Duels. — For these
operations we need very free access to the seat of
the disease, especially in fat patients, in whom the
wound becomes exceedingly deep. At the same time,
the structure of the abdominal wall should, according
to modern ideas, be preserved as much as possible.
To achieve this a number of incisions have beeD
advised. The simplest is Kocher's, shown in Plate II.,
Fig. 2 as incision 1, and he claims that in his large ex-
perience he has always had verj' good results from this
incision. Incision 1 in Fig. 1 shows Robson's modifi-
cation of Arthur Deane Bevan's. It is very good.
Incision 2, Fig. 1, shows Kehr's bayonet incision, as
he used to make it — an excellent incision.
Following the clamor for more physiological inci-
sions, Kehr has now devised an incision, which is
shown as No. 2 in Fig. 2. He claims all the advantages
for this incision, with the least possible injury in an
anatomical sense.
22
In a rather heated controversy, whose fervor it is
not very easy for outsiders to understand, Sprengel,
of Braunschweig, recommends his incision, No. 8,
Fig. 2. • Both are about equally good. Bakes recom-
mends for simple gall-bladder cases, an incision on
the right side, similar to the one on the left side,
shown as No. 1 in Fig. 13. For more difficult operations
on the liver, he recommends incision 4, Fig. 13. The
principal difficulty offered by any incisions carried
across the rectus muscle consists in uniting the re-
tracted fibers of the muscle by suture. If the fascia
and peritoneum are sewed in a layer, and then the two
angles of the wound elevated by single hooks or
inserted threads, the suture of the retracted fibers of
the muscle is somewhat protracted, but not too diffi-
cult, and is in all cases absolutely secure. Especially
is there less difficulty in fighting the protruding
intestines, as so frequently happens in lengthy in-
cisions.
Operations on the Stomach. — Formerly, the median
epigastric incision was nearly universal; then a para-
rectal incision was adopted, shown as No. 3 in Plate II.,
Fig. 2. Very lately Bakes and Sprengel recommend
incisions as shown in Fig. 13, Nos. 1 and 2; No. 1 for
simple gastrostomies and No. 2 for the more difficult
operations on the stomach. A very agreeable feature
of the cross incision is that the patients complain of
less suffering from retching, vomiting, and coughing
after operations.
Operations on the Pancreas. — Since the diagnosis of
diseases of the pancreas, acute or chronic, has become
more certain or, at least, more probable, median
incisions as formerly used, or as employed for ex-
ploratory incisions, will be gradually abandoned and
cross-sections will be preferred. An incision like
No. 2 in Fig. 13, will be extremely well adapted to such
a purpose.
Laparotomy for Operations on the Female Organs. —
Pfannenstiel's incision, No. 8 in Fig. 13, has become
the incision par excellence for gynecological abdominal
operations. It not only is important for its cosmetic
effect, but it prevents, with practically absolute
certainty, the formation of postoperative hernia.
The incision through the skin is made as indicated in
the drawing, and the fascia is also incised crosswise.
In the middle line the fascia has to be dissected with
scissors, while the rest of the fascia can be split and
drawn aside without cutting. After that the recti
muscles are divided in the middle line and the perito-
neum is then opened. No nerves whatsoever are
severed by this incision, therefore atrophy of the
recti muscles is impossible.
It has been claimed that the Pfannenstiel incision
does not give enough room for difficult operations on
the uterus and its adnexa; therefore a number of
authors have used instead of a cross incision into the
fascia, a curved incision with the concavity upward.
This fascia incision can be carried as far to both sides
as may appear necessary. No necrosis of fascia in
aseptic cases has ever been observed.
As in all incisions that follow physiological rules, the
adaptation of the severed tissues is so much better
that the patients can be permitted to get up much
sooner than formerly. No abdominal binder is
necessary after the Pfannenstiel incision.
For extremely difficult operations in the small
pelvis, Bardenheuer's incision may be used, as seen in
No. S of Plate II., Fig. 1. The incision severs skin
and fascia in the same direction, and the recti are cut
off shortly above their insertion on the symphysis.
I have omitted any discussion of operations on the
bladder, kidneys, and ureters, as these organs are
extraperitoneal. I will mention only the new plastic
kidney incision of Bakes, as seen in No. 5 of Fig. 13.
For operations on the spleen a V-shaped incision,
on the left side, as shown, on the right side, in No. 8
of Plate II., Fig. 2, may be applied with advantage;
or incision No. 3 in Fig. 13.
REFERENCE HANDBOOK
OF THE
MEDICAL SCIENCES
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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Abdominal Tumors,
Diagnosis
For inguinal hernia or the Alexander operation,
incision No. 7 of Plate II., Fig. 1, is proper.
Operations on the Intestines. — Incision No. C,
Fig. 13, represents Mackenrodt's incisionfor operations
on the sigmoid flexure and transperitoneal operations
on the rectum. Resection of the cecum is well
accomplished by using an incision like No. 7 in
Fig. 13. For operations on the transverse colon,
incision No. 2 in Fig. 13 is indicated. For operations
on the splenic flexure of the colon, Kocher advises an
incision like No. 3 in Plate II., Fig. 1, while No. 7 in
Fig. '_' is for inguinal colostomy.
An incision for a large umbilical hernia, according
to Mayo's method, is shown in No. -1, Plate II., Fig. _'.
I have mentioned previously that the principal
requisites for success in performing these operations,
so far as abdominal section itself is concerned, are:
absolute asepsis, complete hemostasis, and the most
exact suture, with the avoidance of dead spaci
Wherever drainage is necessary, either because the
hemostasis cannot be as exact as desired, or by reason
of the presence of pus, the entire abdominal section
should be closed with the exception of a small part in
one of the corners, where a cigarette or other drain
may be inserted. For suture material most operators
now use plain catgut for the peritoneum, chromicized
catgut in interrupted sutures for the fascia and
muscles, and silkworm sutures or Michel's clamps for
the skin; the latter can be applied only where the skin
is not too thick.
For dressing the wound most operators now use adhe-
sive plaster strips to hold the dressing in place, and at
the same time compress the wound, also to relieve some
of the strain on the wound produced by vomiting,
retching, coughing, and so on. Over this a binder is
applied which is made to conform to the contours of
the body by the application of safety-pins where
necessary. Thigh-straps may be combined with the
same. Some operators place a sand-bag over the
operated region to prevent the accumulation of blood
in possible dead spaces. Otto Kiliani.
Abdominal Tumors, Diagnosis of. — The word
tumor is used here not in the restricted sense of a neo-
plasm but in the etymological sense of a swelling. It is
at once evident from this that a large number of
pathological processes affecting all the organs con-
tained in the abdomen and the tissues making up the
abdominal walls must be considered. This was
deemed necessary because we start with the assump-
tion that in a certain given case a tumor has been
found in the abdomen and it is necessary to discover
what and where it is. All details of etiology, path-
ology, and symptomatology have been omitted except
in so far as they have a direct bearing upon the dif-
ferential diagnosis. For such details reference must
be made to more special articles. Furthermore, the
diagnosis of conditions which ultimately lead to the
formation of demonstrable tumors has been omitted,
and the discussion of such conditions will be limited
to their course after the formation of a tumor. For
example, when speaking of cancer of the stomach it
will be assumed that a tumor has been discovered.
When confronted with an abdominal tumor, it
must be remembered that the diagnosis should go
beyond the mere recognition of the existence of a
tumor in the abdomen. We must determine first
the organ or tissue in which the tumor is located,
and second the nature of the tumor. If the tumor is
believed to be a malignant neoplasm, we must decide
if possible, whether the tumor arose in the organ in
which it is discovered or is merely a tumor secondary
to a primary tumor in some organ yet to be deter-
mined. If the tumor found is believed to be primary,
secondary deposits in other organs must be sought.
In other cases we must hunt for the cause of the tumor.
If, for example, a certain tumor is thought to be a
gal] bladder distended with fluid, effort Bhould be
made to ascertain the character of the fluid and the
cause and site of the obstruction which prevents
the escape of the fluid from the gall-bladder. With
so broail a subject it is evident that only the more
important methods, facts, and pathological condi-
tions can be included.
After a brief discussion of the methods of examina-
tion employed, we will consider what miiilit be called
tumors of the abdomen as a whole, such as ascites,
diffuse peritonitis, lipomatosis. Then the various
organs will be grouped according to their relations
to the colon, and each group considered in turn.
The organs situated to the cephalic side of the trans-
verse colon, the liver and gall-bladder, the stomach,
pancreas, and spleen, will be described first; then
will follow the organs behind the colon, the kidney,
adrenal bodies, and perirenal tissue; next will come
the organs within the arch of the colon, the small
intestines, mesentery and omentum, peritoneum,
lymph glands, aorta, uterus, ovaries, bladder, spinal
column, and lastly the colon, appendix, and walls of
the abdomen. With each organ we shall so far as
possible take up first the circulatory disturbances,
then the inflammatory processes, cysts, neoplasms,
and malpositions. It is not necessary to state that
this order cannot be followed absolutely, but it can
be approximately, and will be found greatly to fa-
cilitate a grasp of this subject, probably the most diffi-
cult matter handled by the diagnostician.
Methods of Examination employed include the
physical, chemical, and microscopical: the first hav-
ing in general an especial bearing upon the localiza-
tion of the tumor, while the second and third are of
more value in determining the nature of the tumor.
Physical Methods. — Inspection. — The patient
should be placed on a firm narrow bed or table in such
a way that the source of the light lies in a line with
the median line of the body, either directly above or
at the head or foot of the patient. The purpose of
this is to avoid any uneven distribution of the shad-
ows. The kind of light employed is usually a matter
of indifference, but in eases in which there is reason
to suspect the possibility of a jaundice the patient
must be examined by daylight, for the well-known
reason that no artificial light shows even the deepest
shades of jaundice.
Take note first of the size of the abdomen, especially
of any disproportion between the size of the abdomen
and that of the other portions of the body. Next,
note the shape of the abdomen. Is the abdomen
symmetrical? Are there any portions more prom-
inent than the corresponding ones of the other side,
or is the upper half out of proportion to the lower
half? If any part appears large, does it appear
sharply outlined or does it merge gradually into the
surrounding parts? Does the surface of the enlarge-
ment appear smooth or nodular, and are the outlines
rounded or irregular? Does the mass move; and if
so, does it move with the respiration, the pulse, or
independently of either? Almost any tumor of the
abdomen may show respiratory or pulsatile move-
ments (the exceptions will be stated later), but only
a few show independent movements. These are
tumors from the stomach, intestines, and uterus.
Visible vermicular movements of the stomach and
intestines are commonly seen in patients with thin
abdominal walls and are not in themselves patholog-
ical. It is only when they are usually intense and
continuous and in combination with distinctly path-
ological symptoms that they need attention. The
word vermicular quite accurately describes the motion,
for it looks exactly as if some large worm were
moving under the skin. The site and direction of the
movement should be noted. In general the pcris-
talic movements of the stomach are limited to the
upper and median portion of the abdomen and pass
23
Abdominal Tumors,
Diagnosis
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
from left to right. Peristaltic movements of the
stomach from right to left are pathological. The
movements of the small intestines are central and
irregular in direction. Those of the large intes-
tine correspond to the relatively fixed position of
the colon and vary in direction with the portion of
the colon affected. The peristaltic movements
above the site of any stricture in the gastrointes-
tinal tract, either acute or chronic, are more active
than normal, and therefore persistently exaggerated
movements point to some obstruction, but do not
in t hem-elves prove such obstruction.
The independent movements of the uterus are of
two sorts: fetal and uterine. The presence of the fetal
movements is at times a most important point in the
differentiation of abdominal tumors. The move-
ment- arc altogether irregular in time and intensity,
and may be simulated by the peristalsis of the small
intestines. The expulsive contractions of the uterus
are not often visible, but may be so.
Inspection of the abdomen includes attention also
to any subcutaneous collateral circulation, either
arterial or venous. Such circulation often gives
the clew to the site of the Obstruction, which neces-
sitates a collateral circulation and may give some
idea of the degree of the obstruction. Note also
any localized edema or inflammatory process.
Often much valuable information may be gained
by changing the amount of gas in the stomach and
intestines. Not only do we gain information as to
the exact location and size of these organs, but we
learn much of their relation to the tumor found.
Various methods have been employed for this pur-
pose, but the following require only such apparatus
as should be in the armamentarium of every physi-
cian. The stomach may be inflated by means of a
Seidlitz powder mixed after drinking instead of be-
fore, or one can use saleratus in solution followed by
a little vinegar. This method is not entirely without
danger, because the pressure resulting from the gas
envolved cannot be accurately estimated. Acci-
dents, however, are rare. Another method consists
in the passage of the stomach tube and inflation of
the viscus by means of a pump. This has the advan-
tage of enabling one to use as much or as little gas as
desired, and permits the immediate removal of the
gas if necessary.
The colon is inflated by passing the rectal tube well
up into the descending colon and forcing in air by means
of a pump, the ordinary bicycle pump being perfectly
adapted to the purpose. A rather large, cone-
shaped rectal tip is better than the rectal tube, for it
prevents the escape of the air, but is not so easily
supplied as the tube. As the air passes upward and
distends the colon we are able to learn the exact
course of the colon and its relations to the tumor.
Harris, of Chicago, has drawn especial attention to
the value of the relation of the colon to abdominal tu-
mors in the differential diagnosis of such tumors. He
substitutes for the old and superficial division of the ab-
domen into nine areas — the right and left hypochon-
driac, lumbar, and inguinal regions, the epigastric,
umbilical, and hypogastric regions — an anatomical
division into fourareas. The borders of these areas are
not fixed by external points, but are located by the
inner or mesial layer of the longitudinal colon and the
inferior or caudal layer of the transverse colon. The
resulting areas are a central area, surrounded by meso-
colon; aright and left posterolateral area, lying external
to and behind the mesocolon; and a superior area,
lying above the transverse mesocolon. While the boun-
daries of these areas are not fixed, their position is
easily ascertained by determining the position of the
colon by air distention.
In the central area, surrounded by the distended
colon, are found tumors of the omentum and mesen-
tery, retroperitoneal tumors, localized peritoneal
exudates, tumors of the small intestines, tumors of
displaced and movable kidneys, and all tumors of
the female generative organs rising into the abdomen.
In the superior region we find tumors of the liver,
gall bladder, stomach, lesser omentum, pancreas,
retroperitoneal lymph glands, and aneurysms of the
celiac axis.
Tumors of the spleen pass forward close to the
anterior wall, in front of the splenic flexure of the
colon and the neighboring parts of the transverse
and descending colon.
Tumors of the kidneys, suprarenal bodies, and the
connective tissue bordering on these organs, tumors
from remains of the Wolffian bodies, carry the colon
inward and forward. But tumors from floating
kidneys may appear in the central area, i.e. sur-
rounded by the colon.
Skiagraphy. — To these methods of inspection
there has in recent years been an important addition,
namely, the inspection of bismuth suspensions by
means of the z-ray. While this method is of but
little value in the great majority of the cases of
abdominal tumors, in some it is of almost major im-
portance. A suspension of bismuth salts is given
by mouth or per rectum or both and inspection made
at once by means of the fluorescent screen. Plates
should also be made at varying intervals over a period
of twenty-four hours. When the bismuth is given by
mouth the intervals between the plates should be
short, at first only minutes long, but after the first
hour, the intervals should be gradually lengthened.
In this way accurate information as to the size.
location, and motility of the stomach maybe obtained
and in some cases, the presence and size of a carcin-
oma can be accurately proven.
The colonic injections enable one to ascertain, the
location of the colon and the presence of kinks,
strictures, and dilatations.
Work of this sort requires first, a good x-ray operator
and second, considerable experience in the interpre-
tation of the results obtained.
Palpation. — This method of examination is of
much more general application than inspection, for
many tumors easily palpable are not visible. Pal-
pation should always be preceded by thorough and
certain evacuation of the bowels, otherwise fecal
masses may lead to errors. The patient should be
examined first in the dorsal position, but in some
cases a lateral, a knee-chest, or an erect position will
yield results not otherwise obtainable. The patient
should relax the abdominal muscles as completely
as possible. This is often easier when the thighs are
flexed on the abdomen and the mouth held open. In
difficult cases better relaxation is obtained if the
patient is placed in a bath of warm water and exam-
ined in the bath. In still more difficult cases general
anesthesia must be employed. Palpation should be
made gently but firmly, and any pressure used should
be applied gradually; counter-piessure from behind
is often a help. Sometimes, and this is especially
true when there is considerable fluid in the abdominal
cavity, one obtains the best results by dipping the
stiffly held fingers suddenly downward, depressing
the abdominal walls to varying depths. Bodies can
often be felt and outlined in this way that cannot
be felt at all by the ordinary method of palpation.
Attention should be given to the following points:
the location, size, shape, motility, and tenderness of
the tumor. Note also any change in position or ease
of palpation caused by distention of stomach and
colon.
In all cases in which it is impossible absolutely
to exclude a neoplastic origin for the tumor palpated,
the rectum and vagina should be examined.
Percussion. — This method is far less valuable here
than in examination of the chest, but should never
be omitted, and in certain cases exceeds the other
methods of examination in value. Its main uses are
the determination of the position of the diaphragm,
21
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Abdominal Tumors,
Diagnosis
the .shape of the upper border of the liver, the pres-
or absence of free tluul in the abdominal cav-
ity, and the position and approximate size and shape
of the stomach and (-(111111 alter they have been dis-
tended by gas or fluid. Percussion is the main means
of determining the relation of the colon and stom-
ach to the tumor found, and what was said under the
heading of I aspection in this regard could be repeated
here; it might perhaps have been more properly placed
here, for percussion is used much more often than
inspection for this purpose.
Tumors of the abdominal organs caus
areas of dulness only when superficially located or of
large size, and the resulting area of dulness is always
smaller than the tumor.
Percussion is valuable in demonstrating thi
of areas of dulness normally present. Disappearance
or reduction of the hepatic and splenic dulne
often of the highest diagnostic value. Disappear-
ance of the posterior renal dull
In isolated cases auscultatory percussion gives
valuable results.
.1 iscultation. — Almost no results are obtained by
this method. Peritoneal friction, either Idealized or
diffuse, is sometimes heard. Arterial and venous
tones and murmurs are common and usually- of but
little significance.
The presence of fetal heart tones is obviously
significant.
Exploratory Puncture is often 01 the very greatest
value, especially in determining the nature of the
tumor. The details will be given 'ater.
Exploratory Laparotomy. — In certain cases a com-
plete diagnosis — i.e. one which localizes the tumor
and determines its nature — is impossible even after the
most careful examination. In such cases an explora-
tory laparotomy is often justifiable, providing it can
be made by a competent surgeon under favorable
circumstances. Unless the patient presents some
obvious contraindication to the operation, it can be
done with almost no danger and often gives informa-
tion which leads to definite curative treatment.
The chemical and microscopical methods of exami-
nation can be more profitably discussed in the spe-
cial paragraphs referring to the different organs.
Before taking up the various diseases of the abdom-
inal organs leading to tumor formation, it should be
expressly and emphatically stated that any exam-
ination of an abdominal tumor which omits a com-
plete and careful examination of the entire body is
criminally incomplete. Abdominal tumors are often
merely synnptoms of diseases of organs remote from
the abdomen, and such primary disease can be dis-
covered only by T a complete examination of the body.
Enlargement of the Abdomen as a Whole. —
Thi- may occur as the result of accumulations of gas
or fluid in the peritoneal cavity, from large amounts
of gas in the intestines, from deposits of fat in the
abdominal walls, omentum, and mesentery, and in
rare instances from very large tumors.
Ascites. — This is the only common cause for extreme
enlargements of the abdomen. The abdomen is
enlarged in all diameters, but when the cavity 7 is not
completely filled, as is ordinarily true, the horizontal
diameter when the patient is in the dorsal decubitus
will be found considerably greater than the perpen-
dicular diameter. The flanks are bulging while the
umbilical region is flattened. The skin is often tense
and shining, and under it can be seen the overdis-
tended veins. Such veins are present in all well-
marked cases of ascites irrespective of its cause, but
are usually better marked in cases due to atrophic
cirrhosis of the liver than in others. The umbilicus
is flattened out or even bulging. Sometimes when the
patient changes position, one sees the fluid changing
position also, and one is reminded of the appe^ r ance
of an incompletely filled sack when it is shaken.
On palpation the fluid waves can be felt when the
hand is placed Hat on one side of the abdomen and
the other side is percussed gently. If one lay- the
hand lightly over the region of the abdomen which
percussion shows to lie tympanitic and at
time percusses the Hank, the fluid will flap up
strike the hand, i.e. the fluctuation is felt over the
Percussion shows dulness over the dependent por-
tions of (he abdomen but usually about the umbil
ads an area of tympany. The borders of this area
are no ir, but wavy. If one outlines thi- area
very carefully he will find that though the borders
avy, they are at all point ame horizontal
plane. When the position of the patient is changed,
the level of the fluid changes very promptly to cor-
md to the altered position. When tin
of the fluid is very great, the entire abdomen will
be dull on percussion, even fit the highest level.
Auscultation yields no results, except in cases to be
stated la
Such free fluids in the abdomen are usually transu-
but they may be exudates, and the first question
is to determine which. Usually thi- can be done with
a great degree of certainty even without actual ex-
amination of the fluid. If the patient has a perfectly
manifest disease of the heart, kidney, or liver, the
fluid is very probably a transudate. If there is fluid
in the subcutaneous tissues and the other serous sacs
also, this probability becomes a certainty.
If doubt remains, enough fluid must be withdrawn
to ascertain its character. In these cases it is best
to remove at first only sufficient for examination,
for when the fluid is chylous it is best not to withdraw
it except upon the most urgent indications. A trans-
udate is a clear, straw-colored fluid, of low specific
gravity, less than 1.015, containing a small amount
of albumin up to two per cent, and showing almost
no cellular elements. An exudate may be equally
clear, but is usually cloudy from cells and fibrin.
The specifie gravity is above 1.015, usually consider-
ably above. The amount of albumin is higher, over
four per cent. The cellular elements vary greatly
in number and in character, but are always more
abundant than in the transudate.
The rather rare cases of adipose and chylous
ascites show a turbid, milky fluid, very different from
the ordinary ascitic fluid. The adipose ascites is
usually of high specific gravity, for it is merely an
altered exudate, contains a good deal of fat which is
in both large and fine droplets, and is free from sugar.
The chylous ascites contains fat, but only in fine
droplets; sugar is present in most, but not in all cases;
the specific gravity is low.
When it is settled that the enlargement of the
abdomen is due to free fluid, and the nature of the
fluid, whether exudate or transudate, has been dis-
covered, it yet remains to determine the cause of the
trouble. Large peritoneal transudates may come
from a disease of heart, kidney, or liver. If due to
heart or kidney, the ascites is usually a part of an
anasarca; if due to the liver, the ascites exists alone
or preceded the edema elsewhere by days or weeks. A
well-marked collateral circulation on the abdomen
and an enlarged spleen speak for a primary hepatic
process, but it may be necessary to withdraw the
fluid before the spleen can be palpated.
Large exudates in the abdomen are almost always
due either to tuberculosis or to carcinoma. The
physical signs often differ somewhat from those of the
transudate, because as a rule the fluid is not perfectly
free and for this reason does not change its level so
promptly as does the transudate, and oftentimes
certain portions of the intestines become adherent to
the abdominal wall, so that tympany is found even
over the most dependent part of the abdomen. The
clinical differentation of tuberculous from carcinoma-
tous peritonitis is often very difficult. If the patient
is too young for carcinoma or there is a manifest
25
Abdominal Tumors,
Diagnosis
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
carcinoma or tuberculosis of some organ, then it is
easy; but there are many times when it is difficult.
The positive reaction to the Koch tuberculin speaks
for tuberculosis, a leucocytosis speaks for cancer, but
these two sometimes contradict each other. The
development of cachexia speaks for cancer. In
doubtful cases the patient should be laparotomized
for purposes of diagnosis and treatment, if the latter
is found possible.
There have been numerous instances of confusion
of ovarian cysts with free fluid in the abdomen,
both transudates and exudates. There is little excuse
for this error unless the ovarian cyst is so large as
to fill completely the abdomen. Here attention to
the history, which in these cases runs back for years,
together with the absence of any demonstrable cause
for free fluid, will usually enable one to make the
diagnosis. As a further* aid one may make an ex-
ploratory puncture. The fluid of ovarian cysts
presents characteristics to be described in a later
paragraph.
Sometimes great dilatation of the stomach has been
mistaken for ascites, the air and fluid in the stomach
giving the same physical signs as free fluid in the ab-
dominal cavity. The history of this condition differs
from that of the ascites. In cases of any doubt, the
stomach tube, by withdrawing any fluid in the
stomach, will enable one to make the diagnosis with
certainty.
Collection of gas in the free peritoneal cavity often
causes a very considerable increase in the size of the
abdomen, but percussion and the tympany thus de-
veloped clearly prove the nature of the enlargement.
Whether the gas is in the intestines or in the peritoneal
cavity is often difficult to decide when both are possi-
ble, as after trauma or in the course of some ulcerative
process in the gastrointestinal tract. Here the progres-
sive decrease in the size of a liver dulness, known from
former examinations to be present, speaks for gas in
the peritoneal cavity. It is usually associated with
shock and symptoms of peritonitis.
Enlargement of the abdomen from fat is common,
and is readily recognized, as a rule. We sometimes
see lipomata of the mesentery or omentum, which
present themselves as tumors of the abdomen and
are really such, but it is not to these that we refer.
Careful examination of this very common condition
will protect one from error.
Tumors of the Liver. — The pathological process
causing enlargement of the liver may be well placed
in two groups, according as the enlargement is diffuse
or circumscribed. It must, however, be stated that
this division, like most other divisions in medicine,
is not at all sharply marked, for most of the patholog-
ical processes may occur in either group. For example,
amyloid infiltration usually causes a diffuse enlarge-
ment of the liver, but may cause sharply circum-
scribed masses; while, on the other hand, carcinoma
usually causes localized masses, but may cause diffuse
enlargements.
Diffuse enlargements of the liver, no matter what the
cause, bring about no change in the general shape; the
liver is, so to speak, merely magnified. The borders
lose their normal sharpness and become rounded and
thickened. The notch in the anterior border for
the gall-bladder is retained. The consistency of the
liver is often altered, usually becoming firmer, but
sometimes it feels softer. The surface may be per-
fectly smooth or slightly granular, depending upon
the pathological process in play. A granular surface
may be simulated by the presence in the subcutane-
ous tissues of partially atrophied adipose tissue, but
under such circumstances the granules can be felt
all over the abdomen, and they feel more superficial
than granules in the liver.
Diffuse enlargements of the liver generally take
place downward rather than upward. Percussion
shows that the upper border of the liver occupies its
normal position; presents its normal shape, that of a
straight line perpendicular to the surface on which
the patient is lying; and shows only a slightly decreased
respiratory mobility.
Passive Congestion of the Liver. — This is the com-
monest example of a diffusely enlarged liver, and
inasmuch as the subjective symptoms from which
the patient suffers may be, and often are, entirely
limited to the hepatic region, the tumor of the liver
is often mistaken for some primary condition, while
in reality it is not primary but always a mere symp-
tom of some disease causing obstruction to the venous
circulation at a point above the juncture of the
hepatic veins with the inferior vena cava.
The subjective symptoms are pain, fulness, ten-
sion, and weight in the right hypochondriac region,
cither constant or intermittent. These symptoms
may, and often do, overshadow all other symptoms
of the primary disease. Examination shows a uni-
formly enlarged liver, reaching usually only a few
centimeters below the costal arch, but sometimes
extending to or beyond the umbilicus. The surface
is smooth, the borders are regular but rounded.
Usually, but by no means always, the liver is tender.
Percussion shows a regular upper border with normal
respiratory motility.
The patients often show a moderate degree of
jaundice, usually both conjunctival and cutaneous.
The jaundice is practically never intense unless there
is some complication. This jaundice is apt to still
further strengthen the idea that the patient has a
primary disease of the liver. Examination of the ab-
domen shows an absence of ascites and no enlargement
of the spleen. Exceptionally both these are found,
but in these cases the symptoms of cardiac insuffi-
ciency are so marked that only the most careless can
mistake them.
Examination of the chest will in most instances
show that the primary disease is oftenest a disease
of the heart, endopericardial or myocardial. The
cardiac insufficiency may, however, be secondary to
some disease of the lungs or pleura, oftenest an
emphysema or an obliterative pleuritis.
All patients who present an enlarged liver, especially
when the liver is painful or tender, should be examined
for some disease of the heart, lungs, or pleura as a
possible cause for a passing congestion; and if such
disease is found, the liver should be regarded as a
liver of passive congestion; and this diagnosis should
be given up only on the strongest evidence pointing
to some other disease causing diffuse enlargement
of the liver.
Passive congestion of the liver is liable to rapid
fluctuations, so that marked changes in the size of
the fiver can occur in the course of a few days or
even hours. Such fluctuations do not, however,
always occur, and the enlargement may remain sta-
tionary over weeks and months.
Active Congestion of the Liver. — This occurs in a
variety of conditions, but is usually of so slight a degree
as to pass unrecognized, or if found, is so minimal or
so manifestly of secondary importance as to attract,
little attention. It occurs in a variety of infectious
diseases, the most important examples being scarlet
fever, smallpox, the various forms of sepsis, typhoid
fever, and malaria. Malaria, especially estivo-
autumnal malaria, may cause a marked and persistent
enlargement of the liver which may be difficult to
diagnose. Such cases may present an icteric dis-
coloration of the skin, with marked enlargement of
the spleen, thus closely resembling the hypertrophic
cirrhosis of the liver, a disease which often gives rise
to an intermittent fever resembling the fever of
malaria. The differentiation between the two is
made by an examination of the blood for the Plasmo-
^\~7* i *3\ due not only to his great
<\ "-*»» \ professional skill, but also
Fig. 14.— John Abernethy. in ptu't to the singularity of
his manners. He used great
plainness of speech in his
intercourse with his patients, treating them often
brusquely and sometimes even rudely A
collected edition of his works was published in 1S30."
A. H. B.
Abietic Acid (C 48 H„0 5 ). — An organic acid, which, in
its anhydrous state, chiefly composes common rosin.
It also occurs in many other coniferous plants.
H. H. R.
Abilena Wells. — Dickinson County, Kansas
Location. — On a ridge of high land, at almost the
exact geographical center of the United States. The
wells are about fourteen miles northwest of Abilene, a
station on the Union Pacific and the Chicago, Rock
Island, and Pacific Railroads.
From the report made in 1902 by Dr. E. R. S.
Bailey, of the University of Kansas, we glean the
following facts: The first well was driven in 1S97, for
the purpose of securing drinking water for the animals
of a stock farm. It was found, however, that the
water obtained at a depth of ninety-five feet was unfit
for the purpose. On the other hand, a chemical
analysis revealed the fact that it was rich in salts
possessing cathartic and diuretic properties; and accord-
ingly a company was organized in 1900 for the further
development of the property and for the sale and
distribution of the water. In 1901 two other wells were
bored, and later three additional wells were drilled, all
to the depth of 130 feet.
At the present time there are over fifty wells, the
water of which is filtered through sand and charcoal, to
remove a small quantity of suspended matter. As de-
livered to the public, in bottles of a convenient size,
this water is perfectly clear. The chemical analysis,
which was made in January, 1902, by the late Professor
Albert B. Prescott, of the University of Michigan, is
given below.
(In Grains per U. S. Gallon, 231 Cubic Inches, at Maximum
Water Density.)
Sodium bicarbonate S. 909
Calcium bicarbonate 10.733
Iron bicarbonate 0.917
Sodium nitrate 0. 56S
Sodium sulphate 3229 . 2SS Anhydrous. Equal
to 7322.648 sodii
sulphas, U. S. P.
Magnesium sulphate 71 .345 Anhydrous. Equal to
146.139 macnesii
sulphas, U. S. P.
Calcium sulphate 44 . 966
Sodium chloride 6.5. 176
,Sili<-a 0.293
Total solids 3432 . 195
" The specific gravity of the water is 1.0G5 at 22.5° C.
As seen by the analysis herewith given this water is
remarkably rich in cathartic and diuretic salts, and is
mildly alkaline with bicarbonates. It is an extremely
pure water in respect to freedom from organic con-
tamination."
Probably the most valuable feature of the Abilena
water is its very large content of sodium sulphate in
combination with a correspondingly small percentage
of magnesium sulphate.
The dose, taken preferably one hour before breakfast,
is from one-quarter to one-half of an ordinary drinking
glassful, equal to about two ounces. This dose should
be followed by a liberal drink of table water.
Emma E. Walker.
Abiotrophy. — From a- privative, /?fos, life, and zpo produce, an abortion or
i„i carriage of a woman by artificial means. In a few
this applies only to attempts in the cases of women
actually pregnant; but inasmuch as crime consists of a
combination of a forbidden aci and a wilful and un-
lawful intent, it is both reasonable and just that an
attempt to produce an abortion should be prohibited
even when the woman is not actually pregnant,
although she and tin- perpetrator think she is. In
many of the statutes will be found saving clauses
freeing from criminal liability the person who produces
: i miscarriage by artificial means, under circumstances
from which it must appear that the fetus is dead or that
it is necessary to save the mother. It is suggested as a
precautionary measure to any medical practitioner who
contemplates arresting gestation, in order to avoid
suspicion, to consult some other member of the pro-
fession of unquestioned standing, and to obtain the
consent or approbation of some one or more of the
relatives of the woman.
The statute of Pennsylvania is a good example of the
best of those passed in this country. It is as follows:
1. "If any person shall unlawfully administer to any
woman, pregnant or quick with child, or supposed and
believed to be pregnant or quick with child, any drug,
poison, or any substance whatsoever, or shall unlawfully
use any instrument or other means whatsoever, with
the intent to procure the miscarriage of such woman,
and such woman, or any child with which she may be
quick, shall die in consequence of either of said un-
lawful acts, the person so offending shall be guilty of
felony, and shall be sentenced to pay a fine, not ex-
ceeding five hundred dollars, and to undergo an im-
prisonment by separate or solitary confinement at
labor, not exceeding seven years."
J. " If any person, with intent to procure the mis-
carriage of a woman, shall unlawfully administer to her
any poison, drug, or substance whatsoever, or shall
unlawfully use any instrument or other means whatso-
ever, with the like intent, such person shall be guilty
of felony, and being thereof convicted, shall be sentenced
to pay a fine, not exceeding five hundred dollars, and
undergo an imprisonment by separate or solitary con-
finement at labor, not exceeding three years."
As a practical matter, it is but rarely that the prose-
cuting power has the opportunity of invoking this law
against a violator of it, for the reason that in all cases of
criminal abortion the operation is performed, or the
drug is administered, at the request, or it may be the
earnest solicitation, of the woman herself, who for this
reason is as cautious to avoid detection as is the perpe-
trator of the crime. It will be found that almost all of
the cases of criminal abortion which have proceeded as
far as indictment and trial, are those in which the
patient has died from the effects of the operation or the
administration of the drug. Even in these cases it
has been a rare experience to obtain a conviction
because of the secrecy with which this crime is com-
mitted, resulting usually in the absence of evidence of
those facts which can be used against the culprit.
Persons who commit offences deliberately always avoid
or destroy those circumstances which are incriminating,
so far as is possible.
Irrespective of the above-mentioned statutes, both in
England and in this country one who administers to a
pregnant woman a drug, or employs upon her an instru-
ment for the purpose of procuring a miscarriage, in
consequence of which she dies, or the child dies after
birth, by reason of being prematurely delivered, is guilty
of murder. The culprit will be indicted for murder or
manslaughter, first because any inferior grade of crime
of which he may be guilty will be merged in the felo-
nious homicide, which in the eyes of the law is con-
sidered the gravest of all offences; and secondly, it
may be that a dying deposition has been obtained from
the patient.
It lias been held that if there be no intent to kill, or to
inllict grievous bodily harm, and the means employed
lie not dangerou . although used for an unlawful pur-
pose, the crime, when death ensues, may be man-
slaughter, which is an inferior grade of homicide; other-
wise the crime will be murder, and may render the
accused, if convicted, liable to the death penalty. It is
sugge led. howevi r, thai any known mean-, when used
for this purpose, will be dangerous anil should li.
considered. This question is really dependent upon the
judgment of the criminal prosecutor, for it is always
compel, nt for him, unless he is restricted by some
statutory provision, to elect to have the prisoner in-
dicted for tin' inferior grade of the offence, and abandon,
on behalf of the state, the superior grade.
When a reputable physician takes charge of a patient
upon whom he discovers an abortion has been per-
formed, and who subsequently dies, he is bound by law
to certify the cause of death to the Health Department.
In this it may be necessary for him to disclose the fact
of the perpetration of a crime: but is it his duty to in-
form the police authorities as soon as he has discovered
the (rime? This is an ethical question which need not
be discussed here— it is a proposition which each physi-
cian should consider for himself. Auxiliary to it is this
question: Should he, when the opportunity arises,
obtain from the patient a statement which could be
used as a dying deposition in a criminal prosecution
against the abortionist?
Dying Depositions. — For the benefit of the physician
who' is willing to aid the State in detecting the perpe-
trator of this nefarious crime, it may be stated that if
the patient dies and the perpetrator of the abortion is
charged with either murder or manslaughter, it will be
admissible to offer in evidence the dying declaration
of the patient, if she made one. Statements made
under such circumstances are entitled to great weight.
It hasbeen wiselv said by an eminent English jurist, Lord
Chief Justice Baron Eyre, that "such declarations are
made in extremity, when the party is at the point of
death, and when every hope of this world is gone; when
every motive to falsehood is silenced, and the mind is
induced by the most powerful considerations to speak
the truth; a situation so solemn and so awful is con-
sidered by the law as creating an obligation equal to
that which is imposed by a positive oath in a court of
justice." Such declarations are admissible in evidence
only in those cases in which the indictment charges the
culprit with the murder or manslaughter of the deceased,
and not in those in which the gravamen of the charge is
a violation of one of the above-mentioned abortion
statutes. The declaration should also be confined to a
statement of the circumstances of the death, i.e. the
person who performed the operation, the method, time,
and place of performance, and such other facts as are
germane to these.
To render such a declaration admissible in evidence, it
is requisite that the declarant should be in actual
danger of death at the time it is made, that she should
fully realize her impending danger, and that death
should actually ensue. It is not necessary that the
declarant should state that she realizes that her speedy
demise is impending; it is sufficient if it satisfactorily
appears from any other circumstances, such as taking
leave of her relatives, or receiving extreme unction and
the like. If, however, she has any hope of recovers', no
matter how slight, such testimony will be inadmissible,
though death might speedily ensue. Such a declaration
was rejected where the dying person stated: "I have no
hope of recovery, unless it be the will of God"; it being
held by the court that such statement indicated that all
hope had not been abandoned. It need not be under
oath, as the solemnity of the occasion is held to be
equivalent to the sanctity of an oath. It may be taken
orally, but if reduced to writing, it should be carefully
preserved and produced at the proper time. It should
be confined to a statement of facts, no theories or
opinions.
45
Abortion, Criminal
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Criminality of the Act. — So far as the culpability of
the act is concerned, it is immaterial whether or not
quickening has occurred, and whether or not the fetus
in utero is dead, unless there is a saving clause in the
abortion statute as above stated. The criminality is
just as great on the day of conception as at any other
period of gestation. Nor is it a defence or excuse to the
criminal charge that the mother consented to, or
solicited the performance of, the abortion. It has been
decided by some courts that a woman who consents to
the performance of an abortion is an accomplice, by
others that she is not, but this is a purely legal question.
The rule of law generally adhered to is, that where a
witness is held to be an accomplice there should be
some corroboration of her testimony in order to justify
a conviction of the accused.
Questions in Cases of Feticide. — In every case of
feticide the important questions for consideration are:
1. Has the fetus in utcro been destroyed?
2. Has this been produced by natural or artificial
causes?
3. If by artificial means, was the act justifiable or
criminal?
In considering the first question an examination
should be made of the clots and other substances ex-
pelled from the genital organs, for the purpose of as-
certaining if they contain any of the products of con-
ception. If the fetus be found it will be necessary to
determine, if possible, if it was born alive; if so, its
probable age and the cause of its death. A careful
scrutiny of it may disclose punctures, wounds, or in-
juries which indicate the unlawful use of an instrument.
If the fetus is not found the expelled substances
should be examined under water, as an ovum, if one is
present, is more easily discovered in this way. Nor
ought the investigator trust to the naked eye, as much
may be lost without the use of a microscope. When the
criminal operation is performed in the early stages of
pregnancy, the ovum is frequently expelled intact; after
the formation of the placenta, the extrusion of the
ovum usually precedes that of the placenta, the time
intervening being variable, ranging from hours to weeks
or months.
Did the abortion result from natural or artificial causes?
— Both criminal and spontaneous abortion occur
generally about the end of the third month. The
symptoms discovered will vary with the period of
geuch cases the fundus should not
be tapped through the vagina, as some I I recom-
ud. bul the proper treatment i abdominal section
and manual reposition of the uterus.
Montgomery A. Crockett.
W. A. Newman Dorland.
Abrus Prccatorius. — Jequirity, T.m-r Pea, Prayer
Beads, Jumble Beads, Crabs Eyes. Abrus L. (fam.
Leguminosce) is a genus of six species, related to the
lentil and the pea, known to medicine by the species
.1. precatorius L., which is indigenous in British
India and very widely distributed in the tropics
of both hemispheres. The plant prefers a light or
sandy soil, and its slender, woody stems climb high
over shrubbery in the edges of forests. The fruit
resembles a miniature pea-pod, a little more than an
inch in length, and contains from four to six seeds.
The roots have been employed as a substitute for lic-
orice under the name of wild or Indian licorice. The
leaves possess the same property, containing con-
siderable glycyrrhizin. The seeds are better known
than the root, under the name Jequirity. They are a
quarter of an inch in length, elongated-globose, smooth,
shining, bright scarlet, a black spot surrounding the
hilum. A black form, with white spot, and a white
form with black spot, occasionally occur. They are
largely employed for rosaries, ornamental beads,
children's toys, and in India, under the name of retti,
(■ ir weighing. They have also been used in India for
criminal poisoning, usually of cattle. For this purpose
the seeds are crushed and worked into a paste with
water. This paste is rolled into a needle-pointed
form, mounted upon a.stick and used to prick the skin
of the fated animal, which quickly succumbs to heart
failure.
In South America originated the practice of painting
a watery infusion upon granulated eyelids, by which
suppuration was induced and the granulations were re-
moved.
The active agent was at first supposed to be the bac-
teria which appear after a time in the infusion. Later,
this theory was disproved, and the properties were re-
ported to reside in an albuminous substance called abrin.
This was later found, by Drs. Sidney Martin and R.
Xorris Wolfenden, to be a mixture, and was by them
separated into two albuminous bodies, a globulin one-
fifth as poisonous as the venom of the common adder
and an albumose one-sixth as strong as the globulin.
These poisons are destroyed by heat. Their effect re-
sembles that of snake venom, the temperature falling
greatly and the blood remaining semi-fluid after death.
It is by no means certain, however, that this resem-
blance is not superficial.
Jequirity acts as a powerful irritant to mucous mem-
branes. If taken internally, uncooked and concen-
trated, it produces vomiting and purgation, the feces
being often bloody. Forty seeds produced these
symptoms, with partial collapse, but recovery followed.
If it is applied to the eyelids, inflammation quickly
ensues, with suppuration usually on the third day.
The inflammation is characterized by great swelling
and pain. If the applications are continued, there is
great systemic disturbance also. The applications
have been continued by most practitioners for 'from
erity
of its symptoms, which result from the incn I
difficulty in "pointing" and the severity of the coagula-
tion necrosis which the toxins of the infecting bacti ri i
produce. The symptoms of abscess formation are
present, but in a mild form. As the process of destruc-
tion and the breaking down of the tissues proceed the
boil beer. lues mi|V ;i!ii1 tender nil ] He-- 1 ire. A el'll-t
forms over the duct. When it is removed a probe can
be passed down into the abscess, even before it has
begun to discharge. The suppuration increases, and
finalty the core, or the result of the coagulation necrosis,
is expelled, when the cavity heals by granulation.
This is the natural process without treatment.
Since a series of boils may follow in the same indi-
vidual, a condition is determined called furunculosis.
Constitutional and prophylactic treatment are therefore
as essential in many instances as surgical treatment.
Frequent baths and changing of underclothing, with
scrupulous care of the nails and the avoidance of
scratching, are among the preventive measures, while,
when the boils are in process of formation, antiseptic
washes should protect the surrounding skin. An ounce
of sulphonaphthol in a bathtub of warm water makes
a mild antiseptic bath that is not injurious and
that cleanses the skin of the superficially located
bacteria.
Boils may be aborted, when they are small and are
situated superficially, by applying a few crystals of
pure carbolic acid on a glass rod or piece of wood; or,
when the disease is further advanced, by the injection
into the parenchyma of a three-per-cent. solution of
carbolic acid in amounts proportionate to the size of
the boil. This method is somewhat painful and not
always successful.
The expectant treatment should be employed only
when a scar is to be avoided and no organ is threatened,
and when it is too late for abortive treatment. An anti-
septic poultice, gauze or cotton wet in 1:3,000 bichloride
solution under a protective, should be applied over the
boil and the cavity should be syringed out daily until
the core is discharged, when the cavity may be packed
and an occlusive dressing (cotton held in place by
collodion) applied.
The crucial incision will frequently abort a boil and
permit an antiseptic in the dressing to reach the seat of
infection and destroy the bacteria. When the disease
is further advanced free opening, curetting, and sub-
sequent treatment as for any other abscess constitute
the most rapid and radical method and furnish the
best results. Any of these operations can be rendered
painless by the employment of infiltration anesthesia
or by the subcutaneous injection of a two-per-cent.
solution of eucaine B or cocaine. These injections
should commence outside the inflamed area, as the
increased pressure causes great pain.
A carbuncle is the result of an infection by bacteria
that enter the skin in the same manner as they do in
the case of a boil. The conditions under which they
develop are responsible for the difference in the symp-
toms and the gangrenous inflammation and sloughing
that take place in the subcutaneous cellular tissue.
The conditions which predispose to carbuncle forma-
tion are the location of the infection in the thicker
portions of the skin, where it is difficult for the pus to
find a mode of exit, and hence it spreads, causing
pressure and coagulation necroses over large areas,
and pointing through the numerous columna? adiposae,
which offer its only points of exit through the toughened
skin. It is distinguishable by the extent of the tissues
involved and by the multiple points or heads which
53
Abscess, Treatment
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
first show themselves. Pain is not so marked a
symptom and is not commensurate with the extent of
the suppurative process.
The treatment is antiseptic, and always should be in
a measure operative to permit the outflow of pus and
the action of an antiseptic on the foci of infection. The
amount of operative interference demanded varies
with the gravity of the case, from a deep crucial incision,
with or without curetting and an antiseptic poultice,
to complete excision of the entire carbuncle. The
latter is of course reserved for the severer cases, while
there are varying degrees of operating which depend
on the extent of the infection. All parts should be
thoroughly exposed and subjected to the action of
antiseptics.
Felons (panaritium) vary in degree and in their situa-
tion. They are abscesses that form in the fingers and
hands. The varieties are the cutaneous, tendinous, and
subperiosteal, together with a more general form which
is known as a palmar abscess and may be either super-
ficial or deep according to its relation to the palmar
fascia. It is of special importance because it endangers
the integrity and function of the hand.
The various forms of felon are named according to
the structures in which they originate. Their com-
plications, sequela?, and gravity depend upon these
relations. The subperiosteal felon may destroy a
phalanx or involve an articulation. The tendinous
felon may spread through the tendon sheaths, and
involve these spaces in the hand, if the primary disease
is in the thumb or little finger. The cutaneous felon is
liable to produce, as are all the others, lymphangitis and
possible suppuration in the glands of the elbow and
axilla.
All of these panaritium cases demand radical anti-
septic treatment: early deep incision down to the seat
of the suppuration, curetting, antiseptic washing, in
many cases packing with gauze wrung out of a 1:2,000
bichloride solution, and the application of an antiseptic
poultice till the infection is gone. Prompt treatment
of this character will save many fingers and hands that
are of the utmost value to those most generally afflicted
— the working classes. Carbolic solutions have a
tendency to produce gangrene in the extremities and
should be avoided in these cases. Bichloride solutions
should be employed according to the dermal irritability
of the individual. If too strong they may produce an
irritation of the skin, and even poisoning.
Charles Lester Leonard.
Absinthism. — A term applied to the train of morbid
symptoms following the abuse of the liquor called
absinthe. This is a liquor of an emerald green color,
consisting of from forty-seven to eighty per cent, of
alcohol, highly flavored with the aromatics, wormwood
anise, fennel, coriander, calamus aromaticus, hyssop,
and marjoram. The special variety of this drink
depends upon the proportions and kinds of these flavors
composing it. Its quality also depends upon the
quality of its constituents. Since any unpleasant
taste may be easily concealed by the strong aromatic
used, the alcohol employed in this liquor is frequently
very impure.
Absinthe, Artemisia absinthium, is the common
wormwood, the bitterness of which has passed into a
proverb. It is said to contain only one-third of one
per cent, of the oil of wormwood, to which are due the
characteristic effects of the beverage. The bitter
principle of absinthium, absinthin, is a narcotic
poison. The coloring matters used in absinthe are
often very deleterious; in fact not infrequently cop-
per salts have been used in order to produce the
green color.
Absinthe is chiefly used in France, and especially in
Paris. It was introduced there after the Algerian war
of 184 1-7 by the soldiers, who, on their campaign, had
b sen advised to mix absinthe with their wine as a
febrifuge. Its use rapidly increased in France with
such disastrous results that it has been described by
French physicians as constituting a graver danger to
the public than alcohol itself.
Symptoms. — Absinthism develops most insidiously,
and the habit from the very first seems almost im-
possible to break. The symptoms fall naturally into
two groups, due respectively to the chief ingredients of
the liquor — alcohol, and the essential oil of wormwood
which has a special affinity for the brain and nervous
system in general. These groups may be subdivided
according to their physiological, pathological, and
mental effects.
The Physiological Effects. — In small quantities the
oil of wormwood quickens the heart's action, and in
larger ones it is a narcotic. It slightly increases the
secretions. Amory, in his experiments with absinthe,
found that after its administration the nervous centers,
especially the cord, were congested. Magnan found the
cerebrum and spinal cord congested.
The Pathological Effects. — Amory found an infil-
tration of blood in some places in the nervous centers.
The heart was soft and flaccid. Phillips states that
the membranes of the brain and cord are always
injured. The lungs are congested, and extravasations
of blood are found in the membranes of the heart.
Absinthe drinking is followed by a softening of the
brain and general paralysis more often than is the
drinking of alcohol.
The Mental Effects. — Cadeac and Meunier sum up
the mental effects of this drug as follows: Somnolence,
torpor, loss of memory, intellectual paralysis, dul-
ness, complete loss of will, and brutishness. These
effects are, as a rule, observed in the absinthe
drinker.
Absinthism resembles alcoholism, except that certain
features are exaggerated and some new features are
added, for absinthe has a marked physical action of its
own. The symptoms of absinthism develop far more
rapidly than those of alcohol. What has been said of
alcoholism can also be said of absinthism: " Alcoholism
is primarily a physiological disease comprising: 1.
Paralysis of the inhibitory power of the will; 2. A
temporary amnesia; 3. A temporary affective and
intellective modification of the personality."
The effects of a small dose of the drug are giddiness,
vertigo, muscular disorders, and convulsive movements
like those produced by successive electric shocks. In
a stronger dose attacks of epilepsy, more or less violent,
occur which are not produced by alcohol. Brunton
declares that these convulsions are due to the action
of absinthe upon the medulla — not upon the cerebrum.
The end is favorable, as a rule, but may be fatal.
Corning has investigated the action of absinthe upon
the brain and other nervous centers, and confirms
this theory. Brunton says that absinthe is a spinal
stimulant
Absinthe Epilepsy. — Abel says that absinthe gives
rise to hallucinations from the very first. States of
delirium are often observed between the epileptic
attacks, and there may be delirium without epileptic
seizures. Marce in his experimental work with animals
well established the fact that the principles of absinthe
are the agents in causing the special toxic effects noted
in absinthism. The epilepsy may develop into acute
epileptic insanity; it sometimes occurs without any
convulsive attacks. The mania may begin suddenly.
The return to sanity is usually sudden, and is accom-
panied by forgetfulness of the acts performed.
Instead of ordinary convulsive attacks of epilepsy, a
person may have a variety of acute mental disturbances.
The delirious attacks of absinthism develop suddenly.
The symptom-complex appears to be condensed within
the shortest possible period.
Amory gives a comparative table of the temporary
and permanent effects of absinthe and alcoholic bever-
ages generally, founded on the experiments conducted
by Magnan and himself:
54
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Absorption, Nutritive
Absinthe.
Animal perfectly well for
fifteen minutes, at the
least, after the ingestion,
with the exception of a
few muscular Switchings
and a slight uneasiness.
Muscular agitation, com-
mencing in the anterior
portion of the body.
No paralysis.
Alcohol.
In a very few minutes
symptoms of inebriation,
resulting in torpor.
Epileptiform convulsions
and rigidity, resulting
in a speedy death.
No apparent lesion, ex-
cept perhaps a slight
cerebral congestion,
showing the cause of
death to be intoxication
by the poison.
Paralysis, commencing in
p o s t e r i o r extremities,
and then extending to
the anterior.
Paralysis of both poste-
rior and anterior ex-
tremities in succession.
No convulsions. Stupor,
coma, resolution, and a
gradual death.
Lesions of the brain and
of the alimentary canal;
gastritis and enteritis
might have supervened,
had the animals lived
long enough for their
development.
In general, the effects of absinthe are like those of
alcohol, but the former develop much earlier, and arc
of a severer nature. In absinthism there is also a
more striking disturbance of the nervous system.
Emma E. Walker.
Absorption, Nutritive. — In the limited sense of this
article, and as usually accepted in physiology, absorp-
tion is merely the process by means of which nutritive
material is taken from the digestive tract into the
circulation. [In order that this may be possible, the
food must undergo a process of digestion by which the
large molecules in the ingested material are broken up
into molecules of sufficiently small size to pass through
the intestinal mucous membrane into the Iacteals.]
Certain fluids when brought into contact with one
another will mix until the liquids present a uniform
composition, and the passage of the molecules of the one
liquid into the intermolecular spaces of the other has
been named "diffusion." When the same or similar
two liquids are separated by a membrane, this diffusion
takes place through the membrane and is then called
"osmosis."
For a long time osmosis was supposed to be sufficient
to account for all the phenomena of absorption, the
process seemed so delightfully simple; but careful studies
revealed the fact that while dead membranes, fluids,
and gases under certain definite conditions obey equally
definite laws, osmosis fails to explain the actions of
living organs. Theories of electrical action and of
differential filtration demonstrate only more clearly the
complexity of the function of living absorbing surfaces.
Living cells obey their own laws, and they are laws of
life, not of mechanics. As the unicellular animal
ingests, digests, absorbs, and excretes, and knows what
it wants and w-hat it has to do, so in the complex higher
animal each cell retains all these functions, while the
differentiation of the organs has imposed upon each
the additional labor of doing something for the general
well-being of the whole organism. The work assigned
to the cells of the different parts of the digestive tract
concerned in absorption is first to keep themselves in
good condition; secondly, to pick out from the contents
of the tract such substances as the body wants, and
pass them into the circulation. It is safe to assert that
normal absorption is a living, not a mechanical act, and
that osmosis, as a factor in these phenomena, must not
be alone taken into account. In pathological condi-
tions, however, in conditions in which the separating
membrane has been injured or its vitality lowered,
osmosis may well come in as a strong factor in swellings,
effusions, lymph accumulations, and all the phenomena
usually designated as poor absorption; here we shall
have til imagine a fight between the Osmotic and the
vital processes, the latter constantly tending In check
the action of the former, until recovery takes place
ami pure osmotic action has ceased.
In a healthy body the skin can be excluded as an
organ of absorption; iii spite of the many careful experi-
ments made pin and con, I he weight of authority to-day
rests with the assertion thai under normal conditions
the skin is passive so far as absorption i- concerned.
The same must lie said about the muCOUS membrane of
the I ith and esophagus, for although we know that
violent poisons can be and are taken up by the mucous
membrane of the mouth, under ordinary conditions f I
docs not stay there long enough to allow of any a I isorp-
tion to take place. That limits the absorbing surfaces
of the human body to the mucous membranes and allied
structures of the stomach and of the small and large
intestines.
While the nature of the food eaten determines the
length of the digestive tract in any given species, the
absorbing surfaces bear a definite relation to the bulk
of the body and explain why the body stops growing
after a certain size has been attained. During a given
limit of time the absorbing surfaces increase as their
square while the body increases in bulk as its cube. In
other words, if we assume that the absorbing surface
equals 2, and the body bulk equals 2, then by the time
the former has grown to equal 4 the latter equals S; and
when the former has increased again to 16, the hitter's
bulk is 512. It is easy to see how the growth of bulk is
checked by the limitations of the absorbing surfaces.
The substances to be absorbed are peptones, glucose,
and emulsified fat, the products of digestion, besides
water and different salts which have remained
unchanged.
The stomach has no specialized organs of absorption,
but its whole mucous membrane may, under certain
conditions, absorb materials digested in its cavity,
peptones and glucose. The older view which made the
stomach practically the only organ worth mentioning
of the digestive tract, and took it for granted that its
function in the absorption of peptones, glucose, salts,
and water was of proportionate importance, has been
slowly changed by the results of modern experiments.
Without going to the other extreme view which makes
the stomach merely the temporary receptacle for food,
these experiments prove that absorption of the above
named substances may take place, but only to a limited
extent. Of the carbohydrates, dextrose, lactose,
maltose, and saccharose, even dextrin, may be absorbed
by the mucous membrane of the stomach, and the more
concentrated the solutions, the more marked is the
absorption. Peptones are absorbed slowly and appar-
ently with difficulty, while condiments and alcohol
increase distinctly the absorbing power of the stomach.
Perhaps the most interesting and least noticed fact
brought out by these experiments is that practically
no water is absorbed by the stomach, but that all passes
into the intestines; on the other hand, alcoholic solu-
tions are readily taken up. This fact may ultimately
help to explain why water is the beverage most desired
when men are thirsty, and why something mixed with
the water seems necessary when people, not thirsty,
gather and drink for social enjoyment.
Peptones, glucose, and emulsified fats are absorbed
mostly in the small, and to a limited extent in the large
intestines. Throughout the large and small intestines
w-e find organs specialized for absorption, viz., the villi
and the solitary glands. The former are most numer-
ous in the duodenum and jejunum, the latter in the
ileum. Throughout the large intestines we find solitary
glands, but no villi, irregularly scattered, the largest
numbers in the cecum and appendix vermiformis; and
their limited number, together with the well-known high
absorbing power of the large intestine, leads us to
think that its mucous membrane is an important factor
in absorption.
The villi, little cone-shaped protuberances in the
55
Absorption, Nutritive
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
mucous membrane, have a dense network of blood capil-
laries just underneath their epithelial covering, while a
lacteal duct occupies the center of the cone. The soli-
tary glands have a dense lacteal plexus beneath the
membrane and a limited supply of blood capillaries. All
the blood capillaries of the intestinal tract are radicles
of the portal vein, while the lacteal ducts are radicles
of the abdominal lymphatics. The villi, however, are
the principal organs and carry the bulk of the peptones
and sugars into the circulation directly, while the emul-
sified fats absorbed are poured by the way of the lac-
teals and abdominal lymphatics into the cisterna chyii,
and from there through the thoracic duct into the left
subclavian vein.
How much the peptones absorbed are changed in their
passage through the epithelial cells of the villi, and how
much additional modification takes place in the capil-
laries and veins before the absorbed material enters the
liver, is as yet a matter of conjecture. [The modern
teaching inclines, however, to the theory that the pep-
tones as such are not absorbed, but are further split into
aminoacids which are synthetized in the columnar cells
of the villi into serum-globulin and serum-albumin and
in this form the protein is carried to the tissues.] The
knowledge that everything ingested, with the exception
of fat, and water enough to emulsify the fat, has to pass
through the liver before the body can make use of it,
will probably increase our respect for that long-neglected
and much-abused organ.
The emulsified fats are split up into fatty acids and
glycerin which are taken up by the epithelial cells and
passed into the stroma of the villus, there to be recon-
verted into minute fat globules. Whether these now
pass directly into the delicate lymph channels which
traverse the villus and finally unite to form the lacteal,
or whether the lymphocytes, so abundantly found in the
stroma, carry the small fat globules from the epithelial
cells directly into the lacteal, is yet an unsettled ques-
tion. Under ordinary conditions only fat enters the
lacteals, while peptones and sugar find their way into
the blood capillaries; but that does not preclude the
possibility that after an excessively fat meal, a trace of
fat can find its way into the blood capillaries, as well as
that, in cases in which an excess of meat and carbohy-
drates has been eaten, a trace of either can be found in
the lacteals.
[The carbohydrates of the food are converted into the
small-molecular glucoses which are taken into the
radicles of the portal vein and pass into the liver.]
The absorbing power of the small intestine is about
equal to the task of taking up the quantity of fluid
formed by the action of the digestive ferments plus the
quantity of fluids secreted by the pancreas, liver, and
intestinal glands, and thus, as these quantities com-
bined do not represent the total amount of fluid present,
the contents of the small intestine remain fluid through-
out its entire length. In the large intestine the
conditions change, the absorbing power is high, secre-
tion and digestion are limited, and, as a consequence,
the contents become more and more pasty as they near
the rectum, until finally the feces contain that portion of
the food ingested which has escaped digestion and
absorption. The absorbing power of the large intestine
is not limited to substances prepared by the action of
the digestive fluids, but it can absorb undigested food,
such as white of egg, although it is probable that even
here there is a splitting up of the protein molecule into
smaller molecules before absorption takes place. Nutri-
ent enemata, based upon this knowledge, have saved the
lives of many patients.
The final test of the activity of absorption as well as
of digestion is a chemical ami physical examination of
the f sees, for the details of which the reader is referred
tn the article cm Fir,:,, crniui 'nation fftlir.
Julius Pohlman.
Abstracta. — Abstracts are solid, powdered prepara-
tions, no longer official. They were introduced into the
United States Pharmacopoeia of 1SS0, and were believed
to have advantages not possessed by the ordinary ex-
tracts, which latter preparations they were designed to
supplant. However, in spite of certain good qualities,
they did not come into general use; and in subsequent
revisions of the Pharmacopoeia they were not retained.
Abstracts possessed the advantage of definite and uni-
form strength, each gram of the abstract being equal
to two grains of the crude drug or fluidextract. The
advantages of the abstracts are given by Remington, as
follows: "(1) Each abstract represents twice the
strength of the drug or fluidextract from which it is
prepared. (2) They are dry powders, if properly
made, and thus are permanent and portable; not sub-
ject to precipitation as fluidextracts are; not liable to
become hard, tough, and variable in strength, as is the
case with extracts. (3) Injurious exposure to heat is
entirely avoided, and the official process of 1SS0 requires
no apparatus but such as either is at hand in the phar-
macy, or can be easily obtained by a pharmacist operat-
ing on a small scale. (4) The final thorough tritura-
tion of the dry powder reduces the soluble and active
constituent of the drug to a pulverulent condition, the
diluent is soluble, and the fine state of division of ab-
stracts is the most favorable condition that a powder
can possess to secure efficient medication." Eleven
abstracts were official in the U. S. Pharmacopoeia of
1S80. R. J. E. Scott.
Abulia. — From a- privative, and flo>Sk-q, will. Paralysis
of the will, a condition in which the subject has lost
the power of decision or initiation. It may be mistaken
for paralysis in certain extreme cases, but the power of
movement is present, the motor impulse only being in
abeyance.
Abulkasim. — (Abul Kasim Chalaf Ben Abbas el-
Zahrawi.) Arabian physician and surgeon born in
Zahra near Cordova, Spain. The exact dates of his
birth and death are not positively known, but he flour-
ished in the tenth century and was physician to the
Caliph Abd-el-Rahman III. According to the Arabian
chronicles he died in the year 1013 at the age of 101
years, so that the year of his birth was 912. No details
of his life are known. The first part of his compendium
of medicine (" Altasrif") was published in Latin in the
sixteenth century as Liber tkeoricm nee non practices
Alsaharavii i Augsburg, 1519). The second, surgical,
part was published at Venice in 1497: a Latin transla-
tion appeared at Basle in 1541; an edition in Arabic and
Latin, edited by Channing, was published at Oxford in
1778. A. H. B.
Acacia. — Gum Arabic, Gum Acacia, Gum Senegal.
"A gummy exudation from Acacia Senegal Willd.
and other species of Acacia (fain. Leguminosa)"
(U. S. P.). In roundish tears, often an inch or more
in diameter, transparent, except for the whitish
fissures, of a glassy, veiny, or fissured fracture,
ranging from nearly colorless to a deep reddish-
yellow, nearly tasteless and odorless, wholly soluble
in two parts of water, to form a thick mucilage of
a faintly acid reaction. The official article is re-
stricted to a color not darker than "pale amber."
The presence of starch in powdered acacia is detected
by a blue color on the addition of iodine, that of
dextrin by a red color. A pure solution will not be
affected by neutral lead acetate.
This gum was formerly yielded by other species of
Acacia, notably -4. vera Willd., and the very finest
gum of commerce still proceeds from this species.
It is chiefly in smaller tears, which are more brittle
and broken, and less translucent and glassy, owing
to the much more numerous fissures. Both species
are small thorny trees of northern Africa, A. vera
more abundant in the eastern, A. Senegal in the
western districts. The gum is a decomposition
product from cellulose and is more abundantly pro-
56
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Acanthosis Nigricans
duced by unhealthy trees. It exudes from natural
fissures and artificial incisions. Gums practically
equivalent to acacia are produced by species in
related genera. An excellent article is produced by
species of Proaopis, growing in the southwestern
United States, and known as Mesquit gum, bu1 the
supply is too irregular to be utilized. Some of these
substituted articles, as, for example, Ghatti gum, are
very inferior. The varieties of acacia are now little
known by the locality-names formerly applied to
them, the grading being done almost wholly by
number, the quality depending upon whiteness and
solubility. The pure gum consists wholly of com-
pounds of arabic acid with potassium, calcium, and
magnesium. Acacia has no physiological action,
except that of a mechanical demulcent. Its pharma-
ceutical uses, as an excipient, for emulsionizing, and
for suspending insoluble substances or those the
acridity of which it is desired to mitigate, are very
numerous and important. Henry H. Rusby.
Acanthaceae. — (Acanthus family). A large family,
related to the Mints and Vervains, but unimportant
except for its very rich ornamental properties.
Many species have been utilized in the materia
medica of British India, and the properties of Adha-
toda (see Vasicine) are very peculiar. The principles
are mostly resinous and amaroidal, with a few-
alkaloids, and all the recorded actions and uses,
except those of Adhatoda, are rather indifferent.
H. H. R.
■Want hia. — A genus of true bugs, Hemiptera, para-
sitic on birds. These insects are sometimes introduced
into human habitations and attack man. They are
serious house pests in some parts of Mexico. See
Insects, parasitic. A. S. P.
Acanthocephala. — A suborder of nematode worms
which have no alimentary canal. The adult stage
occurs in the intestine of vertebrates, as a rule those
which live in or near water; the larva are found in
the bodies of certain invertebrates, very frequently
small Crustacea. All these worms possess a retrac-
tile proboscis armed with rows of hooks by means
of which they cling to the intestinal wall of their
host; hence they are called "hook-headed worms."
The genus Gigantorhi/nchus occurs commonly in pigs,
mice, rats, etc., and has been reported in man; Echi-
norhynchus has also been taken from the human
intestine. See Nematoda. A. S. P.
Acantholysis Bullosa. — This rare dermatosis, known
formerly as epidermolysis bullosa hereditaria, is a
typical familial anomaly, capable of being perpetuated
through several generations, manifest in infancy or
early childhood and insusceptible of modification by
treatment. Like urticaria factitia and hemophilia
it is a predisposition only, requiring slight external
irritation to become manifest. As some eases occur
in isolated individuals the adjective hereditary cannot
literally be used to designate the affection as a whole.
A comparatively new disease, acantholysis bullosa
has very probably masqueraded in past years as
pemphigus, or as a simple idiosyncrasy, since it is
obvious that very slight irritation will raise blisters on
certain subjects.
The bulls which characterize the disease vary
considerably in size and aside from a slight tendency
to hemorrhage present no peculiarities. They tend
to appear wherever the clothing bears or rubs against
the skin (neck band, wrists); on pressure surfaces
where ordinary blisters and callosities tend to form;
over the knees and elbows, because these joints when
flexed serve for support, and at the site of chance
knocks, etc. It is asserted confidently that blebs
never appear spontaneously. In cases in which
patients use certain members habitually a sort of
occupational disease may !)!• set up. A draughtsman
constantly holding a pencil bet ween his fingers and
thumb may suffer from an almost Continuous forma-
tion of bulla' where the implement presses He may
even as a result undergo slight atrophy of the linger
lips and lii-s of the nails. Under ordinary circum-
stances no permanent changes occur beyond possible
slight scarring and pigmentation, with alopecia in
hairy regions. A rare sequela is miliary retention
cysts from occluded sweat glands.
Nothing is known of the nature of the affection.
Certain features suggest a vasomotor lability, such
as underlies a number of other superficial affections.
The trauma acts upon the supposedly irritable blood-
vessels and causes an effusion into the rote.
Treatment may be summed up in protection of
exposed areas as far as practicable.
Acanthoma Adenoides Cysticum. — This affection of
the skin, to which many designations have been
applied, is most commonly spoken of as multiple
benign cystic epithelioma or simply benign epitheli-
oma. It is characterized by the formation of insensi-
tive tubercles or nodules, which are at first of pin-
head size and seldom exceed that of a pea. They
resemble very much a beginning epithelioma, having
the same pearly appearance, varying to pinkish or
yellowish. They are, however, numerous as a rule;
and, usually discrete in distribution, are at times
clumped together. They usually' occur on the face,
especially the central portion, including the eyelids,
root of the nose, lower part of the forehead, and
cheeks, but are sometimes seen on the trunk and
arms. Their growth is slow, and has a well defined
limit. More or less colloid transformation may ensue.
Firmly embedded in the skin, they cannot be shelled
out and when punctured only a little serum or blood
escapes, unless colloid degeneration has occurred. In
rare cases in which epithelioma has developed in these
growths there may have been no actual transition
from benign to malignant, for this is always extremely
rare in benign growths of any sort.
In the recorded material are a number of instances
of familial incidence, but this is not the rule. The
affection occurs irrespective of age and sex, but has
some tendency to appear at puberty. Some forms
have evidently been classed as varieties of the acne of
puberty, for both milium and comedones may be
closely simulated during the onset of the affection.
According to a number of authors some of the cases
reported as belonging to this affection should have
been lymphangioma tuberosum multiplex, an un-
related dermatosis having only a possible clinical
resemblance.
Benign epithelioma is purely a neoplasm, the
etiology and nature of which are no clearer than those
of other benign growths. Histologically it is com-
posed of formless masses and long processes of
epithelial cells not unlike those seen in true epitheli-
oma. Cell nests or pearls are to be found. The irre-
sponsible arrangement of the cells suggests an origin
from misplaced embryonal residues. We are entirely
in the dark as to how formations so generally resem-
bling true epithelioma can be benign, but the latter
is a disease of the degenerative period of life, while
benign epithelioma usually develops at puberty.
Practically there is hardly any chance of confounding
the two affections in the clinic. When benign epithe-
lioma is removed with the curette, incision and
evacuation, or electrolysis, there is considerable
tendency toward recurrence. The affection should
not be confounded with molluscum contagiosum,
simple colloid degeneration of the skin, or cysts of the
sweat glands (hydrocystadenoma).
Acanthosis Nigricans. — Synonym: Dystrophie pap-
illaire et pigmentaire (Darier). A disease of the
skin and mucous membranes characterized by
57
Acanthosis Nigricans
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
hyperpigmentation and papillary hypertrophy, devel-
oping, in the majority of cases, in the course of an
abdominal cancer.
The first recorded case of this disease occurred in
a patient in Unna's Clinique for Skin Diseases in
Hamburg, and was described by the present writer
in the "International Atlas for Rare Skin Diseases,"
No. 4, Plate X., in 1889. Since then cases have been
observed in nearly all the countries of Europe and
in this country. Couillaud, 1 in a monograph pub-
lished in 1S9G, was able to record thirteen cases. In
1909 the writer was able to report' fifty-two cases of
the disease collected from the literature.
The disease usually begins with a slaty or brownish
discoloration of the skin of the neck, about the genital
organs, and the umbilicus. In other cases the first
symptom to attract the patient's attention is the
papillary or condylomatoid proliferation affecting the
mucous membranes of the mouth. Other regions
that may be affected are the flexor surfaces of the
extremities, the axilla?, and the inframammillary
region, the anal region, and in women the vulval and
vaginal mucosa? A. striking feature of the distribu-
tion of the disease is its almost perfect symmetry.
The pigmentation varies from a light gray to a
bluish-black in color. It occurs over large areas and
fades at their borders into the normal color of the
skin. It is generally coextensive with the papillary
hypertrophy, but sometimes appears as a precursor
of this condition. It has never been noticed on the
mucous membranes.
The papillary hypertrophy varies in degree from a
slight prominence of the normal areas of the cuticle to
warty excrescences that may attain an elevation of a
centimeter. It occurs in extensive patches in the
regions noted and its borders merge insensibly into
the normal skin. The patches are always dry, there
is no exudation even from pronounced filiform
excrescences, and they impart a harsh grating sensa-
tion on palpation. On pinching up the skin the
epidermis is seen to have lost its elasticity, but the
affected regions are freely movable over the subcutis.
There is no appreciable desquamation from the
affected areas. On the mucous membranes the
papillary elevations may be discrete or they may occur
in patches. The excrescences sometimes attain a
very considerable size, and in appearance and con-
sistency are strikingly like venereal warts, but, unlike
them, do not bleed readily on palpation.
In some cases of long duration, changes in the
appendages of the skin have been noted. The nails
of the fingers and toes become dry, cracked, and mis-
shapen. The hairs on the head and over the entire
body become dry and fragile and may fall out spon-
taneously, producing a total alopecia.
Anatomy and Pathology. — Under the microscope
changes corresponding to the clinical picture are
found. The horny layer appears somewhat thick-
ened; the granular layer shows several rows of
keratohyaline cells; the rete Malpighii is the seat of an
hypertrophy which in some sections attains the
enormous dimensions seen ordinarily in common
warts, and its lowest layer contains great quantities
of pigment. The papilla? are elongated, sometimes
attaining a length of six or eight millimeters, and
often ramify, following the digitations of the epithe-
lium above them. They show no evidence of increase
in width. The subpapillary layer and the cutis itself
show but very slight changes — a moderate increase
in the number of emigrated cells, of mast and pigment
cells.
In considering all the cases recorded we may divide
them into two groups: those occurring in children,
the juvenile type, and those occurring in adults.
In the juvenile type, about one-third of the known
cases, the disease once established remains stationary
and the patients seem to suffer no inconvenience
except from the disfigurement. In the adult cases,
that is, those developing after the age of nineteen or
twenty years, an abdominal cancer has been found
or strongly suspected on clinical grounds in a pre-
ponderating number, not less than eighty per cent.
In the two cases in which an autopsy was obtainable
there was an extensive carcinosis of the abdomen,
which, while it spared the adrenal bodies, was
especially noted as involving the lymph glands in
close proximity to the large sympathetic ganglia.
There is little doubt but that the disease is directly
dependent on the existence of abdominal cancer, but
whether it be a cutaneous manifestation of a peculiar
cancer intoxication or w-hether it be due to changes
induced in the great sympathetic ganglia through
the pressure of the tumors on them, or to the com-
bined action of both these causes, is a matter that
future investigation must determine, but from the
fact that acanthosis nigricans does not occur in the
vast majority of cases of cancer, it seems reasonable
to ascribe the disease to a special localization of the
tumor which deranges the functions of the sympa-
thetic ganglia and the adrenals. In the juvenile
cases there is some ground for assuming a similar
action through benign tumors, connective-tissue
bands, etc.
i Diagnosis. — Ichthyosis, pityriasis rubra pilaris,
and keratosis folliculorum (Darier's disease) are the
only diseases which may bear even a remote resem-
blance to acanthosis nigricans. Ichthyosis is a mild
congenital disease, persists throughout life without
producing any general disturbances, is most pro-
nounced on the extensor surfaces, never affects the
mucous membranes, and is characterized by constant
desquamation in more or less extensive scales.
Pityriasis rubra pilaris, sometimes occurring in
extensive sheets about the great flexures and pre-
senting the peculiar discoloration common to many
hyperkeratoses, may suggest acanthosis nigricans, but
in all other respects there are more points of difference
than of resemblance between the diseases. Darier's
disease is differentiated by the limitation of the
affection to the follicles, the non-involvement of the
mucosa, the peculiar greasy character of the affected
surfaces, and the occasional occurrence of large
nodular masses from which a foul secretion is dis-
charged. The differentiation from the various
pigmentary affections of the skin need not be entered
into.
The prognosis of the disease in the adult cases is, of
course, that of the underlying cause — the abdominal
cancer; that is, it is hopeless. In some of the cases
the cutaneous manifestations have undergone a
varied course, probably depending upon changes in
the location or size of the tumors in the abdomen.
In one typical case the cutaneous lesions disappeared
in the course of six months after a radical operation
for malignant deciduoma. In my own case there
was an almost complete disappearance of the affection
of the skin and mucous membranes shortly before
the patient died. Sigmund Pollitzer.
References.
1. Couillaud: Dystrophie pap. et pig. ou acanthosis nigricans,
Paris, 1896.
2. Pollitzer: Journal Am. Med. Assoc, Oct. 23, 1909, vol. liii., p.
1369.
Acapnia. — From a- privative and na-rvbi, smoke,
vapor. A condition in which the amount of carbon
dioxide in the blood is reduced below the normal. This
may be produced voluntarily by taking a number of
deep and rapid inspirations; the carbon dioxide in the
blood is thereby reduced in amount, and as this gas in
the blood is the normal stimulus to the respiratory
center, the result is apnea. Persons who are obliged
to hold the breath for a long time, such as the pearl
divers <>f Ceylon, are aware of this effect of rapid
breathing and make use of it in their occupation. The
respiratory paralysis sometimes occurring under ether
anesthesia is attributed by Yandell Henderson 1 to
;,.s
iference Handbook
OF THE
lEDICAL 5CIENCES.
Plate IN
Fig. 2. Shows the discoloration about the lips
and chin, and the condylomatoid proliferation at
the angles of the mouth.
H
Fig. 3. Microscopic section through one of the condylomatoid masses
at the mouth.
Acanthosis Nigricans. "Case of Dr. S. Pollitzerj from the International Atlas of
Rare Skin Diseases.'
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Acclimatization
acapnia induced by the excessive pulmonary ventila-
tion in the primary excitement occurring in unskillful
etherization. The same investigator 2 attributes the
shock after operation largely to acapnia resulting from
hyperpnea during beginning etherization. He holds
also that the cessation of peristalsis when the abdomen
is opened is due to local acapnia from direct exhala-
tion of CO,, this being still further increased by laying
hot damp" clothes over the intestine. Again the
uterine contractions of normal labor, he thinks, arc
stimulated by the normal carbon dioxide content of
the blood; and the ineffective pains of tedious labor
arc due in large part to rapid breathing and the con-
sequent acapnia. The conclusion at which he arrives
as a result of numerous observations is that "C0 2
tension in the nerve centers and in the tissues and
fluids of the body is a factor in the maintenance of
tonus (in the broad sense of the word) of the same
order of importance, as temperature, oxygen supply,
osmotic pressure, and the equilibrium of anions and
cations." (See also Anesthesia, general surgical, sec-
tion on the Role of carbon dioxide. j T. L. S.
References.
1. Surgery, Gynecology, and Obstetrics, August, 1911.
2. American Journal of Physiology, April, 1909.
Acardius. — See Teratology.
Acarina. — Acarida. An order of mites of the class
Arachnida. These arthropods are of small size, are
usually ectoparasitic in habit, and their structure
shows some degeneration. The order includes a
number of species which cause various dermal dis-
orders. Among the most important families the
following may be mentioned: Detnodicida:, par-
asitic in hair follicles; Sarcoptidw, the itch-mites of
mammals; Ixodidw, the ticks temporarily parasitic on
terrestrial vertebrates. Mites usually hatch from
eggs in an immature condition and undergo a meta-
morphosis. See Arachnida. A. S. P.
Acaroides gum.— See Xanthorrhcea Resin.
Acarus. — An old name for the genus Sarcoptes
which includes a number of species of itch-mites.
S. scabiei bores galleries in the human skin, pro-
ducing itch, and may also be a cause of eczema. See
Arachnida. A. S. P.
Acinesia Algera. — A condition characterized by
pain on movement. This is purely a symptomatic
designation and has little clinical significance. Most
of the cases previouslj' called by this name are of
patients suffering from myalgias, indurative myositis,
or intermittent claudication. S. E. J.
Accidents. — See Injuries, and Workingmen's Com-
pensation Acts.
Acclimatization. — When an3>- animal, brute or
human, is removed from the environment to which he
and his ancestors have long been accustomed, a con-
siderable disturbance of the whole economy is liable to
ensue. The process of evolution has developed
certain organs and certain functions in accordance
with the requirements of those circumstances under
which his race has found itself, and when he is sud-
denly transplanted into new conditions some of his
faculties become without occupation, while others
hitherto uncalled upon, and therefore undeveloped,
are suddenly subjected to a demand to which they are
quite unable to respond. The process of accommoda-
tion of the individual to new conditions of climate is
known as acclimatization or acclimation.
No other animal is so facile in his accommodation to
changes of climate as man. The lower animals and
plants often do not recover for several generations
from the effects of transplantation. The Society d'-
Acclimatisation of Paris has for years been rallying
on, in its gardens, an extensive zoological experiment
on the domestication of foreign animals and plants
which it is believed can be made useful to European
countries. The re >:>° N. latitude, Euro-
peans acclimate much less readily than in the same
latitudes south. Algiers, for instance, is vastly more
difficult for the European to live in than < ape ( lolony,
yet both places are about latitude :i.">°. The Argentine
( 'mi federation and New South Wales are more healthy
than the East and West Indies, which are of the same
latitude. The mortality of the French and English
troops has been found to be about eleven times as
great at foreign stations in the northern as at those in
the southern hemisphere. The chief cause of the dif-
ference is in the prevalence of miasmatic fevers so
deadly to Europeans. Those fevers in the northern
hemisphere occur even in high altitudes, while south
of the equator they do not extend beyond the tropic.
The island of Tahiti, for instance, about latitude 18 S.,
is quite exempt from these fevers. The records of the
French and English soldiers on foreign service show,
in South America, a sickness from malarial fevers of
L.6 in 1,000 men per annum; while in a similar latitude
in the northern hemisphere, the number of such cases
annually is 224 per 1,000.
To the question, "Can Anglo-Saxons ever become
completely acclimatized in the tropics?" a more or
less guarded negative reply has been given by proba-
bly a majority of the most eminent authorities. This,
it will be observed, does not mean that Anglo-Saxons
cannot live in the tropics under conditions of special
caution. It does imply, in the minds of its advocates,
that Europeans can never expect to perform the same
work under the same conditions as the natives. If this
be the case, it presupposes the continuance of a
distinctively menial or servile class as a permanency,
which appears to be inconsistent with the theory of a
purely democratic colony.
In favor of the pessimistic view regarding tropical
acclimatization are urged the high death rate, the
physical deterioration, and the reduced fertility of
Europeans in the tropics. The first two of these
considerations are certainly matters in which the
improved sanitation of recent times may be expected
to count for much. In fact, the annual mortality of
European troops in India, which prior to 1S59 had
been 69 per 1,000, had fallen in thirty years to 12 per
1,000. The death rate of European children in India
is considerably less than that of native children, and
in some colonies compares favorably with that in
many districts of Europe.
Whether, as has been sometimes claimed, white
families in the tropics are likely to die out, is difficult
of demonstration, because the stock is liable on the
one hand to be reinforced by fresh European immigra-
tion, or on the other to be deteriorated by mixed
marriages. But a paper presented at the Seventh
International Congress of Hygiene and Demography
by Sir Clements Markham shows that families of pure
European blood had been settled in tropical places for
more than two centuries without any deterioration,
mentally or physically, of the later, as compared with
the earlier representatives.
Regarding fertility as affected by removal of Euro-
peans to the tropics, great diversity of opinion has
existed. The analogy of plants seems to sugge-t a
loss of fertility, at least temporarily, from a change of
climate. For example, the chrysanthemum is said to
59
Acclimatization
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
have remained infertile for sixty years after its trans-
Elantation from China into France, so that the seed
ad to be continually imported. But after that time
fertility began to be regained, till now the species
propagates itself. European fowls, which when first-
brought to Bolivia became sterile, later regained their
fecundity.
Regarding the human species, however, we are lia-
ble to error in judging from cases in which infertility
is due to crossing of the breed with inferior races; or
when possible lack of fecundity is overcome by fresh
European admixture. Yet, as against a permanent
sterility of pure European families in the tropics there
are abundant instances. It is said that Spanish
women in Guayaquil, at a temperature rarely below
S3 F., are exceedingly prolific, and that the French
have a higher birth rate in Algeria than in France.
In general, we may say that it is not temperature or
climate intrinsically which is the obstacle to acclima-
tization. Physiology has shown the marvellous
adaptability of man to withstand the widest ranges of
thermometric variation. Moreover, anthropologists
agree that mankind is all descended from one primi-
tive stock. Hence man has acclimatized himself, as a
matter of fact, wherever by successive migrations he
has permanently occupied new fields.
The principal climatological changes to which one
must accustom himself in making a change of residence
may be divided into those of (1) barometric pressure,
(2) humidity, and (3) temperature; of these the last
are by far the most important.
1. Barometric Pressure. — Leaving out of account, of
course, conditions of increased atmospheric pressure
which are usually artificial (see Caisson Disease) and
if not, as in removing from a high altitude to a low one,
are of little practical importance, we pass at once to
phenomena accompanying change to a rarefied atmos-
phere, as in removing from the sea-level to a mountain-
ous locality. Persons with sound hearts and arteries
usually experience little difficulty in accustoming
themselves to altitudes of 6,000, 7,000 or even 10,000
feet. Many of the most thriving cities on our conti-
nent are at such heights and the inhabitants suffer no
inconvenience. Mountain climbers inure themselves
to elevations of upward of 20,000 feet. On the other
hand, people with weak cardiac muscles may be
incapacitated at elevations of 3.000 feet or less.
Tuberculous patients visiting high altitudes for cure are
probably somewhat more prone to pulmonary hemor-
rhages than if they had remained at a lower level.
The main precaution to be observed for those who
find the increased respiratory rate embarrassing is to
keep perfectly quiet for a time and then to begin
exercise only with great moderation. Usually, unless
the cardiac insufficiency is considerable, they cam
gradually work up to a degree of activity equal to
their fellows. If they return to a lower level, however,
and from thence go back to the higher, the same pre-
cautions must be taken as in the original instance.
2. Humidity. — This is generally far greater in the
tropics during certain seasons than in temperate
zones. It generally goes hand in hand with the
amount of rainfall, which sometimes, in the Philippine,
for instance, rises as high as eighty inches in two
successive days. Independently of the fact that a
high humidity makes heat more oppressive, great
moisture is liable to aggravate rheumatic affections.
The dangers of high humidity are of course largelv
unavoidable, but one should, if possible, make his
entrance to a tropical region in the dry rather than
the rainy season.
3. Temperature Changes. — These may be in the
direction of either a colder or a warmer climate.
Regarding the former, lit lie need be said. Apart from
cases of starvation and freezing, Arctic explorers usu-
ally endure cold very well. The facility of the
acclimatization of the negro even to the far north is
shown by the fact that among the few men who
accompanied Peary nearly or all the way to the north
pole was a negro. Abundant clothing and food of a
high caloric value, especially fats, are the obvious and
chief fortifications against cold. Four thousand or
more calories per day are requisite for an adult.
Acclimatization against Hot Climates. — With the
great expansion in late years of our country's colonial
possessions, tropical acclimatization has assumed an
importance greater than ever before, and fortunately
nearly coincidently with the acquirement of new
territory, new knowledge has come to us of how to
meet many of the dangers hitherto so fatal.
First under this head we naturally think of the
effects of heat, per se. The precautions to be ob-
served here differ only in degree from those we are
familiar with as necessary in our summers at home.
Avoidance so far as may be of the direct rays of the
sun, through keeping in doors in the middle of the day,
is made easier by the tropical custom of suspending
business for three or four hours about noon and con-
cent rating work in the morning or late afternoon.
Pleasure-seeking is naturally confined to evening
hours. The pith helmet, the umbrella, and the ha-
bitual use of the shady side of the street (if any) are
natural protections against heat stroke and sun stroke.
Quite as important is a dietetic regimen which will
supply less calories than are needed in a temperate
clime. Two thousand or less calories should suffice
the average adult. Rice as a staple of diet has long
approved itself in hot countries. Fruits and vege-
tables may largely replace protein and especially fat
foods. Alcohol, especially in its stronger forms,
should be avoided or minimized. The free use of
spirits by Englishmen translated to India has long
been a by-word as a contributor to sickness. Care
must, however, be exerted in the use of drinking water
for reasons which will shortly be considered.
We come now to the greatest dangers in the way of
warm acclimatization. These are from diseases
many of them caused by protozoa which find inter-
mediate hosts in insects.
First of these in importance is the group of malarial
diseases. It is these that have made large tracts of
the earth uninhabitable to white men for centuries.
While the typical tertian, double tertian, and quartan
types, characterized by more complete periodicity,
are found in many temperate climates it is the sub-
tertian, or estivoautumnal type which manifests the
greatest malignancy and this is practically limited to
tropical and subtropical climates. In all kinds of
malaria, however, the microorganism penetrating to
the blood-corpuscles develops asexually and with the
pouring forth of the new-formed organism after the
rupture of the blood-cell, comes the chill.
The sexual propagation of the various parasites
takes place generally in the body of the mosquito,
which sucks out the parasites in the action of biting a
person who carried them. After undergoing develop-
ment in the mosquito they are again injected into
the next person when that insect bites. It is the
Anophelina: alone among mosquitos which carry the
malaria parasite. They take it from man and recarry
it to man.
The aim in preventing this infection is therefore to
protect from this mosquito. If this protection is
made complete the otherwise deadliest malarial
swamp will be perfectly safe. In the attempt to
fortify every portion of the line one seeks:
(1) To limit the malarial-bearing pabulum of the
mosquito by treating all infected persons with quinine
to kill off, as far as possible, the organisms from their
blood.
(2) To prevent the mosquito from hatching by
(n) removing by a drainage-system standing water
where they may breed; the cultivation of soil also
tends to absorb standing water; ('0 when water cannot
be got rid of, by covering its surface with petroleum,
so that any larva; may thus be killed; (c) screening
60
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Acclimatization
houses and also beds so thai any mosquitos if they are
hatched and then become infected, they cannot bite
another individual; (ii
pediculi and also by certain species of ticks. Another,
i he African relapsing fever, is definitely known to be
conveyed to man by a specific tick, so that the dis-
ea e i^ called "tick fever.'' Prophylaxis for Euro-
peans is easy because the I iek cannot climb a smooth
surface and if bedclothes are kept from touching the
floor the insects cannot get upon a bed, and they do
not bile by day. Resting or sleeping in a native hut,
however, should be avoided, as the ticks might get
upon the clothing.
The acclimatizing European must be especially
careful of the drinking water and it is safer to drink
only bottled or distilled water till he can have the
benefit of a careful examination of the local supply.
Among his dangers from this source are the ingestion
of Amoeba coli. This is a common cause of tropical
dysentery and it may leave the intestinal tract and
cause abscess of the liver. The Shiga bacillus is
another cause of dysentery. Typhoid fever and
cholera are of course due to their specific bacteria
which are generally absorbed with the drinking
w ater.
Certain intestinal parasites constitute a danger to
be reckoned with by acclimatizing strangers. The
ordinary cestodes or tape-worms require only a pass-
ing mention as their cysticerci can be readily killed
by the cooking of the flesh of their intermediate hosts,
swine {Taenia solium), cattle {T. saginata) and fish
(7\ bolhricephalus).
A schistosomum, known as Bilharzia ha-matobia
(Schistosomum haematobium), is common in most parts
of Africa and was brought home by many British sol-
diers from the Boer war. It is introduced by drinking
water and possibly through bathing. The adult worm
causes no disease but the irritating effects of the eggs
upon various mucous surfaces when they are deposited
in great number, are most serious. In the intestinal
tract the inflammation thus set up causes bloody
diarrhea. But the worst, effect is in the urinary tract
where these eggs cause hematuria, cystitis, and oc-
casionally calculi. They may exist also in the lungs
and cause hemoptysis.
A most important parasite is the Ankylostonium
duodenale or its allied Necator americanus, the "hook-
worm." This requires no intermediate host. The
eggs when passed with the feces and spread upon the
ground under conditions of warmth and moisture,
develop rapidly and may in moist earth remain alive
for months or even years. If introduced into another
person on vegetables or by the dirty fingers of him-
self or of a cook, they develop in this new person.
Moreover, if a person goes barefooted upon such
infected soil the larvoe can penetrate the skin of the
foot-sole, pass in the blood-stream to the lungs thence
into the trachea thence to the esophagus and so to the
stomach. In the duodenum they are prepared to
hook themselves to the mucous membrane. From
the laceration which they cause, a permanent blood-
drain is caused and the patient begins to suffer from
progressively increasing anemia which may become
as profound as pernicious anemia. Fatty degenera-
tion of viscera follows. The patient may have
constipation or dysentery, but in either case is always
passing the eggs, to be a menace to others. The
prophylaxis is in the care of excrement, precautions
about vegetables and drinking water, cleanliness of
the hands of cooks, and of course always going with
the feet shod. Superficial burials must be forbidden.
61
Acclimatization
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Deposition of feces in sea-water destroys eggs and
larvae.
Plague has been endemic in the Far East for a
number of years though the disease has been relatively
harmless compared with the great pandemics of
"Black Death" which swept Europe in previous
centuries. Before a fresh outbreak in any locality it
has been noted that an increase of sickness among
rats has occurred. Doubtless these animals and also
perhaps squirrels serve to propagate the plague
bacillus and to infect man. Rats with open ulcers
are especially active agents in keeping the disease alive.
In this condition fleas may serve to convey the infec-
tion from the rats to man. From the end of winter
to the beginning of the rainy season is the term of
greatest danger (January to June). The destruction
of all vermin of whatever size is the chief element of
prophylaxis.
It will be noted that most of the precautions needed
by a European coming into the tropics center about
insects and vermin which are the most important
carriers to man of the worst tropical diseases. The
antityphoid vaccination now so generally practised
among large bodies of men in our own country is
an especially wise precaution for the immigrant into
tropical countries where enteric fever is known to be,
as it usually is, prevalent.
Beyond the foregoing considerations, the principal
factors conducing to acclimatization are those of
general hygiene and social environment. Every
means should be taken to overcome homesickness.
If society is wanting, work must be relied upon to
take up the mind. It is said that the workers
acclimatize more readily than the idlers in hot
countries. Of the various forms of exercise, which
is always so important from a hygienic point of view,
riding and driving are especially desirable in warm
countries. Cool and cold baths daily are of use. The
advantages of hydrotherapy are often combined with
those of high elevation in the sanatoria which are
located in the mountainous districts (where such
exist) in many warm countries, and whither the half-
acclimated European repairs from time to time with
much benefit to paludic, dysenteric, and hepatic
affections. Finally, if dysentery obstinately recurs
in the high altitude, or if the system does not throw
off miasmatic impressions, it is better, after a reason-
able time, to abandon the attempt at acclimatization
and return to a temperate climate. The ocean
voyage will be likely to cause some relief, and after
a reconstitution of the bodily powers in the home
country, a second attempt at acclimatization may be
more successful. Chakles F. Withington.
Accommodation and Refraction. — Accommodation
is the word used to designate the adjustive power of
the eye for distinct vision at different distances: in
modern ophthalmology it denotes the active increase
in optical power by which the eye changes its adjust-
ment from longer to shorter distance--.
The existence of an active accommodation, effected
through an increase in the convexity of the crystalline
lens, was demonstrated by Thomas Young (Philo-
sophical Transactions, 1801), but the conclusiveness of
his proofs was not generally recognized until fully
half a century later. The first actual observation of
th<> change in curvature at the anterior surface of the
crystalline lens, by Maximilian Langenbeck (1849),
was confirmed (1853) by A. Cramer, who, by the
employment of more refined methods, demonstrated
an associated forward displacement of the anterior
lens surface. Cramer's observations were followed
closely in time by the wholly independent research
of H. Helmholtz (1S55), which definitively estab-
lished the fundamental theory of accommodation
and opened the way for the exhaustive investigations
of Donders, as presented in his monumental work
"On the Anomalies of Accommodation and Refrac-
62
tion of the Eye" (1864). Tscherning, who took up
the subject anew (1S94, 1895), brought to light impor-
tant additional details.
The changes in the eye in accommodation consist
essentially in (a) a notable increase of curvature in a
central area of the anterior surface of the crystalline
lens, (6) a much smaller but positively demonstrated
increase of curvature in a central area of the poste-
rior surface of the crystalline lens, and (c) an increase
in the axial thickness of the crystalline lens, measured
by the central displacement of its anterior surface;
the position of the center of the posterior lens surface
remaining unchanged.
Accommodation is accompanied by active contrac-
tion of the pupil, the effect of which is to stop off all
but a comparatively small central portion of the
crystalline lens, with exclusion of the much larger
equatorial zone from participation in the formation
of the retinal image. Both accommodation and the
accompanying pupillary contraction are essentially
binocular acts, and are sensibly equal in the two eyes.
They are, moreover, intimately associated with con-
vergence of the visual axes, thereby making it possible
to see near objects single, as well as distinctly, with the
two eyes.
The several adjustments which go to make up the
complex act of binocular accommodation are coordi-
nated under the control of the third (oculomotor)
pair of cranial nerves. Thus the impulse to accommo-
date, in order to see a small near object distinctly,
evokes not only the needful lenticular changes with
contraction of the pupil, in both eyes, but also the
correlated action of the exterior muscles of both eyes
in convergence for the distance of the object. Con-
versely, the impulse to converge, so as to make the two
retinal images fall each at the central fovea in its own
eye and so prevent confusion from double vision,
evokes commensurate exercise of the accommodation
with contraction of the pupil, in both eyes.
The physiological bond by which accommodation
and convergence are coordinated is, however, elastic,
within certain limits. Thus the relation of the two
adjustments may be altered, for the time being, by
looking through concave or convex spectacles, or
through divergent or convergent prisms, so as, with
unchanged convergence, to force or to relax the accom-
modation, or, with unchanged accommodation, to
increase or to diminish the convergence of the visual
axes. Such experiments are, however, fatiguing,
and cannot, as a rule, be long continued without
giving rise to a sense of ocular strain, or to headache
or other reflex nervous disturbance.
Again, accommodation becomes more and more
difficult, with advancing age, as a result of progressive
induration of the crystalline lens, but is nevertheless
maintained, under convergence for a practicable read-
ing distance, to an average age of about forty-five
years at which the disability of old sight {presbyopia)
ordinarily asserts itself.
Again, many persons, subjects of anomalies which
involve notable alteration of the relation of accommo-
dation to convergence, experience no difficulty in
near work or perhaps even imagine that they enjoy
exceptionally good vision. These are generally cases
either of congenital anomaly or of an anomaly of so
gradual development as to afford time for a corre-
spondingly gradual change in the mutual relation of
the two adjustments.
The accommodative increase in the optical power
of the eye, designated by Donders (1858) as the range
of accommoiliilinn, is conveniently estimated in units
called dioptries; one dioptric (1 D) denoting the power
of a convex lens of one meter focal length, 2 D the
power of a lens of one-half meter focal length, etc.
The maximum range of accommodation for any eye
is attained when the fellow eye is covered or otherwise
excluded from participation in the visual act and is
free to assume a position of extreme convergence.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
AcooniT lallon and
Refraction
This maximum range is called the absolute range of
accommodation. The range of accommodation for
the two eyes together, under convergence for any
particular distance, is called the binocular range of
accommodation; and the range "over which we have
control at a given convergence of the visual lines,
[which] represents the degree in which accommodat ion
is independent of convergence," is called the relative
range of accommodation.
The relative range of accommodation varies greatly
for different distances. Thus Donders found thai in
the case of a young person, of the age of fifteen years
it was possible to accommodate with either eye
singly up to a distance of 3.69 Paris inches (about 10
cm. = T \ T meter), indicating an absolute range of
accommodation of about 10 D. With the two eyes
together, it was possible to see distant objects dis-
tinctly through concave glasses of any power up to a
limit of eleven Paris inches (negative) focal length
(about 29.7 cm. =r£, meter), indicating a relative
range of accommodation of about 3.37 D under
parallelism of the visual axes. Under convergence
for a distance of 3.9 Paris inches (about 10.5 cm. = oH
meter) it was just possible to accommodate for that
distance, but it was also possible to see distinctly,
with the two eyes, through convex glasses up to a
limit of nine Paris inches (about 24.3 cm. = £i meter
focal length, indicating a negative relative range of
accommodation of about —4.1 D. Under higher
grades of convergence, i.e. for distances less than 3.9
Paris inches (10.5 cm. =^j meter), it was impossible
to accommodate with the two eyes for the distance of
the point of intersection of the visual axes. At all
distances greater than 10.5 centimeters small objects
were seen distinctly and single through concave glasses,
and also through convex glasses; in other words, the
relative range of accommodation was in part positive
and in part negative. "This distinction acquires
practical importance from the fact that the accommo-
dation can be maintained only for a distance at which,
in reference to the negative, the positive part of the
relative range of accommodation is tolerably great."
(Donders.)
Fig. 15 shows, in the form of a diagram, a series
of measurements of the relative accommodation in the
ease cited, as plotted by Donders; the ordinates in-
dicating dioptrics of accommodation, and the abscissas
the distances of points of intersection of the visual axes,
in fractional parts of a meter.
By inspection of the diagram it is seen that the
positive part of the relative range of accommodation
— i.e. the part above and to the left of the diagonal
KK — appears only in convergence for distances
greater than about rSr meter (10.5 cm.). At
a distance of I meter (12.5 cm.) the positive part
is about four-tenths as great as the negative; at
one-third meter (33.3 cm.) the positive part exceeds
the negative in the ratio of about 16 to 10.
These observed relations of the positive to the
negative part of the relative range of accommodation
are in close accord with every-day observation of the
working of the accommodation in young persons.
Thus a child of say twelve years can ordinarily force
his accommodation so as to see minute objects dis-
tinctly for a short time at a minimum distance of about
10 centimeters, using about 10 D of accommodation.
At a little greater distance, about 12.5 centimeters,
using about 8 D of accommodation, he can read for a
much longer time, although not, as a rule, without
consciousness of effort leading to fatigue. At about
20 centimeters, using about 5 D of accommodation,
the accommodation can . often be maintained for
hours together in close work, but not without in-
curring the risk of ultimate injury to the eyes when
reading at so short a distance has become habitual.
The limit of ease and safety, for young persons, in
long-continued use of the eyes in reading and study, is
about 33 centimeters (about thirteen English inches),
or perhaps a little less, corresponding to an habitual
use of about 3 Dofaccon lation. At this distance
the relative range of accommodation Is ample, and the
positive part is al about its maximum.
The letters r, r„ r„ and p, p„ p, (Fig. 15) indicate
the observed absolute, relative, and binocular fait he I
and nearest points, respectively, of distinct vi ion.
Under parallelism of the visual axes the absolute far
point (r) and the binocular far point (r 2 ) fall together
al an infinite distance; but there is a positive relati e
accommodation of about 3.37 1). Under convergence
for a distance of '. meter (10.5 cm.) the relative near
point (p,) and the binocular near point (p..) fall
•
>;
r
ft,
'"
P|
M
j
' ,
/
y
/
//'.
1
y
r,
l i l_l_J_JLJ_J.iliii_L±AJ-XX-LJ
1 £ 3 4 5 7 8 9 10 11 12 13 14 15 10 17 18 l'J £'
Fig. 15. — Diagram showing the relative range of accommodation
for different distances. (After Donders.)*
together, but there is a negative relative accommoda-
tion of about 4.1 D. Under increased convergence,
for distances less than 10.5 centimeters, at which
binocular accommodation is no longer possible, the
i negative) relative range of accommodation decreases
until, under forced convergence for about one-
eighteenth meter (about 5.5 cm.), the relative
near point (p,) and the relative far point (r,) fall
together at the absolute near point (p).
Table A.
Accommodation t i 2 34567S9 10 11 12 13 1115 1617 1819 20
in dioptries. J
Distances in 1 « uiiiitu 1 j i i i i I i J i i
\ 00 1 2 3 i 5 u 7 S § ID 11 I: 13 II IB 13 17 Ifl i Q
meters. J
Table A represents, in parallel series, consecutive
dioptries of accommodation and the corresponding
distances of the points of intersection of the visual axes
in binocular fixation. It will be remarked that the
first dioptrie of accommodation covers all distances
from infinity to 1 meter; that the second covers a
distance, 1-4 =\ meter; the third, £-i=tj meter;
the fourth, £-i= T W meter; the tenth, | - T V = ^
meter; etc.
Designating the distance of the farthest point (r)
of distinct vision for any eye by R, and the distance
of the nearest point (p) of distinct vision for the
same eye by P, the distance, R — P, increases at a
progressively increasing rate as R approaches infinity,
and decreases at a progressively decreasing rate for
* Fig. 15 has been slightly changed to conform to the metric sys-
tem, which has come into general use in ophthalmology since the
publication of Donders' work.
63
Accommodation and
Refraction
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
decreasing values of R. The linear distance R — P,
— the region of accommodation of Donders — has a
significance wholly distinct from that of the range of
accommodation, (p — w) dioptries, as will appear in
connection with the study of the Anomalies of
Refraction and their correction by spectacles.
Refraction, as the word is used in ophthalmology,
denotes either the absolute optical power of the eye
as determined by the radii of curvature of its several
surfaces and the refractive indices of its several
media, or the power estimated as deficient or ex-
cessive according as the focus of the eye for parallel
rays falls behind or in front of the retina. The
refraction of the eye as a whole is the sum of consecu-
tive refractions, (a) from the air into the cornea, (6)
from the cornea into the aqueous humor, (c) from the
aqueous humor into the crystalline lens, (d) from
layer to layer of the crystalline lens, through a
medium of progressively increasing refractive power
(index of refraction) from its anterior surface toward
its center and of decreasing refractive power from its
center to its posterior surface, and (c) from the crys-
talline lens into the vitreous humor. Inasmuch as the
curvatures of the several refracting surfaces and the
indices of refraction of the several transparent media
remain constant or nearly constant, after the eye has
once attained to its full development, the absolute
refraction is practically constant for any particular
eye.
The principal posterior focus of the eye falls at an
average distance estimated as 14. SO millimeters
behind its second nodal point (k"), 19. S7 millimeters
behind its second principal point (h"), and 2_ > ._':i
millimeters behind the anterior surface of the cornea
at its center; the last measure representing the distance
of the retina from the vertex of the cornea in a
normally proportioned eye of average dimensions.
Inasmuch as the power (in dioptries) of a compound
refractive system is the reciprocal of the distance
(in meters or decimal parts of a meter) at which its
principal focus falls beyond its second nodal point
(k"), the quotient, ^-FTTToZ = 67.29 represents, the
U.U14ou
optical power of the average human eye, in dioptries.*
Measurements of the curvature of the cornea and of
the two surfaces of the crystalline lens are found to
vary considerably in different persons, and this without
giving rise to any related functional disturbance.
The explanation is found in a corresponding variation
in the size (length of axis) of the eyeball. In a
person of large stature all the measurements of the
eye are apt to exceed the average; the absolute re-
fraction of the larger eye being someu hat less and the
size of the inverted retinal image somewhat greater,
than in the case of a smaller eye. A larger eye is
therefore, ceteris paribus, of somewhat greater
visual acuity than a smaller eye, just as a photo-
graphic lens of longer focus, in a larger camera, gives
* By making permissible small changes in the computed dis-
tance of the second principal point (A") and of the second nodal
point (fc") from the retina, Donders showed that it is possible to
reduce the several refractions in the eye to an equivalent single
refraction at a convex spherical surface of 5 nun. radius of curva-
ture, bounding a refractive medium of g = 1.3 index. In this
"reduced" eye the focus for parallel rays falls 20 mm. behind the
single principal point (p) at the vertex of the spherical surface, and
15 mm. behind the single nodal point (k) at its center of curvature.
The power of the reduced eye, n „, ^ =66.6 dioptries, and the
0.01 o
ratio of the size of a distant object to that of its inverted image,
— , differ negligibly from those based on the
measurement, used in the "schematic" eye of Listing as revised
by Helmhobz. The easily remembered numbers, 5, 15, 20, or
their ratios, 1 : .'! : 1, may therefore be used without appreciable
error in numerical calculations, ami in geometrical constructions
illustrating fundamental problems ifi physiological optics.
a larger and more perfect picture than a lens of shorter
focus, in a smaller camera.
The estimation of the absolute refraction in a
particular eye involves objective measurements too
refined to be attempted in clinical work, and also of
no practical significance unless supplemented by a
tin ire accurate measurement of the length of the eye-
ball than is possible in the living subject. On the
other hand, estimates in terms of refractive defi-
ciency or excess are readily made by testing with
convex or concave trial-glasses, and are also directly
available in prescribing spectacles.
We have, therefore, to recognize, first of all, a
standard of correct proportion, emmetropia, E (from
epperpos, proportionate, and Sxp, eye), in which a
sharply defined image of a distant object is formed
on the retina without the exercise of any part of the
accommodation, so that the entire range of accom-
modation is available to meet the requirements of
distinct vision for near objects. The region of accom-
modation includes, therefore, all distances from
infinity to a near point (p) which is near enough to
the eye to satisfy exacting requirements in close work.
The definition of emmetropia as correct proportion
implies the negative concept of incorrect proportion,
ametropia (from dpiTpos, disproportionate, and &ii,
eye), in which the principal focus of the eye falls
elsewhere than at the distance of the retina. Ame-
tropia occurs under two opposite types, according as
the retina lies in front of or behind the principal focus.
Hypermetropia, H (from v-(p, over, phpov, meas-
ure, and &(,'■, eye), is the condition in which the prin-
cipal focus falls behind the retina. A hypermetrope
whose range of accommodation is in excess of that
required to advance the focus for parallel rays to the
actual position of the retina, is able, through the
exercise of some part of his accommodation, to see
clearly at a distance. A part only of the range of
accommodation is then available for near vision and,
by reason of the near point falling too far from the
eye, the region of accommodation is commensurately
curtailed. In the higher grades of hypermetropia
the normal range of accommodation is often insuffi-
cient for distinct vision even at a distance; in the
lower grades it is generally possible to read, but pro-
longed effort is apt to give rise to a feeling of strain or
fatigue, with blurring or "running together" of the
print. With the progressive recession of the near
point incident to advancing age, these (asthenopic)
symptoms and disabilities give place to those of pre-
mature old sight (presbyopia), and ultimately to
indistinctness of vision at all distances.
In typical hj-permetropia the disproportion is the
expression of actual deficiency in the length of the
anteroposterior diameter of the eyeball. The relative
nearness of the retina to the second nodal point of
the eye, and the fact that hypermetropia is hereditary,
suggest reversion to structural conditions found in
the lower mammalia. The crucial test of hyperme-
tropia is the ability to see distinctly at a distance
through convex glasses; its measure, in dioptrics, is
the strongest convex lens through which vision at a
distance is unimpaired. (See Hypermetropia.)
Myopia, M (puunrlct, puio-laois, pou*,'', from piu), to
close or contract, and &ib, eye), so named by early
writers from the habit of contracting the opening of
the eyelids in looking at distant objects, is the exact
opposite of hypermetropia in that the principal focus
of the eye falls in front of the retina. A myope sees
indistinctly at long distances, but is able to accom-
modate for a distance a little less than that of the
near point in emmetropia. The region of accom-
modation is greatly curtailed through the approach
of the far point to the eye, with unimportant com-
pensation in the approach of the near point; in very
high grades of myopia the region of accommodation
i~ reduced to insignificance. In myopia of low grade
the disability of old sight (presbyopia) first asserts
64
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Accommodation and
Refraction
itself at a later period of life than in emmetropia; in
the higher grades, in which the far point (r) lies well
within the ordinary reading distance, presbyopia,
in the ordinary acceptation of the word, is an
Impossibility.
In typical myopia the disproportion is the expres-
sion of axial elongation in a pathologically distended
eyeball. Myopia generally appears in childhood,
and increases progressively during the period of
school life; the increase in grade being in direct
relation to the habitual use of the eyes at too short a
working distance. Unlike hypermetropia, myopia
is the visual expression of disease which, in later life,
may progress even to loss of sight. The test of myopia
is the inability to see distant objects distinctly except
through concave glasses; its measure, in dioptries,
is the weakest concave lens which brings distant vision
up to the same relative acuteness as at distances
within that of the far point. (See Myopia.)
The positions of the far point (r) and the near point
(p) are measured from the first nodal point (A-') which
is situated about 6.95 millimeters behind the vertex
of the cornea. Representing these distances by R
and P, respectively, the range of accommodation, in
dioptrics, by A, and the degree of myopia or of hyper-
metropia, in dioptries, by M or by — H, we have:
In emmetropia,
in myopia,
in hypermetropia.
R =infinity,
P = meter;
R =,, meter,
M
P =
1
A + M
meter;
1
R = — ■' meter,
It
P = -7 — ;. meter.
A — H
From a comparison of these equations it will be seen
how, for the same range of accommodation, the region
of accommodation is most extensive in emmetropia.
In myopia the region of accommodation is greatly
curtailed through the approach of the far point (r),
with unimportant compensation in the approach of the
near point (/>). In hypermetropia of low grade, in
which only a part of the range of accommodation is
available in near vision, the region of accommoda-
tion is curtailed through the recession of the near
point (p) from the eye, the visual far point falling,
as in emmetropia, at infinity. When H is so large, or
A so small, that A is less than H, the entire range of
accommodation becomes negative, and distinct vision
is impossible at any distance.
When a concave spectacle lens of an effective power
equivalent to — M dioptries is worn in front of a myopic
eye, or a convex lens of +H effective power is worn
in front of a hypermetropic eye, the corrected linear
values
in myopia,
in hypermetropia,
R =
P =
1
= infinity,
M - M
1 1
-j .-,- — ., ■= , meter
A + M - M A
R =g-— g = p=infinity,
P = A-H + H = A meter;
are the same as in emmetropia; the far point (r)
falling at infinity, and the near point (p) at a dis-
tance expressed by the reciprocal of the range of
accommodation.
We have thus far considered myopia and hyper-
metropia from the standpoint of vision with one eye,
ignoring, for the moment, the complications which
grow out of the participation of the two eyes in
binocular vision. In brief, it may be said that in order
to see an object single and distinctly with the two
eyes together, the eyes must be directed each to the
same point, and this point must be a point for whose
distance each eye is accommodated. This close
interrelation of accommodation and convergence
gives rise to important complications both in myopia
and in hypermetropia. In myopia, there is com-
paratively little occasion for the exercise of the accom-
modation, whereas the angle of convergence for the
distance of most distinct near vision is never less and
may be notably greater than in emmetropia. This,
normal or excessive, convergence may in turn evoke
accommodation for a shorter distance, thereby neces-
sitating increased convergence. Thus through vicious
interaction of the two adjustments the grade of
myopia may appear to be greater than it really is,
and, under habitual use of the eyes at too short a
distance, the distention of the eyeballs may increase
to the point of imminent danger. On the other hand,
a myope may faL into the habit ot relaxing the
accommodation to the degree requisite for distinct
vision at or near his far point, in which case the at-
tendant relaxation of the convergence may lead to
relative insufficiency of the recti interni muscles
(muscular asthenopia); or the effort to maintain
binocular vision may be abandoned, and actual
muscular insufficiency (crossed double vision, or
divergent strabismus) ensue. In hypermetropia the
eyes accommodate even in distant vision, and must
accommodate more strongly than in emmetropia in
order to see near objects distinctly. Accordingly,
in hypermetropia one of two complications may arise:
either convergence may be maintained for the
distance of the object, in which case the over-burdened
accommodation may prove unequal to the demand
made on it in sustained near work (accommodative
asthenopia), or the accommodation may be maintained
under excessive convergence, with suppression of
binocular vision, which may be the forerunner of
convergent strabismus.
The complications growing out of faulty relation
between accommodation and convergence have been
formulated by Donders in the pregnant antithesis:
Hypermetropia causes accommodative asthenopia,
to be actively overcome by strabismus convergens.
Myopia leads to muscular asthenopia, passively
yielding to strabismus divergens.
Astigmatism, As (from a- privative and ozlyiia. a
point), is a very common structural anomaly in which
the power of the eye is unequal in different meridians.
This inequality is greatest in two ocular meridians
at right angles to each other, called the principal
meridians. An astigmatic eye may be emmetropic
in one of its principal meridians, in which case it is
either myopic or hypermetropic in the other; or it
may be myopic or hypermetropic in both meridians;
or it may be myopic in one of its principal meridians
and hypermetropic in the other. In binocular
hypermetropic astigmatism the disabilities are, in
general, those of hypermetropia; and in binocular
myopic astigmatism are, in general, those of myopia.
As the acuity of vision is below the normal at all
distances, an astigmatic person is apt to fall into the
habit of reading at too short a distance, and may
thus awaken or revive a pre-existing tendency to
myopia.
The correction of regular astigmatism together with
any accompanying ametropia, by wearing appro-
priate cylindrical, spherico-cylindrical, or toric spec-
tacles, both improves vision at all distances and mini-
mizes the incidental disabilities and dangers (see
Astigmatism.)
Anisometropia (from Jywos, unequal, fihpov, meas-
ure, and Slip, eye) — signifying a difference in the meas-
urements of the two eyes — is the word commonly used
Vol. I.— 5
65
Accommodation and
ltd' raction
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
to denote inequality of refraction; as when: (a) one
eye is emmetropic and the other eye is either hyper-
metropic or myopic; (6) the two eyes are unequally
hypermetropic or myopic; or (c) one eye is hyper-
metropic and the other myopic.* As the increase
of power in accommodation is sensibly equal in the
two eyes, the refractive inequality is virtually the
same in vision at all distances; s<. tiiat, when one eye
is accommodated for any particular distance, the
fellow eye accommodates for some other distance
and the image formed on its retina is imperfectly
denned. In cases of small or medium difference in
refraction the difference in definition may pass un-
noticed, and cases of greater difference are often
vaguely described as "something wrong with one
eye." In uncomplicated anisometropia both images
are commonly utilized in binocular vision, with
more or less perfect conservation of the faculty of
recognizing differences in distance and the forms of
solid bodies (stereoscopic vision). An anisometrope
with one emmetropic or moderately hypermetropic eye
of approximately normal acuity of vision will
generally use that eye in distant vision, and also in
reading unless the other eye happens to be myopic;
in either case he may remain unconscious of the fact
that he does not see distinctly with both eyes at the
same time until, perhaps, an intercurrent disabling of
the eye in habitual use for a particular distance reveals
a previously unrecognized anomaly in the fellow eye.
In hypermetropia of unequal grade in the two eyes,
the disabilities and complications are ordinarily the
same as in binocular hypermetropia of a grade equal
to that in the less hypermetropic eye (see Hyperme-
tropic!). In myopia of unequal grade in the two eyes
the more important complications are those of binoc-
ular myopia of a grade equal to that in the more
myopic eye (see Myopia).
The indications, and also the opportunity, for
prescribing glasses of unequal power, with a view to
equalizing the adjustments of the two eyes in binocular
vision, vary notably for different cases. An aniso-
metrope who sees clearly at a distance, and also
reads ordinary print fluently, seldom thinks of
glasses, and when one eye is myopic he may be able
to read without glasses far beyond the age at which
Eresbyopia ordinarily asserts itself as a disability. In
ypermetropia of unequal grade in the two eyes, an
increasingly disabling asthenopia, passing gradually
to presbyopic vision, may suggest the purchase of a
pair of convex glasses which afford needed help in
reading and which may be found to be helpful also in
seeing at a distance. In myopia of unequal grade in
the two eyes a pair of concave glasses, which ap-
proximately correct the less myopic eye for distance
and partially correct the fellow eye, may be accepted
as satisfying recognized needs, and when the uncor-
rected part of the myopia in the more myopic eye is
rather large the disability of presbyopic vision, even
with the concave glasses, may be long or perhaps
indefinitely deferred. In any of these cases an
ani-ometrope may see cause only for self-congratula-
tion in his enjoyment of special immunities, and may
give little heed to less obvious disabilities or to in-
sidious changes in vision.
The complications which may make it imperative
to prescribe glasses of unequal power occur oftenest
in myopia of one eye or in myopia of unequal grade
in the two eyes. In both of these cases the habitual
relaxation of the accommodation, inhibiting free
exercise of the convergence, may lead to relative
insufficiency of the recti interni muscles (muscular
asthenopia), or absolute insufficiency of the recti
interni (crossed double vision, or divergent strabis-
mus). On the other hand, habitual convergence
for a short reading distance may evoke accommoda-
* The name antimetropin has been proposed for the particular
form of anisometropia in which one eye is hypermetropic and the
other myopic.
66
tion for a shorter distance, at which binocular vision
is possible only under increased convergence, and the
pathological processes which find expression in pro-
gressive distention of the eyeball may take on renewed
and perhaps dangerous activity. In any one of
these conditions the wearing of a concave glass
chosen with reference to this grade of myopia in the
eye habitually used in reading may be indicated, but
the effect of a second concave glass of the same power
would ordinarily be detrimental by creating a possibly
disabling artificial hypermetropia of the fellow eye.
In general, the treatment of a case of anisometropia
by glasses involves (a) the determination of the
acuteness of vision and of the refraction, including
astigmatism, in both eyes; (6) an estimate of the
range of accommodation in both eyes; (c) the detec-
tion and approximate estimation of any actual or
latent error in the direction of the visual axes in
distant or in near vision; and (d) such provisional
or final correction of both eyes as may be found to be
most helpful in binocular vision. In many cases the
best results are attained by wearing glasses of unequal
power corresponding to the difference in refraction;
in other cases a partial equalization of the refraction
may be preferred in the beginning, and a full equal-
ization accepted a few weeks or months later. In
still other cases, in which binocular vision has perhaps
never been established or has been long abandoned,
attempts at binocular correction may be rejected as
of no avail, or as reviving disabilities from w'hich the
patient has found relief through the habitual exclu-
sion of one eye from participation in the visual act.
Aphakia (from a- privative, and ai<6s, lens, a
lentil) is the condition in which the crystalline lens is
either wholly wanting or is so displaced that it no
longer lies in the axis of the eyeball. As. a result of
loss of the crystalline lens the first and second prin-
cipal points of the eye fall together in a single princi-
pal point at the vertex of the cornea, and the first
and second nodal points fall together in a single nodal
point (optical center) at its center of curvature.
Computing the principal focal length from the aver-
age radius of curvature of the cornea at its
center (8 mm.) and an assumed common index of
refraction for the cornea and the aqueous and vitre-
ous humors (^- = 1.337) , the principal focus of the
aphakial eye falls 31.7 millimeters behind the vertex
of the cornea, and 23.7 millimeters behind the (single)
nodal point at its center of curvature. The absolute
power ( „.,„-. =42.2 dioptries) of the aphakial eye
is therefore about twenty-five dioptries less than
thai of the average unmutilated eye. As the apha-
kial eye has also suffered a total loss of accommoda-
tion, it requires a strong convex glass in distant
vision and a still stronger convex glass in reading.
The effective power of a convex spectacle lens in-
creases, however, for every increase in its distance
from the (first) nodal point of the eye, so that a glass
of ten to twelve dioptries worn about 15 millimeters
in front of the cornea of an aphakial eye ordinarily
suffices to advance its focus for parallel rays to the
actual position of the retina. The convex glass also
enlarges the retinal image by advancing the (second)
nodal point (of the corrected eye) to a position
farther from the retina than in the emmetropic eye.
A partial adjustment for the near, with additional
enlargement of the retinal image, may be obtained
by wearing the convex glass still farther from the eye,
but as such increase in distance is limited practically
to the length of the nose it is generally too small to
afford the additional help required in reading. In
the case of aphakia in a previously hypermetropic eye
stronger convex glasses, and in the case of aphakia
in a previously myopic eye weaker convex glasses,
are required for distance and in reading. In a case
of pre-existent myopia of exceptionally high grade,
REFERENCE HANDBOOK OF THE MEDICAL S( 1KN< i;s
\. commoda Hon and
Kef r.i. 1 1. .11
with excessive elongation of the eyeball, much weaker
convex glasses suffice; a fact which Ion;; ago SUg-
ge ted tin- surgical removal of the crystalline lens in
cases of myopia of so high a grade as to constitute
extreme and otherwise irremediable disability (see
M>i<>pia). In corrected aphakia of one eye the
retinal image is notably larger than in the fellow eye,
but even with this drawback the correction is gener-
ally of value by helping to keep the aphakia! eye in
use in binocular vision. An uncorrected aphakial
eye may, however, continue to take part in binocular
vision, and it is also an important safeguard against
the danger of colliding with a moving object, such as
a horse or vehicle, approaching from the side corre-
sponding to the affected eye. A considerable grade
el astigmatism is frequently present in aphakia,
and may be due either to original asymmetry of
the cornea or to acquired asymmetry following the
healing of a corneal wound or of the corneal incision
in the operation for the extraction of cataract. Low
grades of astigmatism are often overcome by looking
obliquely through the strong convex glasses worn to
correct the aphakia; higher grades may require
correction by a special lens. (See Astigmatism.)
Disorders of accommodation- occur as a result
either of progressive induration of the crystalline
lens, or of disordered innervation.
The crystalline lens, which in a young child is of
the consistency of a firm jelly, becomes gradually
harder from year to year. With increasing indura-
tion, the range of accommodation decreases until,
after middle life, it is no longer possible for the
emmetropic eye to accommodate for the ordinary
reading distance. (See Presbyopia.) The age at
which the failure of accommodation is recognized
a- a disability varies according to the refractive con-
dition. A myope whose farthest point (r) of distinct
vision lies well within a reading distance of thirty-
three centimeters (thirteen inches) never becomes
presbyopic in the sense of being unable to read with-
out the aid of convex glasses; but whereas in youth
he reads easily with the concave glasses which correct
his myopia, he is compelled, with advancing age,
either to lay aside his glasses in reading or to exchange
them for weaker concave glasses than those through
which he sees well at a distance. In hypermetropia
the loss of accommodation shows itself by an early
recession of the near point (p), so that help is sought
from convex glasses, perhaps long before the usual
age of from forty to forty-five years. The young
hypermetrope, wearing convex glasses which correct
his hypermetropia, sees distinctly at all distances,
anil it is only at the age of about forty-five years that
he finds himself compelled to make use of stronger
reading glasses. In no condition of the refraction
does a presbyope see clearly at a distance and read
easily with the same glasses. Either he is an emme-
trope, in which case he requires convex glasses for
reading, but sees imperfectly through them at a
distance; or he is a myope, and so requires concave
glasses for distance, and weaker concave glasses, or
no glasses at all, or possibly weak convex glasses, in
reading; or he is a hypermetrope, and so sees dis-
tinctly at a distance with neutralizing convex glasses,
but requires stronger convex glasses for reading.
Paralysis or paresis of accommodation from defective
innervation may be the result of an affection limited
to the terminal ramifications of the ciliary nerves, or
involving the oculomotor nerve in any part of its
course or at its origin. It is generally accompanied
by dilatation and loss of mobility of the pupil, and in
many cases also by paralysis or paresis of one or more
of the muscles supplied by the oculomotor nerve,
namely, the levator palpebral superioris, the rectus
superior, the rectus inferior, the rectus internus, and
the obliquus inferior.
A typical example of paralysis of accommodation
dependent on suppression of the function of the
terminal branches of the ciliary nerves is that which
follows the instillation of a mydriatic solution into
ilie conjunctival sac. Within fifteen minutes after
the instillation of a drop of a solution of atropine sul-
phate of a strength of one per cent. (1 :100), tne pupil
begins to dilate, and within half an hour the dilata-
tion reaches its maximum; the pupil no longer con-
tracting under the stimul ong light, closely
following the dilatation of the pupil, the ileal point
i/ii recedes from the eye, ami the paralysis of accom-
i lation is generally complete at the end of about
an hour and a half. The dilatation of the pupil and
the paralysis of accommodation continue without
sensible change for about two days, after which both
begin to pass away, the former very gradually, the
latter more rapidly for two or three days and after-
ward more slowly, until at the end of ten or twelve
days the effect of the drug disappears altogether. A
very weak solution of atropine, say of a strength of
one one-hundredth of one per cent. (1:10,000),
dilates the pupil in the course of an hour and a half
or two hours, but without rendering it immovable
under the influence of strong light, and without
sensibly affecting the accommodation. Under full
action of atropine the near point (/>) recedes from the
eye until it comes to coincide with the far point (r).
The visual disturbance varies greatly according to
the refractive condition of the eye. In emmetropia
distant vision remains clear, but it is impossible to
read without convex glasses; in hypermetropia
vision becomes indistinct for distance, and still more
so for the near; in myopia of a rather high grade
there may be no trouble in reading without glasses
and the recession of the near point may pass unno-
ticed. In the case of a hypermetrope or a myope
wearing neutralizing glasses the visual disturbance
is the same as in emmetropia. Several plants, of
the natural family Solanacece, yield alkaloids whose
action is nearly identical with that of atropine. Hom-
atropine, a derivative of atropine or of hyosciamine,
is less lasting in its effect, and is used to paralyze the
accommodation in measuring errors of refraction.
Cocaine, the active alkaloid of Erythroxylon coca, and
euphthalmin hydrochlorate, a synthetic product
used in ophthalmic practice, dilate the pupil without
sensibly affecting the accommodation.
Concussion of the eyeball is sometimes followed by
more or less persistent dilatation of the pupil and loss
of accommodation, without demonstrable gross ocular
lesion.
Paresis of accommodation, oftenest without marked
dilatation or loss of mobility of the pupils,* is a
frequent complication of diphtheria. It appears
late in the disease, after recovery from the throat
affection, and is generally accompanied by paresis
of the faucial muscles giving rise to characteristic
alteration of speech with difficulty in swallowing solid
food and regurgitation of liquids through the nose.
One or more of the external muscles of the eyeball
may also be affected, and cases of true convergent
st rabismus have been observed as a result of the exces-
sive effort to accommodate in the weakened condition
of the accommodation. The paretic symptoms simu-
late those of overloaded accommodation in hyperme-
tropia, and convex glasses are similarly helpful in
reading. The instillation of a drop of a weak solu-
tion of pilocarpine, several times in the course of the
day, may also be helpful.
Paralysis of accommodation with dilatation of the
pupil (ophthalmoplegia interna) may be the only
symptom of a circumscribed cerebral lesion. Oftener
* Donders, who was the first to study the disturbance of vision
in diphtheria, found dilatation with sluggishness of the pupils in
the cases observed by him (1S60) at the time of a grave epidemic
in Holland. Binocular paresis of accommodation unaccom-
panied by dilatation of the pupils is now generally regarded as
evidence of diphtheritic intoxication.
67
Accommodation and
Refraction
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
the paralysis includes one or more of the muscles
supplied by the third nerve, or it may extend to the
fourth nerve (trochlearis) and to the sixth nerve (abdu-
cens), with resultant complete immobility of the
eyeball (ophthalmoplegia externa).
An overdose of one of the more active mydriatic
drugs (belladonna, stramonium, hyoscyamus, etc.) is
followed by wade dilatation of the pupils and paraly-
sis of accommodation. With the elimination of the
toxic agent the ocular symptoms disappear.
Spasm of accommodation, with spasmodic contrac-
tion of the pupil, has been studied almost exclusively
as induced by Calabar bean {Physostigma venenosum).
The instillation of one-fourth minim of a one-half per
cent, solution of eserine (physostigmine) into the con-
junctival sac is followed after five to ten minutes
by spasmodic "twitching," with beginning contrac-
tion of the pupil and displacement of the region of
accommodation towards the eye. In the course of
the next half-hour the pupil is reduced to a diameter
of less than two millimeters, with advancement of the
farthest point of distinct vision indicating an increase
in refraction equal to about two-thirds of the absolute
range of accommodation.* Recession of the far
point follows, and is complete, in distant fixation,
after a little more than an hour, but excessive accom-
modation, in convergence for the near, persists for
twelve hours or longer; near objects, seen under
consciously relaxed accommodation, appearing as
if farther away, and therefore larger, than under
normal conditions (macropsia).t
The instillation of eserine in larger quantity or in
a stronger solution is followed by more intense and
painful spasm, which may continue for several hours;
the persistent instillation of a strong solution of eser-
ine, in animals, is attended by general toxic manifes-
tations ending in death.
Pilocarpine (the active alkaloid of Pilocarpus
jaborandi) acts much more mildly than eserine, but
is, nevertheless, an efficient myotic and stimulant
of the accommodation.
Extreme contraction with immobility of the pupils
is a typical symptom of poisoning by opium, and
v. Graefe showed (1S61) that the hypodermic injec-
tion of morphine, in therapeutic doses, is followed also
by a temporary increase in refraction due to stimula-
tion of the accommodation. In the earlier studies of
the general toxic action of Calabar bean, in animals,
strong contraction of the pupil was noted as a con-
stant condition, and there can be little doubt that the
myosis is accompanied by acute spasm of accommoda-
tion. The hypodermic injection of pilocarpine in
maximum therapeutic doses is not followed either by
contraction of the pupils or by stimulation of the
accommodation.
Stimulation of the ophthalmic division of the fifth
nerve (trigeminus), in animals, causes contraction of
thr pupil, and the same (reflex) symptom, accompan-
ied by photophobia, is generally present in cases of
painful abrasion, phlyctenula, etc., of the cornea.
Spasm of accommodation, with strongly myopic vision
and a sluggish but not conspicuously contracted pupil,
has been known to persist after apparently perfect
recovery from a superficial injury of the cornea.
Tension of accommodation is a permanent condi-
tion in young hypermetropes, who necessarily make
use of some part of their accommodation in distant
vision; subjective tests, made with convex glasses,
showing a lower grade of hypermetropia than is
revealed after paralyzing the accommodation by
* As measured by Donders. The advancement of the far point
i I. 3 in patients wi th restricted than with large range of accommo-
dation. The distance of the advanced far point from the eye is
greater in hypermetropia, and less in myopia, than in emmetropia.
t Conversely, as remarked by Donders (1851), in artificially
induced paresis of accommodation, near objects, viewed under
consciously increased accommodation, appear smaller than under
normal conditions (micropsia).
atropine. This state of unconscious tension may be
maintained for many years in a person with normal
acuteness of vision and ample range of accommodation,
his hypermetropia first asserting itself as a recognized
disability under the aspect of premature old sight
(presbyopia).
Tension of accommodation simulating myopia,
may be induced in a young person by excessive use
of the eyes in near work. Enforced study or per-
sistent reading in a bad light, prolonged strain in fine
needlework or in mechanical drawing, and subnormal
acuity of vision in which compensation for imperfect
definition is sought by shortening the reading or
working distance, are among the more obvious excit-
ing causes. The habitual use of the eyes at too
short a distance under excessive convergence, inciting
in turn to increased accommodation and convergence,
is a principal initial and continuing factor in the
development and progressive increase of myopia,
Under atropine the acquired tension of accommodation
disappears; and the correction of any existing ame-
tropia, or of an astigmatism revealed by the shadow-
test or by the opthalmometer and verified by sub-
jective tests, may be all that is needed to reestablish
normal conditions.
Spasm of accommodation in near work, yielding
promptly to atropine but recurring with the passing of
the mydriasis, was observed by Donders in three
cases; all relieved by atropine used, at intervals of a
few days, for several months. Such cases are infre-
quent, but probably not as rare as commonly supposed.
John Green.
Accouchement force. — See Labor, Induction of.
Acephalus. — See Teratology.
Aceta. — Aceta, or vinegars, are liquid preparations
made by treating vegetable drugs or their active prin-
ciples, with dilute acetic acid. Vinegar is no longer
used as a menstruum, it place being taken by dilute
acetic acid. There are only two aceta official in the
U. S. P. of 1900; they are of uniform strength, ten per
cent. The B. P. contains three aceta and the N. F.,
three. The official (U. S. P.) aceta are acetum opii
(dose rn viii.) and acetum scillre (dose nx x.-xxx.).
R. J. E. Scott.
Acetal. — Diethylaldehyde, ethylidene -diethylic
ether, CH 3 .CH(OC 2 H 5 ) 2 ; a substance produced by
the imperfect oxidation of alcohol, distilled from a
mixture of the latter with manganese dioxide,
sulphuric acid, and water. It is a colorless volatile
liquid of an agreeable odor and rather sharp but not
unpleasant taste, leaving a nutty after-flavor. It is
soluble in eighteen parts of water at 77° F., somewhat
less at a lower temperature, and freely in alcohol and
ether. Acetal possesses sedative and mildly hypnotic
properties. It may be given for the relief of headache
and nervous excitement and as an hypnotic in mild
degrees of insomnia, especially in those cases in which
the early part of the night is wakeful. The dose is
from 1 to 3 fluidrams (4.0-12.0) in emulsion with
acacia flavored with orange-flower water. T. L. S.
Acetaminol. — Para-acetamidobenzoyl-eugenol ; oc-
curs in the form of a whitish crystalline powder,
soluble in alcohol, but very slightly in water. It
possesses antiseptic and mildly hypnotic properties,
and has been employed as an intestinal antiseptic in
doses of five to fifteen grains (0.3-1.0). T. L. S.
Acetanilide. — Acetanilidum (U. S. P.). Phenyl-
acetamide, antifebrin, C„N 5 NH.CH 3 CO. This is one
of the earliest of the antipyretic and analgesic syn-
thetic preparations, introduced as a remedy by Kahn
and Hoff in Germany in 1SS6, though first prepared by
Gerhard in 1852. It is a monacetyl derivative of ani-
line, prepared by the action of glacial acetic acid on ani-
line, occurring as a white odorless crystalline powder,
or in minute shining scales, having a slightly burning
68
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
ArHIc KtliiT
taste, soluble in 200 parts of water, in 4.2 parts of 90
per cent, alcohol, in IS parts of ether, and freely soluble
in chloroform.
Acetanilide is antipyretic, analgesic, and sedative,
and is in large doses a cardiac and blood poison. Its
first employment was as an antipyretic, but it is
seldom so used now owing to its depressing effect.
As an analgesic it is still largely used, being given to
relieve headache, intercostal and other formse of neu-
ralgia, and to still the pains of tabetic crises. As
an analgesic it is one of the most powerful of the
synthetic drugs, but at the same time one of the most
dangerous, and should therefore be used with extreme
caution. It acts upon the hemoglobin of the blood,
reducing it to methemoglobin and so affecting its
oxygen-carrying function and causing cyanosis; it
depresses the action of the heart and causes excessive
sweating and general debility, and when taken con-
tinuously for some time tends to establish a habit.
The dose as an anodyne is from one to three grains
(0.00-0.2) ; as an antipyretic, two to four grains
(0.13-0.25). It possesses antiseptic properties and
may be used as a dusting powder to wounds, chan-
eroidal and other ulcers, and is also used as an errhine
in the treatment of epistaxis.
In poisoning from an overdose, stimulants, strych-
nine, and atropine should be exhibited, and heat
should be applied to the extremities. Strong coffee
may be of service and bicarbonate of sodium in large
doses has been recommended.
Acetanilide is largely employed as the active agent
in many of the much advertised headache powders
and a number of cases of acute poisoning from its
indiscriminate employment by the laity have been
recorded, as also cases of habituation from its long
continued use. For this reason it has been urged that
it be dropped from the Pharmacopoeia, but it is doubt-
ful whether such action would diminish its use by
the laity, and its really great service as an anodyne
in severe pain, such as that of tabes, gives it a rank
as one of the most valuable drugs of its class.
T. L. S.
Acetic Acid.— Acetic acid, CH,.COOH, the well-
known acid of vinegar, is a liquid at ordinary tem-
peratures, and miscible in all proportions with water.
Mixtures of the acid and water in different proportions
constitute the different grades of the acid in commerce.
Strong acetic acid is caustic, largely through its prop-
erty of dissolving the formed material of the connective
tissues to a pultaceous translucent substance. Be-
ing caustic, it is of course irritant, and swallowed in
concentrated condition operates as a corrosive poison,
the effects and symptoms being substantially the same
as in corrosion by the strong mineral acids. But few
cases of death have been recorded. The treatment is
similar to that to be employed in case of poisoning by
a mineral acid. In non-corrosive strength of solution
(five or six per cent., the equivalent of vinegar), acetic
acid produces the usual local effects of the sour acids
— exciting the flow of saliva and tending to oppose sour
fermentation of the food — and is also distinctly astrin-
gent. Inhaled the fumes are reviving in faintness and
may relieve headache.
Acetic acid has many uses in pharmacy. It has been
urged that the Pharmacopoeia should substitute
acetic acid largely for alcohol as a menstruum for the
preparation of extracts; and it has even been proposed
that this class of extracts shall bear the special
name "Acetracts." In medicine the strong acid
may be employed as a caustic, as to warts or cancers,
and the weak acid used to make refreshing acid
draughts in fever, or cooling lotions in inflammatory
skin affections. Acetic acid is official in the U. S.
Pharmacopoeia in three forms:
Acidum Aceticum Glaciate, Glacial Acetic Add. — This
is defined to be "a liquid containing not less than ninety-
nine per cent., by weight, of absolute acetic acid
(CH,. COOH =59.58), and not more than one per cent,
of water." It is "a clear, colorless liquid, of a strong,
vinegar-like odor, and a very pungent arid ta te.
At a temperature somewhat below 15° C. (.59° F.),
the acid becomes a crystalline solid. At 1 17° to 1 ls J
C. (242.0° to 211.1 " I'.j it boils, evolving inflammable
vapors." (U S. P.) This grade of the acid is for
pharinaeeul ieal uses.
Acidum Aceticum, Acetic Acid. — The grade of acid
thus simply named is a "liquid composed of not
less than thirty-six per cent., by weight, of absolute
acetic acid and about sixty-four per cent, of water,
obtained by the oxidation of ethyl alcohol or
by the destructive distillation of wood." It is "a
clear, colorless liquid, having a strong, vinegar-
like odor, a purely acid taste, and a strongly
acid reaction. Specific gravity, about 1.04.5 at 25°
C. (77° F.). Miscible with water or alcohol in all
proportions. When heated, the acid is volatil-
ized without leaving a residue" (U. S. P.). This is the
acid that results from the purification of the crude
acid — mult pyroligneous acid, so called — obtained by
the destructive distillation of wood. This is sharply
irritant and even mildly caustic. Dangerous symp-
toms have resulted from swallowing it, undiluted, in
quantity of two or three ounces. The acid maj' be
used as a mild caustic, but its principal uses under its
own form are pharmaceutical.
Acidum Aceticum Dilutum, Diluted Acetic Acid. —
It should contain not less than six per cent., bv weight,
of absolute acetic acid (CTI 3 .COOH =59.58), and
about ninety-four per cent, of water. Specific
gravity, about 1.009 at 25° C. (77° F. ) (U. S. P.)
This diluted acid is of the strength of the best qualities
of vinegar, and is better than vinegar for all the pur-
poses of the same, medicinal or dietetic. Squibb
says: " If one part of alcohol be added to about two
hundred and fifty-six parts of this diluted acetic acid —
that is, about half a fluidounce to the gallon — and the
mixture be set aside for a few weeks (the longer the
better), enough acetic ether is generated to give it the
full, clean aroma of fine vinegar, and then for table use
it is very far superior to any vinegar made in the
ordinary way by fermenting cider."
Diluted acetic acid is the most convenient grade of
the acid for medicinal use, and has also, in the U. S.
Pharmacopoeia, superseded vinegar for pharmaceuti-
cal purposes. For an acid draught a five-per-cent.
addition to water is appropriate, and for a lotion a
twenty-five-per-cent. addition. The popular notion
that the habitual use of vinegar tends to deterioration
of nutrition and health is certainly not true of a
moderate indulgence, if indeed it be true at all.
Edward Curtis.
R. J. E. Scott.
Acetic Ether. — Under the title Mfher Aceticus,
Acetic Ether, the U. S. Pharmacopoeia makes
official a preparation consisting of the ethereal salt,
ethyl acetate (about ninety per cent., by weight),
with a little contaminating alcohol and water,
Acetic ether is described as "a transparent, colorless
liquid, of a fragrant, and refreshing, slightly acetous
odor, and a peculiar acetous and burning taste.
Specific gravity, 0.883 to 0.885 at 25° C. (77° F.).
Boiling-point, about 72° C (161.0° F.). Soluble in
about seven parts of water at 25° C. (77° F.) ; miscible in
all proportions with alcohol, ether, and the fixed and
volatile oils. Acetic ether is readilj r volatilized, even
at a low temperature. It is inflammable, burning
with a yellowish flame and an acetous odor" (TJ. S. P.).
Acetic ether should be kept in well stoppered bottles
and away from lights or fire.
The effects of acetic ether upon the animal economy
are similar, in a general way, to those of common
ether, the most important point of difference being
that acetic ether is the slower in operation. For this
reason this ether is not available as a surgical an-
69
Acetic Ether
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
esthetic; but, on the other hand, by reason of its
agreeable odor, it makes an excellent and grateful
cardiac stimulant, antispasmodic, and carminative,
taken internally. Used externally, it may serve to
mask disagreeable odors. It may be given internally,
in quantities ranging from fifteen to thirty drops,
well diluted with water or with some medicinal prepa-
ration, to which the ether is added as an adjuvant
or corrigent. R. J. E. Scott.
Acetone. — Acetone, CH,.CO.CH„ dimethyl ketone,
is a colorless limpid, and inflammable liquid of pungent
quality, miscible in all proportions with water, alcohol,
and ether. Its effects upon the animal system are,
doubtless, of the general nature of those of the volatile
alcohols and ethers, but the substance has never been
systematically employed as a medicine.
It is used for chemical purposes in the manufacture
of chloroform, and as a solvent for fats and resins.
It occurs normally, in small amounts, as an ingre-
dient of blood, urine, etc. R. J. E. Scott.
Acetonuria. Definition. — The presence in the
urine of a pathological quantity of acetone, CO(CH 3 ) 2 .
Historical. — Petters in 1S57 discovered acetone
in the urine of a patient suffering from diabetic coma,
and three years later Kaulich demonstrated its
occurrence in ordinary cases of diabetes and added a
clinical picture of the condition known as acetonemia.
Kussmaul in 1874, writing on diabetic coma, first
threw doubt on the previously expressed idea that a
definite relation existed between diabetic coma and
acetonuria, while Gerhardt later on showed the
occurrence of diacetic acid in the urine, a substance
which has, clinically, even greater importance.
Occurrence. — Physiologically, acetone occurs in
the urine in very minute proportions, probably never
more than .02 gram being excreted in twenty-four
hours. Pathologically, more than 5 grams have
been in the daily quantity of urine.
The main conditions under which increased acetone
is found may be briefly summarized as follows:
1. Alimentary, i.e. according to diet; withdrawal of
carbohydrates; this may reach 0.7 gram after pro-
longed dieting.
2. Diabetes, especially after some duration of the
disease and with protein diet or increased fats.
3. Fevers (often with diacetic acid and /3-oxybutyric
acid as well); infectious diseases, e.g. enteric fever,
sepsis, pneumonia, exanthems, tuberculosis, acute in-
flammatory rheumatism; in the fevers it occurs only
in prolonged cases, probably because of the nature of
the diet; acute fevers present no increased acetonuria.
4. Starvation and inanition; cachexia; early car-
cinoma of stomach.
5. Digestive disturbances with autointoxication;
peritonitis.
6. Pregnancy with dead fetus.
7. Nervous lesions and mental disease; tabes;
general paralysis; melancholia, etc.
S. Artificially induced general anesthesia (chloro-
form).
9. Experimental — after extirpation of the solar
plexus or of the pancreas.
10. Medicinal — phlorizin; chronic morphinism.
[For a discussion of the source and mode of pro-
duction of the acetone bodies, see the article Acidosis.]
Clinical Significance. — In all probability the
acetone per se is harmless and the toxic symptoms are
produced by the diacetic and /?-oxybutyric acids;
and possibly also others, e.^. lactic acid' or volatile fatty
acids, come into action, too, at times. At all events,
it is the acid intoxication (or excessive acidosis, as it
has been called) that induces the serious changes whioh
occur. Patients manifesting this acid intoxication
usually get diabetic coma if no intercurrent affection
occur to carry them off.
The Prognosis, then, depends rather upon the evi-
dence of acidosis than of acetonuria to a large extent,
and Hallervorden has for this reason suggested the
importance of frequent estimation of the ammonia
eliminated, this giving a fairly accurate idea of the
acid intoxication. (More than three grams of NH 3
in twenty-four hours indicates excessive acidosis,
while if more than four grams exist, the onset of dia-
betic coma is almost certain, even though due treat-
ment temporarily diminish the amount of NH 3 elimi-
nation.) This theory is proven, too, by Stadelmann's
and Minkowski's observations, that diminished CO a
was in the blood (i.e. less alkalinity), and by the fact,
too, that in severe diabetes the sudden restricting
to meat diet (i.e. acid) is often followed by coma.
The acetone is to some extent, however, in definite
ratio to the intensity of the diabetes, and the presence
of a large quantity is of grave import — though not as
a prodrome of approaching coma, as Hirschfeldt once
supposed. Intercurrent fevers, e.g. pneumonia, may
greatly increase the acetone temporarily, and with
convalescence the quantity may return to its previ-
ous amount. So it was in the case of a diabetic whose
urine increased during an intercurrent pneumonia
from 0.4 gram to 4 grams acetone, daily, and with
convalescence the amount returned to 0.4 gram in
the twenty-four hours; coma did not supervene and
the patient lived for months afterward, until fatal
marasmus came on. It is well, however, to follow the
acetone excretion in diabetes, for its increase is so
frequent with threatening symptoms; hence the bene-
fit, at such a time, of judicious administration of
carbohydrates.
The diagnostic significance of acetonuria lies in the
fact that its presence to any extent with glycosuria
renders the diagnosis of diabetes certain.
Tests. — Before testing for acetone one should ascer-
tain the possible presence of diacetic acid. For this,
Gerhardt's reaction is to be tried and the following
three steps must be taken: Fifteen cubic centimeters
of urine are treated with dilute (not too acid) ferric
chloride so long as it gives a precipitate. The pre-
cipitate (ferric phosphate) is filtered and more ferric
chloride added to the filtrate. In presence of diacetic
acid a claret-red color appears. A second portion of
the urine is boiled and the same test repeated after
cooling. A negative result should follow, because the
diacetic acid was decomposed by the boiling. (If a
positive result were again obtained it would indicate
the presence of acetic or some other acid in the urine.)
A third portion is next acidified with sulphuric acid
and shaken with ether. The ether is removed and
shaken with a very dilute aqueous solution of ferric
chloride, when the watery layer becomes violet red or
claret red. The color disappears on warming or after
standing twenty-four hours.
In the absence of diacetic acid we proceed to test
directly for acetone. No single test for acetone is
completely satisfactory; hence the necessity of employ-
ing several as confirmatory evidence. One may use
the urine as it is, although it is more accurate to resort
first to distillation. About 250 c.c. of urine are boiled
after faintly acidifying with sulphuric acid, and, a
good condensation being secured, all the acetone will
distil in the first 20 c.c.
When diacetic acid is present the urine should first
be rendered faintly alkaline and carefully shaken up
in a separator funnel with ether (the ether must be
free from alcohol and acetone). The removed ether
is then shaken up with water, which takes up the
acetone, and this watery liquid is tested.
Qualitative Texts. — Lichen's Iodoform Test. — Treat a
few cubic centimeters of the distilled urine (which
should be freshly voided always) with some sodium
hydrate and iodine potassic iodide solution and gently
warm. With traces of acetone a yellow precipitate
of iodoform occurs, and this will be recognized by its
odor and by the hexagonal plates or stellate crystals.
While this test is delicate enough for acetone, there are
70
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Acctplifncttdln
many other constituents of the urine and other sub-
stances (at least seventeen) which yield a similar re-
action. Among them is alcohol; hence the possibility
of error from using an alcoholic solution of iodine to
make up one of the reagents — which must, of course,
be avoided.
Gunning modified the test by using an alcoholic solu-
tion of iodine and ammonia instead of the mixture
mentioned above. A black precipitate of iodide of
nitrogen results, and this, in the presence of acetone,
gradually disappears, leaving the yellow iodoform
behind. The test, though not quite so delicate, is
more accurate, neither alcohol nor aldehyde produc-
ing a similar result; and, moreover, it is eminently
suited for clinical purposes, in view of the temptation
to test without the time-absorbing distillation.
Legal's Sodium Nitroprusside Test. — Treat a feu-
cubic centimeters of the urine with two or three drops
of a freshly prepared concentrated solution of sodium
nitroprusside and add a thirty-per-eent. solution of
caustic potash. A ruby red color appears, which
changes to yellow. Any urine may give this reaction.
But if acetone be present in pathological amount the
addition of acetic acid changes the color to a purple-
red or violet. Paracresol and creatinin give some-
what similar reactions. In presence of the former,
however, the yellow color changes to pink on addition
of acetic acid, while with the latter a saturation with
acetic acid gives a yellow color, soon changing to
green and blue. Acetone, under similar conditions,
gives a carmine color.
Fehr modifies this test by floating the acetic acid on
the urine as the color changes to yellow. A violet is
produced at the line of contact, its intensity being
proportionate to the amount of acetone present.
Notwithstanding its frequent commendation for
clinical purposes, Legal's test is certainly unreliable
unless the urine be first distilled.
Le Nobel's test is similar. One adds an alkaline
solution of sodium nitroprusside (so dilute as merely
to give a faint reddish tint to the solution) to the urine;
a ruby red color is obtained, soon changing to yellow.
On boiling and adding the acid a greenish-blue or
violet results.
Penzoldt's Indigo Test. — Treat the urine with a
warm saturated and then cooled solution of ortho-
nitrobenzaldehyde and add caustic soda. If acetone
be present the liquid becomes first yellow, then green,
and finally indigo forms, which may be dissolved in
chloroform.
Chautard takes fuchsin solution into which a cur-
rent of sulphurous acid gas has been passed. This
decolorizes the liquid and gives it a clear yellow tint.
When added to urine containing acetone a deep violet
color is produced.
Reynolds' mercuric oxide test depends on the power
of acetone to dissolve freshly precipitated mercuric
oxide. A mercuric chloride solution is first precipi-
tated by alcoholic caustic potash. The urine is added
to this and the mixture well shaken and filtered. If
acetone be present the filtrate contains mercury, which
may be detected by the black color on adding ammo-
nium sulphide.
Reynolds' and Gunning's tests are particularly
recommended for delicacy and reliability combined.
Quantitative Test. — Huppert's modification of Mes-
singer's is that most recommended; Lieben's iodo-
form test being the method on which it is based.
Acetone forms iodoform when treated in an alkaline
solution with iodine. By treating the urine with a
known amount of iodine one need simply estimate the
quantity unused by the iodoform to know how much
has been combined. This can be done by titration
with sodium thiosulphate solution. For the details of
the method, as well as for the methods for determin-
ing ,3-oxybutyric acid quantitatively, the reader is
referred to Neubauer-Huppert's " Analyse des Harns,"
1910. Charles F. Martin.
Acctozone. — The trade name of a grayish-white
powder e posed of equal parts by weight of ben-
zoyl-acetyl dioxide ami an inert absorbent powder of
infusorial earth. The active ingredient, C.ll .< '< M >.-
(>.('< )( 'II-,, is similar in structure to hydrogen dioxide,
the hydrogen atoms being replaced by acetic and
benzoic acid radicles. It occurs as a white crystalline
powder, very slightly soluble in water or alcohol,
melting at 98° F. (36.6° C), and d mposed by
heat and by alkalies. It decomposes organic material
in the presence of water and is consequently anti-
septic and deodorant. It is employed externally as
an antiseptic in gonorrhea, ulcers, tonsillitis, corneal
ulcers, and suppurative nasal and aural affections,
being applied in the form of powder, ointment with
petroleum base, or solution in water or oils. Its
chief use, however, is as an intestinal disinfectant
in typhoid fever and dysentery; in the former con-
dition especially it acts very favorably in reducing
tympanites, controlling diarrhea, and destroying the
odor of the stools. For this purpose the powder is
added to warm water in the proportion of seven and
one-half to fifteen grains (0.5-1.0) to the quart
(1,000 c.c. or 1 liter), the mixture being thoroughly
shaken and then, after standing for an hour or two,
decanted. The dose of the decanted solution is
indefinite, one or two quarts being drunk in the
course of twenty-four hours.
Acetozone inhalant is a mixture of benzoyl-acetyl
dioxide 2, chloretone 1, and liquid petrolatum 107;
it is employed in the form of spray in diseases of the
nose and throat. Ointments of 0.1 to 1 per cent,
strength should be made with a petroleum base, as
acetozone is gradually decomposed by animal or
vegetable fats.
Acetphenetidin. — Aoetphexetidinum (U. S. P.),
phenacetin, CjHsO.CjHj.NHCOCH,; "a phenol deriv-
ative, acetparaphenetidin, the product of the acetyl-
ization of para-amidophenetol." Occurs in the
form of a white crystalline powder or glistening
scales, without odor or taste, soluble in 92.5 parts of
cold water, 70 parts of boiling water, 12 parts of
alcohol, and 20 parts of chloroform. Phenacetin,
like the other synthetic members of its class, was
introduced as an antipyretic but has found its chief
employment as an analgesic, in which respect it is
less powerful, but safer and less depressant than
acetanilide. In ordinary doses it has but little
depressant effect upon the heart, but in overdose it
reduces the hemoglobin of the blood to met hemo-
globin, whereby the oxygen carrying power is dimin-
ished and cyanosis is produced. As an antipyretic
it may be of service in sthenic fevers, but in cases of
adynamia it should be employed with caution as it
is apt to cause profuse sweating and is debilitating.
The latter effect may be obviated in a measure by
combining the drug with caffeine. As an anodyne
it is given for the relief of headache, neuralgia,
gastralgia, and the lightning pains of tabes, but for
the latter is inferior to acetanilide. It is sometimes
useful as a sedative and mild hypnotic in cases of
sleeplessness due to fatigue, nervousness, or slight
pain. The dose as an antipyretic or analgesic is five
grains (0.3), repeated in two hours if necessary. It
is best given in powder, in capsules, or in compressed
tablets.
In the treatment of poisoning by an overdose of
acetphenetidin, heat should be applied to the extremi-
ties, and stimulants, strychnine or caffeine, be given;
if cyanosis is pronounced, inhalation of oxygen may
be serviceable.
It is recommended that acetphenetidin be pre-
scribed under its official title, and not as phenacetin,
the latter being the name of the patented German
preparation and sold at a much higher price. It is
further recommended that, when prescribed as acet-
phenetidin, care be taken to see that it is sold at the
71
Acetphenctidin
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
price of this drug and that it be not charged for at the
rate of the expensive phenacetin. T. L. S.
Acetum. — See Aceta and Vinegar.
Acetylene. — See Gas, Illuminating.
Acetylsalicylic acid. — See Aspirin.
Achondroplasia. — Chondrodystrophy. See under
Na n is m .
Acidol. — See Belaine Hydrochloride.
Acidosis and Acid Intoxication. Definition. — While
acidosis and acid intoxication are frequently used as
synonymous terms, strictly speaking they represent
quite distinct entities.
Acidosis is a condition, pathological or otherwise,
in which an excess of acid products is indicated by an
analysis of the blood or of the urine. It is impossible
in many cases to distinguish whether an excess has
really been formed, or whether the normal amount only
has been formed and this amount has been inhibited
from undergoing further oxidation. In conditions
such as diabetes it is quite certain that the amount of
acid products eliminated is in excess of what may be
formed during normal metabolism. In this con-
dition, at least, one is forced to assume that an ex-
cessive production of acid compounds takes place.
Acid intoxication, on the other hand, distinctly im-
plies a pathological condition of toxic character pro-
duced by acid products formed within the organism.
Acid intoxication may also be produced by the
administration of acids, chiefly inorganic. This
form of poisoning is of importance, as it has a com-
parative bearing on the general problem of acid
intoxication.
The Compounds Taking Part in Acidosis. — The com-
pounds immediately concerned in the problem of
acidosis are three: /3-oxybutyric acid, acetoacetic acid
(diacetic acid), and acetone. They are usually termed
the acetone compounds, although it would be more ad-
visable to speak of them as the oxybutyric-acid com-
pounds, for this substance is the starting-point in the
formation of the other two.
3-oxybutyric acid has the formula:
COOH
I
H— C— H
H— C— OH
I
H— C— H
I
H
This by oxidation is converted into acetoacetic acid:
COOH
I
H— C— II
I
c=o
I
H— C— H
I
H
which by losing a molecule of carbon dioxide from the
carboxyl group is converted into acetone:
COOH H
H— C— II
■ I
C=0
I
H— C— H
I
H
H— C— H
C=0
I
H— C— H
k
/3-oxybutyric acid was discovered simultaneously
by Minkowski and by Kiilz, although Stadelmann had
previously been led to suspect the presence of an
abnormally large amount of an organic acid in
diabetic urines. He mistook a decomposition prod-
uct of /3-oxybutyric acid, a-crotonic acid, for the
former. /3-oxybutyric acid as formed in the body is a
levorotatory syrup, which has been obtained by
Magnus-Levy in a crystalline condition. Ferric chlo-
ride does not give a red color with this acid.
The presence of acetoacetic acid in the urine was in-
dicated by the reaction discovered by Gerhardt, who
found that certain urines gave a Bordeaux-red color
when treated with an aqueous solution of ferric
chloride. Further investigation of this color reaction,
especially by v. Jaksch, led this observer to believe
that he had isolated acetoacetic acid from the urine.
From the unstable character of this acid it is safe to
say that it has never been separated from the urine in
a pure condition. There is no doubt, however, that
the substance giving the red color is really acetoacetic
acid. All the tests which urines give under these con-
ditions are those of aqueous solutions of acetoacetic
acid. The acid is extremely unstable, and rapidly
breaks down in solution into carbon dioxide and
acetone.
Acetone was discovered in the urine by Petters and
by Kaulich in 1S57, and was the first of the acetone
compounds to be detected. It is therefore from an
historical point of view that acetone has lent its name
to this class of compounds.
When attention was first drawn to the connection
between /3-oxybutyric acid, acetoacetic acid, and ace-
tone, it was thought that acetone was the first sub-
stance to be formed. This by synthesis with, possibly,
formic acid would yield acetoacetic acid, which on re-
duction might be transformed into /3-oxybutyric acid.
This has since been shown not to be the case. The
administration of acetone has never been followed by
an increase in the amount of either acetoacetic acid or
/3-oxybutyric acid, while the converse almost invari-
ably happens. The administration of /3-oxybutyric
acid or acetoacetic acid to diabetics or to persons ab-
staining from food is followed by an increase in the ace-
tone content of the urine and of the breath.
Furthermore, these compounds make their appear-
ance in the urine in the following order: acetone, aceto-
acetic acid, /3-oxybutyric acid. They disappear in the
reverse order, fl-oxybutyric acid being the first to van-
ish. As /3-oxybutyric acid is the last to appear and the
first to leave, one can only conclude that its appearance
indicates the greatest departure from normal metabo-
lism, and that, being the first product formed, it
appears in the urine only when the capacity of the or-
ganism to convert it to acetoacetic acid and acetone is
impaired.
One other acid product of metabolism may be
mentioned which has played no inconsiderable role in
some late theories of acid intoxication. This is
-iarcolactic acid. It may be connected with the arc-
inn,- com] nds, bul Hi" relation, biologically, is not
clear. Its place in acid intoxication will be discussed
when eclampsia is considered.
The Source op the Acetone Compounds. —
Theoretically all three classes of compounds which
enter into tissue formation — carbohydrates, fats, and
proteins — may be the sources from which the acetone
compounds are derived. As, however, the carbohy-
drates occupy such an exceptional place in the
mechanism of acetone-compound formation, only
the latter two classes, viz., proteins and fats can be
considered as being acetone formers.
For a long time it was thought that the fats and fatty
acids alone were the source of the acetone compounds.
[Von Noorden still holds to this theory. Although
no doubt, he says, a certain amount of the acetone
bodies are formed within the organism from protein
(amino acids), this process is not extensive enough to
I
72
reference handbook of the medical sciences
\i IcIii-Ih
account for all or even a considerable part of the
pathological acetone formation. Hammarsten also
says that while we cannot deny the possibility of a
formation of acetone from proteins, certain facts nega-
tive the theory that the acetone bodies arise entirely
from the proteins.] It is nevertheless probable that the
! fatty acids occupy a more or less secondary place and
that the proteins, or, what is the equivalent, the
amino acids, are the chief source of these compounds.
According as a substance produces or inhibits the
formation of acetone, it is classed as ketogenic or
ketoplastic, or antiketogenic or antiketoplastic. Bor-
chardt further subdivides the ketogenic compounds
into those from which acetone is directly derived,
which actually break down, yielding acetone or one of
its forerunners, and those which are merely ketoplastic,
that is to say, only increase the output of these com-
pounds in the urine or the breath, without having
contributed directly to their formation.
With regard to the fats, their action is complicated
by the fact that they consist of two parts, fatty acid
and glycerol. Glycerol belongs distinctly to the class
of antiketogenic compounds, and its inhibitory action
may be so great as to prevent any ketogenic action
which the fatty-acid moiety may have. As to the
tatty acids themselves, the results of feeding these
substances to diabetics or persons in a state of inani-
tion are not altogether in concordance. Joslin,
taking into account the absorption of these substances
by the intestinal wall, was unable to attribute to
them a ketogenic function, and this was particularly
- true of palmitic and stearic acids. Oleic acid was
V ketogenic. His results are confirmed by Geelmuyden.
[Magnus-Levy, who regards the fatty acids as the
chief, if not the sole, source of the acetone compounds,
says it is nevertheless unnecessary to restrict the inges-
tion of fat is diabetes. It is not the presence of a large
amount of fat that causes acidosis, but only the in-
creased decomposition of fat. The occurrence of
acidosis, he says, depends not so much (if at all) upon
the formation of acids or upon their combustion.]
It is well known that when fatty acids or soaps are
fed, the acids pass through the intestinal wall in the
form of soaps, and are immediately synthetized to
neutral fats, the glycerol for this purpose being
supplied by the organism itself. Borchardt considers
that the greater part of any ketogenic function which
the fatty acids may have is due to the abstraction of
this necessary amount of glycerol, and they, therefore,
do not act as direct acetone formers. In a control of
this statement, Waldvogel has injected olive oil under
the skin, and found no increase in the acetone elimina-
tion, although when this substance is given by the
mouth the acetonuria is increased. Absolutely neutral
fats have been shown by Geelmuyden and by Hagen-
berg to decrease the formation of acetone. Hence,
one must conclude that the greater part of the ketogenic
action of fats, especially those of the higher fatty
acids, is due to their content in free fatty acids, which
in their resorption combine with the antiketogenic
glycerol, and so remove it from its sphere of action.
As the chief source of the acetone compounds come
the amino acids produced by the breaking down of
p^ytein substances. Between many of the secom-
pounds — leucin, arginin, serin, cystin, etc. — and/3-oxy-
butyric acid there is a very clear chemical relation-
ship. Further it has been shown by Embden that the
perfusion of blood containing leucin through the
surviving liver results in a prompt increase in the
amount of acetone in the blood. Baer and Blum fed
leucin to diabetics and obtained an increase in the
amount of acetone compounds in the urine. Bor-
chardt fed protamines containing a large amount of
arginin, and also obtained a decided increase of
acetone in the urine. Other amino acids have been
fed by Embden and Salomon with like results. These
are tyrosin and phenylalanin. On the other hand,
glycocoll, alanin, glutaminic acid, and asparagin
when circulated through the liver did not increase the
acetone content of the blood.
The laws which govern the formation of acetone
from the substances above mentioned are chemically
somewhat complicated, and even yel have not been
completely worked out. They depend in part on the
capacity of the organism to remove the amino group,
and effect an oxidation at the 5-carbon atom (the
atom next that carbon atom to which is attached the
terminal carboxyl-COOH group). One example will
serve perhaps to indicate the type of reaction which
may occur.
Leucin has the following formula:
CH 3 CH 3
V ■
H— C— H
C— NH,
II
C<
I'OOH
By a simultaneous removal of the amino group, re-
moval of CO a from the carboxyl group, and subse-
quent oxidation, one may have the following hypothet-
ical series of changes taking place:
CH 3 CH 3 CH 3 CH 3
\y CH, CH,
CH r CH r
I I CH
H— C— H0 » h— C— H3 > I
H— C— H
II— C— NH,a H— C Ha
| I COOH
COOH COOH
The final step here is isobutyric acid. If now this
compound be oxidized at the /?-carbon atom, one
obtains acetic acid and acetone as follows:
CH 3 CH 3 CH 3 CH 3
\/ \/ Acetone
CH C=0
J-H —
H-
H
COOH
H — C + H Acetic acid
COOH
As the acetates are easily destroyed by combustion
in the organism, the acetic acid formed in the reaction
disappears, and acetone is left. Similar reactions may
be made out for the other amino acids which produce
acetone compounds. Arginin, one of the diamino
acids, is markedly ketogenic, according to Borchardt,
and therefore substances containing large amounts of "} -i
protamines, and consequently arginin, such as thymus
and roe, are to be avoided in cases of acidosis.
Reactions in which the /?-carbon atom is attacked
by oxidation have been very completely studied by
Knoop. By using compounds in which a straight
chain of a fatty acid is linked to a benzene group, he
was able to show that in every instance oxidation was
effected at this place. The rule, therefore, seems to be
a general one in the catabolism of fatty acids.
The quesion whether the fatty acids or proteins are
the principal source of the acetone compounds is thus
fairly well settled, for it is seen that with the proteins
the intermediary metabolism must take place through
steps involving the formation of a lower fatty acid.
Of very great importance from the standpoint of
acidosis are the antiketoplastic substances. As has
already been defined, these are the substances which
prevent the excessive formation of acetone compounds,
or reduce the amount which is excreted by the urine or
the breath. As v. Noorden remarks, the extension of
these substances is one of the most practical points in
the therapy of diabetes.
73
Acidosis
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Outside of the alkalies, such as sodium carbonate,
or certain salts of easily oxidizable organic acids such
as sodium citrate, the chief members of this group are
the carbohydrates. Without exception, all car-
bohydrates have the property of decreasing the
amount of acetone compounds, whether produced by
starvation or by diabetes. Owing to the somewhat
close similarity between these compounds and
glycerol, the latter is next in antiketogenic action.
It is unfortunate, however, that its use in diabetes is
attended with a marked increase in the amount of
glucose eliminated. Another member of this class is
alcohol. Neubauer has shown beyond question that
alcohol diminished acidosis to a marked degree, and
at the same time appeared to diminish the amount of
sugar excreted.
Besides these, certain of the amino acids are quite
antiketoplastic. Of these may be mentioned alanin
and asparagin. The experiments with glycocoll and
glutaminic acid were not altogether positive. It is
worthy of note that Eppinger gave amino acids with
what would have been fatal doses of inorganic acids,
and was apparently able to effect recovery. His
results, and the conclusions which he has drawn from
his work, will, however, bear a control.
Basing his classification on the content of antiketo-
genic amino acids, Borchardt arranges the proteins in
the following order: Protamin, histone, egg-albumin,
pancreas, casein. Protamin gives the highest amount
of acetone, while casein gives the least.
What the mechanism is whereby the carbohydrates
and certain of the amino acids are able to effect a
reduction in the excretion of acetone compounds, is
absolutely unknown. One reason for this lack of
knowledge is the incompleteness of our information
regarding the normal intermediary metabolism of car-
bohydrates and of fats. These are two of the most
difficult of the problems of biological chemistry.
Waldvogel believes that the carbohydrates act by
sparing the fats from combustion, but it has been shown
repeatedly, and the present writer has confirmed the
results, that only a very small quantity of sugar is
needed in the marked acidosis accompanying the
starvation in a case of pernicious vomiting of preg-
nancy, for example, to abolish all signs of acidosis
from the urine, and this without in the least affecting
the general condition of the patient. The amount of
carbohydrate which is necessary to prevent the appear-
ance of these compounds in the urine is even smaller
than that used to abolish them, once they are present,
and is by no means large enough to protect any very
considerable quantity of body fat.
Nasse some years ago suggested a process of "sec-
ondary oxidation" of the fats as a result of the pri-
mary oxidation of the carbohydrates, and a somewhat
similar idea has been put forward by Hirschfeld.
None of these theories has any very definite experi-
mental groundwork, and on the whole they are quite
inadequate.
To sum up as briefly as possible what is known about
the source of the acetone compounds, it may be said
that the higher fats probably do not form acetone
compounds. Some of the lower fats and fatty acids
have this property. Certain of the amino acids are
probably the chief source of these substances, and
form them by losing the amino (NH„) group, with the
loss of carbon dioxide, and oxidation at the /?-carbon
atom. Thus, in effect, the amino acids are trans-
formed into lower fatty acids, which are changed to
/?-oxybutyric acid and acetone.
Substances which give rise to glucose in the organ-
ism are antiketoplastic. The exception to this rule
i< alcohol, which apparently has the most useful prop-
erty of diminishing the glucose and acetone bodies at
tin- same t ime.
As in the combustion of proteins large amounts of
sulphuric and phosphoric acids arc formed, these also
probably play a part in acidosis. Salkowski showed,
74
many years ago, that the administration of taurin to
rabbits was sufficient to produce enough sulphuric
acid by oxidation to poison these animals. This was
a case of endogenous acid intoxication from inorganic
acids.
The Conditions under which Acidosis takes Place. —
In the healthy subject there is one condition which
produces the elimination of acetone compounds; this
is starvation. Not only complete inanition will bring
about this anomaly, but the mere abstention of the in-
dividual from carbohydrates is almost equally effec-
tive. The length of the fast which is necessary is
very short, less than twenty-four hours, and in all
subsequent discussions of acidosis and the pathologi-
cal significance of acetone compounds in the urine
this fact must constantly be borne in mind. Indeed,
a large amount of the clinical importance which has
been attached to these compounds is rendered abso-
lutely worthless when it is found that the observations
have included no consideration of the condition of
nutrition of the patient or of the amount and kind of
nourishment which he consumed.
Abstention from food for twenty-four hours is
usually sufficient to cause the appearance of acetone
in the urine, so that it can be detected with Lieben's
test. From the twenty-fourth to forty-eighth hour
acetoacetic acid makes its appearance, and at the
same time 3-oxybutyric acid may be detected.
Under-nourishment for any length of time may also
cause acetone to appear, especially if the supply of
carbohydrates has been insufficient for the needs of
the body. That simple starvation may produce a
very considerable acidosis is shown by the recent
work of Brugsch on the professional faster Succi.
This person was a man with a very decided amount of
body fat. During the twenty-fifth day of his fast
he eliminated acetone compounds equivalent to 13.6
grams of /?-oxybutyric acid. Similarly Satta has
shown that carbohydrate starvation alone may lead
to an acidosis equivalent to 20.0 grams of oxybutyric
acid. This is a degree of acidosis which would be
considered high even in cases of diabetes. That all
fasting subjects do not react with the same degree
of acidosis is shown by a parallel case reported by
Brugsch. This was a woman suffering from stricture
of the esophagus. She was in the very extreme of
emaciation, as was shown at the autopsy, when it was
found that even the plantar fat had disappeared.
This patient excreted practically no acetone com-
pounds. From these two observations Brugsch was
led to conclude that the source of the acetone com-
pounds was the abnormal metabolism of body fat.
This is not the only conclusion which can be drawn
from the results. It is also possible that the patient
had adapted herself to an extraordinarily small
caloric need, so that the amount of tissue which she
consumed was adequate for her. Other observers
have seen similar large amounts of acetone com-
pounds appear during starvation. Nebelthau's case,
in which sixty-six per cent, of the total nitrogen
was eliminated as ammonia, must be included in
this group.
Having shown that simple inanition may produce
large amounts of acetone compounds in the urine, one
is led to inquire which of the three classes of food-
stuffs it is that the abstention from is most effective
in causing the increased elimination of acetone com-
pounds in the urine when it is withdrawn from the
diet. As might be expected from their marked anti-
ketogenic action, the carbohydrates, and they alone,
are the substances whose withdrawal causes the fea-
tures of acidosis. One cannot therefore speak in
general of a starvation acidosis, but simply of a
carbohydrate starvation acidosis. The reason why,
as a rule, one gets a less severe type of acidosis in
carbohydrate inanition than in complete starvation is
due largely to the antiketogenic constituents of the
proteins, and to the glycerol content of the fats.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Acidosis
[Tests. — For a description of the various tests for
acetone, the reader is referred to the article Acctonunn.
(3-Oxybutt/ric Acid. — This may be tested for quali-
tatively by I he method (if Hart. Add 20 c.c. of water
and two diups of acetic acid to 20 c.c. of mine.
Boil gently until the volume is reduced to 10 c.c. Add
enough water to bring the volume back to 20 c.c.
and divide the fluid equally in two test-tubes. Add
1 c.c. of hydrogen peroxide to one of the tubes, warm
gently for about a minute and allow to cool. Then
add to each tube seven drops of glacial acetic acid
and three or four drops of freshly prepared solution
of sodium nitroprusside. Add 2 c.c. of concentrated
ammonium hydroxide carefully down the side of each
tube, so as to make a layer over the urine mixture.
At the end of four hours compare the tubes. If
/?-oxybutyric acid was present the tube to which
peroxide was added will show a purplish red ring at
the junction of the ammonia with the urine, while
the control tube will show no ring or only a faint
brown in case there was much creatinin present. If
there is no /9-oxybutyric acid in the urine the two
tubes will show no difference. Sugar does not inter-
fere with the reaction but albumin should be removed.]
Pathological. Acidoses. — There is possibly no one
urinary diagnostic feature in clinical medicine which
has been called upon to account for such a diversity
of symptoms as the presence of acetone and its allied
compounds. A partial list of the affections with
which they have been associated is as follows: cyclic
vomiting in children; vomiting in pregnancy; eclamp-
sia; fetal death; postoperative intoxications, espe-
cially associated with narcosis; hyperthermia; pul-
monary tuberculosis; malignant growths; asthma;
toxic conditions following the use of antipyrin, mor-
phine, atropine; carbon-monoxide poisoning, etc.
It will be noted that almost without exception the
conditions are those in which undernutrition or short
starvation is prominent. In the acetonuria following
narcosis one is usually dealing with abstention from
food for a period of time quite sufficient to provoke
the appearance of acetone in the urine in healthy
Individuals.
What is of paramount importance in the considera-
tion of these cases is a statement of the amount of the
carbohydrate intake and of its resorption. It is quite
possible, for example, in children with a severe gastror
intestinal derangement, that sufficient carbohydrate
may have been given to protect the child from an
acidosis, but owing to the digestive disturbance the
antiketoplastic substance is not resorbed, and so one
has to do with simple carbohydrate starvation.
In a careful analysis of the clinical literature dealing
with acetonuria in its relation to acid intoxication
one is struck with the fact that little attention has
been paid to this side of the question. Mohr, in his
valuable review of diabetic and non-diabetic autoin-
toxications with acids, has come to a similar con-
clusion, and is able to see in the acetonurias of these
various conditions nothing but the acidosis resulting
from an insufficient supply of carbohydrates. Spe-
cial mention might be made of pernicious vomiting
in pregnancy, because here the acidosis as revealed
by the acetone compounds, and more especially by
the relative amount of ammonia in the urine, has been
made a criterion whereby nervous vomiting might be
distinguished from a more pernicious type. The
present writer has criticised this view severely, and
since that time his attitude has been supported by
others who have had occasion to consider the subject.
Certain it is that it is physiologically impossible to
indicate operative interference in cases of pernicious
vomiting in pregnancy from either an analysis of the
urine for ammonia or an examination of the acetone-
compound elimination.
The etiology of eclampsia has been the subject of
numerous investigations in which the starting-point
has been the view that acid intoxication plays a
prominent part, and quite recently Zweifel has nar-
rowed down the toxic agent to sarcolactic acid, which
IS found in the urine during and after the seizures.
Dreyfus has repeated and confirmed Zweifel's results
as to the presence of lactic acid in the urine, but is
quite unable to find any etiological relationship
between the appearance of the acid in the urine and
the convulsions. It is altogether probable that
lactic acid in the urine in eclampsia i.-- the result of
insufficient oxidation and increased muscular effort,
and does not in any way figure as a cause of the con-
vulsive seizures. It has been repeatedly found by
Araki and others in the urine in cases of carbon-mon-
oxide poisoning and other conditions where its forma-
tion certainly gave rise to no additional toxic effects.
Diabetic Acidosis. — When one comes to the consid-
eration of diabetic acidosis one is confronted with a
problem of singular complexity. Obviously one is
dealing with a condition- which is most favorable to
the elimination of acetone compounds. There is in
the first place the usual strict diet of fat and protein,
which induces prompt acidosis in the normal subject;
there is secondly the incapacity of the diabetic to util-
ize the carbohydrate which is formed in the body from
protein, and possibly from fat. This incapacity is
often so complete that on a strict diet containing only
fat and protein, for every gram of nitrogen excreted
the patient excretes 3.5 to 4.0 grams of sugar. One
is not astonished, therefore, that a patient in this con-
dition, rejecting unused the sum total of the antiketo-
plastic substances, excretes very large amounts of
acetone compounds.
It is now important to decide whether this acidosis
is merely a carbohydrate inanition effect, or has a
specific quality not seen in the acidoses previously
discussed. In so far as one may judge at present,
one must acknowledge that diabetic acidosis presents
features which seem to indicate a specific nature apart
from the influence of carbohydrates. The literature
on the subject is extremely full, but v. Noorden has
summed up the evidence in favor of its specific
quality as follows.
1. Certain diabetics tolerating a diet containing
sixty to eighty grams of carbohydrate eliminate no
more acetone than a normal person on full diet. On
transferrence to a carbohydrate-free diet the amount
of acetone compounds increases, but finally on the
same strict diet diminishes.
2. Others with moderately severe diabetes may
eliminate, on a diet containing carbohydrate nearly
to the limit of their tolerance, one gram or more of
acetone. By transferrence to a strict diet the amount
of acetone compounds increases, and continues to
increase so long as the strict diet is adhered to.
3. In the third group, one may have individuals
with certain characteristics of severe diabetes.
They react favorably, so far as the disappearance of
glucose from the urine on a strict diet is concerned;
and yet under all circumstances they excrete large
quantities of acetone compounds in the urine. In
these cases one also gets marked variations in the
amount of the acetone compounds excreted which
have apparently no causal relation with the type of
food administered. Von Noorden mentions a case
in which fifty to sixty grams of /3-oxybutyric acid were
excreted daily over a very long period of time.
Further, there are marked individual differences in
the way patients react with the same amounts and
qualities of food. From these considerations one is
forced to the conclusion that the acidosis of diabetes
is not entirely due to carbohydrate inanition.
Acid Intoxication. — While there can be no doubt
as to the nature and severity of an acidosis due either
to carbohydrate inanition or to diabetes, the matter
is not quite so clear when one comes to connect the
appearance of the acetone compounds in the urine
with definite toxic effects.
Each of the compounds in this series has in its turn
75
Acidosis
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
been the subject of numerous investigations as to its
toxicity. Twenty grams of acetone produce some
drowsiness in a man. The injection of one gram of
acetone hypodermically had no effect whatever in
the general condition of a girl. According to v.
Jaksch, acetoacetic acid is not toxic, and even doses
as large as a gram have been given to a frog without,
the slightest effect. The results with /3-oxybutyric
acid agree in most respects with what v. Jaksch
obtained with acetoacetic acid. Most of the experi-
ments, it is true, have been performed with the
inactive acid, while the acid formed in the organism
is the'levorotatory modification. Schwarz was, how-
ever, unable to produce any toxic symptoms with
eight grams of the active acid when given to a dog.
Wilbur, working in v. Noorden's laboratory, has
apparently obtained some slight degree of toxicity
with the active acid. Very recently Desgrez and
Saggio have claimed that both acetoacetic acid and
/?-oxybutyric acid are toxic and cause a "demineral-
ization" of the organism. The results of the French
authors do not appear to be well enough founded to
deserve serious consideration.
So far as positive evidence is concerned, we have
little of direct value to indicate that the toxemia
which leads to diabetic coma, or, as Naunyn insists it
should be called, dyspneic coma, is an intoxication
produced by acid products. Nevertheless, the opin-
ion in favor of an acid origin is so universal, and there
is so little to supplant it, that one must admit a weight
of opinion in place of a weight of evidence.
The reasons for viewing dyspneic coma as an acid
intoxication are as follows, and are given very com-
pletely by Naunyn in his work on diabetes.
In the onset of coma, the percentage of carbon
dioxide in the blood falls markedly below the normal
thirty to forty volumes per cent. This indicates that
the amount of carbonates present in the blood, by
which the carbon dioxide is transported from the
other tissues to the lungs, has decreased. It has also
been shown that preceding the coma there is usually a
marked rise in the amount of acids, both acetoacetic
and oxybutyric, but this is not always the case; for
numerous cases of coma are on record in which the
amounts of these substances were lower at the time of
the attack than for long periods previously. Further,
the sudden change from a mixed diet to one contain-
ing fat and protein only has often provoked serious
symptoms, which Naunyn believes are due to the
flooding of the organism with acid products both of
inorganic (sulphuric and phosphoric) and organic
character. The clinical observations, too, on the use
of sodium carbonate in preventing the onset of coma
have many features which cannot be ignored, and lead
one to believe that this type of therapy is of very real
value. As much cannot be said for the use of carbon-
ates during the coma itself. Here the reports which
can be relied upon are almost hopelessly unfavorable.
One point which has been suggested by some authors
as to the relation between the acid products appearing
in the urine and the onset of the coma seems worthy of
notice. It is quite possible that there is no definite re-
lation between the urinary products and the onset of
the attack, for the reason that it is not the amount of
acids which appears in the urine which conditions the
coma, but the amount which is retained by the tissues.
This would explain why patients such as v. Noorden's
excreted large amounts of acid in the urine without
having any symptoms of acid intoxication. The pro-
ducts were eliminated as quickly as they were formed.
On the other hand, a patient might form quantities
of acids which would not be eliminated, and that
which was retained might exert its toxic effect.
In explanation of the inefficacy of the sodium carbon-
ate treatment, it has been urged that the alkali circu-
lates in the fluids which bathe the cells, but does in it
actually reach those intimate cell structures where the
toxic action of the acids is exerted.
The most critical analysis of the theory of acid
intoxication has recently appeared from Tangl's
laboratory. Two of his pupils, Szili and Benedict,
have undertaken to compare the findings obtained
in intoxication with inorganic acids with those got
in diabetes. Szili made a careful study of the effects
of inorganic acids on rabbits, dogs, and goats. These
animals were injected with solutions of acids, and
analyses made of the blood by titration, and by the
estimation of the true reaction of the blood by means
of gas-chain cells. It was found that with lethal
doses of acids the blood had a lower concentration of
hydroxyl ions than distilled water; that is to say, the
blood, compared with distilled water, had actually
become acid. At the same time, however, it reacted
alkaline to lacmoid paper. Of extreme importance
in this series of experiments was the fact that it was
possible to bring the animals immediately from a
state of dyspneic coma by the intravenous injection of
solutions of sodium carbonate. As a result of this
work Benedict undertook a study of diabetic coma,
following the methods employed by Szili.
He sums up the reasons which have been given for
believing that, diabetic coma is the result of poisoning
by acids as follows:
1. Severe diabetics produce, besides the normal
acid products of metabolism, excessively large amounts
of organic acids.
2. The fixed alkalies, sodium, potassium, calcium,
and magnesium, are not sufficient to combine with the
continual excess of acids produced, and hence large
quantities of ammonia are used for this purpose.
3. As increased acid production and increased
ammonia elimination almost always precede the onset
of dyspneic coma, and as /9-oxybutyric acid is not
toxic in itself, one must assume that the toxemia is
due to the acid character of the compounds when the
amount of alkali formed is not sufficient for their
neutralization, (o) The similarity between the coma
produced by inorganic acids and the dyspneic coma of
diabetes has long been recognized. (6) Blood investi-
gations of diabetics have led to the assumption of a
decreased alkalinity of the fluid. The carbon dioxide
content is lowered even to four volumes per cent,
instead of the normal thirty to forty volumes per
cent.
The points which stand in the way of believing
that diabetic coma is an acid intoxication are the
following:
1. Between the dyspneic coma and acid intoxica-
tion by inorganic acids there is a fundamental differ-
ence which can scarcely be explained away. While
animals poisoned by inorganic acids may be made to
recover almost immediately by the intravenous injec-
tion of alkalies, this is practically never the case in the
coma of diabetes.
2. It appears impossible to define accurately a dia-
betic coma. One often finds cases of carcinoma, inani-
tion, or hepatic disease in which the terminal coma has
all the clinical signs of diabetic coma.
3. The assumption of an acidification of the tissues
rests on the finding of a diminished carbon-dioxide
content of the blood; but one finds a similar decrease
in this value in other conditions without coma inter-
vening. On the other hand, cases of coma in diabetes
are on record in which the carbon-dioxide content of
the blood was scarcely below the normal.
In a control of these differences, Benedict investi-
gated the actual reaction of the blood in cases of dia-
betes by means of the gas-chain cell. The amount of
titratable alkali was also estimated. Eleven cases of
diabetes were examined, of which three terminated
fatally in coma. In the three cases of coma the con-
centration of hydroxyl ions in the blood was from
0.99X10-' to 0.42X10-', with an average value of
0.74X10 - '. In normal subjects there is a variation
from 4.1 X 10~' to 0.41 X 10-'. So that in all cases the
reaction was alkaline within what has been found to
76
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Acids, Organic
be normal limits. It has also been shown that in
other conditions, e.g. pregnancy, the alkalinity may
fall to 0.2x10-' without any danger to life. He
therefore believes that neither the results of Szili nor
his own investigations lend any support to the view
that the dyspneic coma of diabetes is due to an intoxi-
cation by acids.
Folin doubts that the evidence presented by Szili
and by Benedict is sufficient to discredit the acid-
intoxication theory, and bases his conclusions on the
fact that the Hungarian investigators have viewed the
intoxication from the standpoint of the physical reac-
tion of the blood, and that poisoning with large
amounts of acids does not yield comparable results
with the slow toxemia resulting from the production
of an excessive amount of acid in daily metabplism.
While the latter point is certainly well taken, the
present writer cannot agree that the former criticism
is justified. The acid effects of solutions of acids are
due solely to the concentration of hydrogen ions.
If the effects of the organic acids produced in the ab-
normal metabolism of diabetes are- not those of
hydrogen ions, one must assign a name other than
acid intoxication to the toxemia resulting from their
action in the organism. C. G. L. Wolf
References.
Naunyn: Der Diabetes Mellitus.
\\ aMvogel: Die Acetonkorper.
v. Noorden: Handbueh der Pathologie des Stoffwechsels. Bd.
i. and ii.
Borchardt: Zentralblatt fur die gesammte Physiologie und Patho-
logie des Stoffwechsels, N. F. 1, 129 and 641, 1906.
Folin: Journal of the American Medical Association, 49, 12S, 1907.
Benedict: Archiv fur cUe gesammte Physiologie (Pfliiger), 115,
106. 1906.
Szili: Archiv fur die gesammte Physiologie (Pfliiger), 115, 82,
1906.
Wolf: N. Y. Medical Journal, April, 1906.
Embden: Hofmeister's Beitrage, 7, 121, and 129, 1906.
Mohr: v. Noorden's Sammlung klinischer Beitrage, No. 4, 1904.
Joslin: Journal of Medical Research, 12, 433, 1904.
Knoop: Habilitationsschrift, Freiburg, 1904; Hofmeister's Bei-
trage, 6, 150. 1905.
Dreyfus, Biochemische Zeitschrift, 190S
v. Noorden: Die Zuckerkrankheit und ihre Behaudlung. 6th Edi-
tion, 1912.
Hammarsten: A Text-book of Physiological Chemistry. English
Translation, 6th Edition. 1911.
Magnus- Levy: Johns Hopkins Hospital Bulletin, 46, 1911.
Acids, Organic. Drfi nitrons. — Acids are compounds
which when dissolved in water are dissociated, yielding
positively charged hydrogen atoms; these hydrogen
atoms may be replaced by metals with the formation
of salts. Organic acids are characterized by the
presence of one or more carboxyl (COOH) groups in
which the hydrogen atoms may be replaced by metals
to form salts or by organic (alkyl) radicals to form
esters. The basisity of an organic acid is determined
by the number of carboxyl groups it contains:
Fatty Acid Series, CnH 2n O,. — Fatty acids are found
in the body chiefly in combination with glycerin in
the glycerides or neutral fats of adipose tissue. They
are also found combined with alkalies, as soaps, and, in
small quantities, as free fatty acids. Free fatty acids
occur in the intestine as a result of the breaking up of
neutral fats in pancreatic digestion. Some of the
lower members of the series are found free in blood
and sweat. As we ascend the series, the molecules
become more complex and the melting and volatilizing
points rise. For each acid they vary slightly, accord-
ing to the mode of preparation. Many fatty acids
crystallize in characteristic forms. The following are
of most physiological importance:
Formic acid, H.COOH, is found combined as salts
in minute traces in normal urine, and in increased
amount in certain diseases with deranged meta-
bolism, such as leueocythemia and diabetes. It is
present in the stings of certain insects, giving them
their irritating qualities. It is a colorless liquid, of
strong odor, volatilizing at 100° C.
Acetic acid, CH..COOH, is found in the intestine
and sometimes in the stomach as a result of fermenta-
tion processes occurring in carbohydrates and higher
fatty acids. Its salts are present in normal urine in
t races, and in increased amount in diabetes and leuco-
cythemia. In the diseases named, it is also found in
the urine combined with acetyl, CH 3 .CO, to form
diacetic acid, CH 3 .CO.CH 2 .COOH. Acetic acid has
a characteristic odor like vinegar, a sour taste, and
forms transparent crystals which melt at 17° C.
Propionic acid, CH 3 .CH 2 .COOH, occurs occasion-
ally in sweat. It is present in the blood, urine, and
vomit of certain diseases. It is the first fatty acid to
form a neutral fat with glycerin. It has an odor like
acetic acid and volatilizes at 142° C.
Butyric acid, CH 3 .(CH 2 ) 2 .COOH, is found in the
intestines and occasionally in the stomach, as a result
of fermentations. It may be formed from the
decomposition of proteins, carbohydrates, fatty acids
higher in the series, or lactic acid. It is found in sweat,
and traces have been demonstrated in blood and
urine. It is present in milk and butter, combined
with glycerin as butyrin. Butyric acid is an oily
liquid, volatilizing at 162.3° C. and solidifying at
-19° C.
Isovalerianic acid, (CH 3 ) 2 .CH.CH 2 .COOH, is found
in cheese, the sweat of the foot, and the urine in cer-
tain diseases. It is a product of protein decomposi-
tion. It is found combined as a neutral fat in dolphin
blubber. It is an oily, colorless liquid, smelling like
rotten cheese, and volatilizing at 176.3°.
Caproic acid, CH 3 .(CH 2 ),.COOH, is found in the
feces and sweat, also in cheese, is formed from putre-
faction of proteins, and occurs as a glyceride in butter.
It is an oily, colorless liquid, with a faint, unpleasant
smell. It volatilizes at 205° C. and solidifies at - 18° C.
Caprylic acid, CH 3 .(CH,) 6 .COOH, and
Capric acid, CH 3 .(CH,),COOH, are found in
sweat, in cheese, and as glycerides in butter. Ca-
prylic melts at 16.5° C. and volatilizes at 236° C"
Ca'pric melts at 30° C. and volatilizes at 270° C.
Laurie acid, CH 3 .(CH 2 ), .COOH, and
Myristic acid, CH,.(CH,) 12 .COOH, are present as
glycerides in human fat and in butter, also combined
as esters in spermaceti. Laurie acid melts at 43.6°
and myristic at 53.8° C.
Palmitic acid, CH 3 .(CH 2 ) 14 .COOH, is found as a
glyceride in all animal fats and combined as esters
of cetyl and myricyl alcohol in spermaceti and bees-
wax respectively; it is also found combined with
cholesterin in wool fat (lanolin). It melts at 62° C.
Stearic acid, CH 3 .(CH,)i„.COOH, is found combined
like palmitic acid in animal fats and spermaceti. It
melts at 69.2° C. Margaric acid is a name sometimes
applied to a mixture of palmitic and stearic acids.
Arachidic acid, CH 3 .(CH,)„.COOH, is found in
butter as a glyceride. It melts at 75° C.
Cerotic acid, CH 3 .(CH 2 ) 25 .COOH, is found free in
beeswax. Combined as cetyl ether, it forms the
principal part of Chinese wax. The free acid forms
granular crystals, which melt at 78° C.
Acrylic Acid Series, C n H 2 n 2 - 2 0,. — Some of the
higher members of this series form compounds with
glycerin, resembling the neutral fats. The most
important member of this group physiologically is —
Oleic acid, CH 3 .(CH,)„.(CH) 2 .COOH; it is found
united with glycerin in all the fats of the body, as a
liquid fat, olein, which holds the higher fats of the
fatty acid series in solution at the body temperature.
It is more abundant proportionally in the fats of cold-
blooded animals and in vegetable oils.
Gh/colic Acid Series, C n H,n0 3 . — Carbonic acid,
OH. COOH, is unknown in its free state, being doubt-
less too unstable to exist. Its salts, however, are
present in large quantities in the body, and play an
important part in the alkalinity of the tissues and
77
Acids, Organic
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
fluids. Its corresponding oxide, C0 2 , is the principal
form in which carbon leaves the body.
Glycolic acid, H.CHOH.COOH, does not occur in
tic body.
Lactic acid (better distinguished as ethylidene-
lactic acid), CH 3 .CHOH.COOH, exists in three
isomeric varieties:
1. Fermentation lactic acid is present in sour milk,
and in the stomach and intestines during digestion.
It is also found in small quantities in the muscles
and brain, and in diabetic urine. It is a colorless or
faintly yellow liquid of syrupy consistency. It may
be regarded as a mixture of the two following from
which it is distinguished by being optically inactive.
2. Paralactic or sarcolactic acid is the principal
acid of meat extracts and of muscle, and is also found
in numerous glands. It is present in the sweat in
puerperal fever, and in the urine after severe fatigue,
in acute yellow atrophy of the liver, and in phos-
phorus poisoning. It is dextro-rotatory to polarized
light.
3. A third levo-rotatory lactic acid has been
obtained by the fermentation of cane sugar by a
special bacillus.
Oxybutyric acid, CH 3 .CH 2 .CHOH.COOH, found
along with diacetic acid and acetone in the blood and
urine of diabetes, is an odorless syrupy liquid, which
mixes freely with water, alcohol, and ether, and
rotates polarized light to the left.
Oxalic Acid Series, CnH 2 n 2 — ( . — Oxalic acid,
COOH.COOH, is found in small quantities in the
urine as calcium oxalate, and often occurs in excess
after the ingestion of rhubarb, strawberries, or
cabbage. It is usually increased where the amount
of uric acid is increased. It may be obtained in the
laboratory along with urea and carbonic acid gas
from the oxidation of uric acid, and it is believed to
be formed from the latter in the body to some extent.
Oxalic acid is a violent poison. It crystallizes from
aqueous solutions in large, transparent prisms, which
effloresce when exposed to the air.
Succinic acid, COOH. (CH 2 ),. COOH, has occasion-
ally been found in the urine after the ingestion of
asparagus and other vegetables and fruits. It has
also been detected in the sweat, the intestinal con-
tents, and in the thymus and thyroid glands. It
forms large colorless crystals which are unaltered by
the air and which fuse at 180° C.
Amino Acids are cleavage products obtained by
the decomposition of proteins by various means and
represent in part the nuclei making up the protein
molecule. Chemically they are organic acids which
contain one (monoamino) or two (diamino) amino
(NIL,) groups. They may also contain either one
(monobasic) or two (dibasic) carboxyl (COOH)
groups in which the hydrogen is capable of being
replaced by a metal or base. The most common and
important amino acids are the following:
I. Aliphatic (fatty) series formed from acids belong-
ing to or derjved from the fatty acid series and in
which the arrangement of atoms is essentially
in an open chain.
1. Monoamino acids.
A. Monobasic.
Glycin, glycocoll or ammo-acetic acid, CH,.-
NIL.COOH.
Alanin hi- ,i -amino-propionic acid, CH,.CH.-
NIL.COoII.
Serin, oxyalanin or oxyamino-propionic acid,
CIL 0H.CH.NH 2 .C00H.
Amino-isovaleric acid, (CH,).,.CH.CH.NH.„-
COOH.
Leucin or a-amino-isobut vl-acetic acid,
(CH 3 ) 2 .CH.CH 2 .CH.NH a .COOH.
R. Dibasic.
\ partic or a-amino-succinic acid, COOH.CH.-
NH 2 .CH 2 .CO()ll.
78
Glutamic or a-amino-glutaric acid, COOH -
CH.NIL.CIL.CLL.COOII.
2. Diamino acids.
Lysin or «-s-diamino-caproic acid, NH 2 .CH,.-
CH 2 .CH,.CH 2 .CH.NH,.COOH.
Arginin or guanidin-amino-valeric acid, NIL-
NH 2 .CNH.CH,.CH 2 .CH 2 .CH.NH 2 .COOH.
3. Acids containing sulphur.
Cystin or <*-diamino-;9-dithio-dilactylic acid,
(CH 2 .S.CH.NH 2 .COOH) 2 .
Cystein or a-amino-^-thio-propionic acid,
SH.CH,.riL.\lL.C.,.OH, cresol-
sulpnuric acid, C,H 7 .O.S0 2 .OH, indoxyl-sulphuric
acid or indican, (' Jl. .\.<>.SO„.OH, and skatoxyl-sul-
phuric acid, C H,.N.O.S< >..< HI.
These acids are all found in the urine, and are de-
rived from the phenol, cresol, indol, and skatol which
are formed in the intestines as a result of the putre-
faction of proteins. Any circumstances favoring the
latter process, such as intestinal diseases accompanied
by obstruction, increase the amount of these acids in
the urine.
Aromatic oxyacids, of which the principal are
paraoxyphenyl-acetic acid, C„H ( .OH.CH 2 .COOH, and
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Acne
paraoxyphenyl-propionio acid, C„H 4 .OH.C s H 4 .CO< Ml,
are formed from tyrosin in small quantities in the in-
testine and pass unchanged into the urine.
Nucleic Acids. — These are acids rich in phosphorus,
of complex and variable composition, found among
the most characteristic constituents of cell nuclei.
They combine with proteins to form varieties of nu-
olein and nucleoprotein. Among the products of
their decomposition, the most important are phos-
phoric acid and the alloxuric bases, also known as the
tanthin or still better as the purin bases.
Uric Acid. — C s H t N 4 3 , trioxypurin, is found in
adult human urine to the extent of from seven to ten
grains per day, combined with bases to form urates.
In birds and reptiles it replaces urea in the urine as
the principal end product of protein metabolism. In
man it is derived principally from the nuclei of broken-
down cells and from the purin bases contained in the
food. The extent to which it is formed from pro-
teins in the body cannot be considered settled. For
further details about uric acid, see Urine.
Wesley Mills.
William S. Morrow.
Acids, Therapeutic Action of. — (See also under
heading of each individual acid). In treating of
the therapeutic action of acids, consideration is
given to the stronger acids which possess all the chemi-
cal characters of this group in a marked degree. The
most important are sulphuric, nitric, hydrochloric,
phosphoric, acetic, citric, and tartaric acids. Of
other so-called acids, represented by boric, benzoic, ol-
eic, carbolic, salicylic acid, etc., the chemical charac-
ters of the true acid are either absent or gradually
diminish until they are over-shadowed by other
important therapeutic properties.
When applied to the tissues, their local effect
varies from the powerful corrosive action of sulphuric
acid to the mild irritation of the vegetable acids.
Sulphuric acid is destructive to all tissues, altering
and destroying them beyond recognition. It is
extremely hygroscopic, and this affinity for water is
the cause of its great penetrating and diffused action.
It combines with the albumin, fibrin, etc, producing a
jelly-like mass which may be partially discolored and
charred. The milder solutions simply coagulate and
disorganize the albuminous structures. Nitric acid
acts similarly, but is less severe. In addition to its
corrosive effects, it produces a characteristic yellowish
stain, which serves to distinguish it from other acids.
A somewhat similar stain is caused by bromine and
iodine, but marks of either of these are readily re-
moved by a little caustic potash, while the nitric acid
stain becomes of a brighter hue by the action of the
alkali. Hydrochloric acid is very much weaker.
It does not cause the same destruction of tissue as
the other two acids, but the parts become white or
whitish brown by its coagulation of the albumin; at
times bulke and blisters may form. On the soft
mucous surfaces, the strong acid may produce a
swollen, structureless mass. The other acids, with
the exception of glacial acetic acid, are simply
irritants.
In medicinal doses, the beneficial effects of dilute
acids are marked, but how far this is due to their
local action or is secondary to action after absorption,
is still an unsettled question. After absorption they
lose their acid character. They combine with the
alkaline bases in the blood, and render it less alkaline,
but never produce acidity. They are excreted as
sulphates, chlorides, etc. The presence of hydroch-
loric acid in the gastric juice is a true secretion of the
gastric glands. As eseharotics the strong acids are
a useful adjunct to the therapeutic armamentarium.
Sulphuric acid is not so much employed as it was
formerly, when it was a favorite reagent for removing
morbid growths. Its painful effects and great pene-
trating power are objectionable, and it is replaced by
other caustics which are more easily controlled.
This penetrating property, however, renders ii , as well
as nitric acid, of value in bites and wounds of poison-
ous animals. Nitric acid is always selected when
any destruction of tissue is desired. It removes the
necrosed tissue and produces a healthy growth of
granulations. Hydrochloric acid is seldom used,
although it was at once time often employed to
destroy the membrane in diphtheritic throats. The
use of acetic arid is almost limited to the slow removal
of warty growths and the treatment of ringworm.
In very dilute solutions all acids possess a cooling and
refreshing action when applied to the surface of the
body; they also exert an astringent effect upon the
blood-vessels and sweat glands, as when employed to
prevent or lessen the night sweats of phthisis. Nitro-
iiydrochloric acid baths and compresses have been ex-
tolled as a means of relieving the hepatitis of hot
climates.
When administered as a beverage all acids are most
refreshing. This is well known in tropical countries.
Lemonade, lime juice, dilute phosphoric, acetic,
citric, and tartaric acids are universally employed.
Their effervescing salts are particularly useful. They
prove refrigerant and disinfectant, promote digestion,
and if there is any diarrheal tendency, their astrin-
gent properties become of service.
Beaumont Small.
Acne. — Definition. — Acne may be defined as a
disease of the sebaceous glands of the skin and of the
follicles of the lanugo hairs attached to them, thus
being both a folliculitis and a perifolliculitis. It is
characterized by their inflammation and suppuration
and often by their destruction, with a resulting scar.
The term acne has been qualified in accordance
with various salient features presented by its lesions
or with certain clinical characteristics predominant in
a case, and there are therefore found in literature
such terms as acne vulgaris, pustulosa, punctata,
juvenilis, adolescentium, etc. All, however, rep-
resent the same process. In addition to these, the
name acne has also been applied to a large number of
affections, which have nothing whatever in common
with true acne, but which represent totally different
pathological entities, and among these are included
tuberculous affections, drug eruptions (iodine and bro-
mine acne), or folliculitides of artificial origin (tar, oils,
and grease, etc). For the sake of simplicity and
definiteness, the disease will be treated of here under
the heading of acne simplex — the more superficial form
— and of acne indurata — the deeper-seated variety.
Acne rosacea, being a compound process, will receive
separate mention.
Symptomatology. — Acne Simplex. — Acne simplex
possibly represents the most common form of the
disease, as it is the one developing particularly about
the age of puberty and in young people. Instances
have also been seen at a much earlier age, and like-
wise later in life, about the climacteric. Apparently,
it occurs more often in the female than in the
male sex, but the ratio between them is probably
more relative than exact. The lesions characterizing
the affection occur without regularity or symmetry,
though they are usually distributed bilaterally.
Still, variations are met with, such as one side of
the face being intensely attacked, and the other side
only silghtly, and sometimes it is found unilateral.
Acne occurs on the face especially, but it also often
appears on the chest and shoulders, and sometimes
on the upper arms, or it extends down the back even
to the thighs.
The lesions characterizing acne simplex are come-
dones, papules, and pustules. In this variety of the
disease, the comedo, or popularly the blackhead, as
a rule constitutes a central point around which the
inflammatory changes take place. These can usually
be seen and traced in every case, and consist of redness
79
Acne
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
around the comedo, then formation of a papule, and
lastly transformation into a pustule. Lesions may,
however, arise independently of the comedo. The
lesion having become pustular, remains as such for a
few days; the redness then begins to fade and a crust
forms, which falls off in the course of a few days or
more, leaving a slight stain, or a scar, or a pitting.
The pustular transformation does not, however, take
place in all of the lesions. Many of them having
reached the papular stage, remain in that form for
a variable length of time and then gradually undergo
involution. Neither do all the comedones become im-
plicated and result in papules or pustules, but many
persist in situ unchanged. In consequence, on an
affected surface all stages of the disease are usually met
with, and comedones, papules, pustules, crusts,
stains, and scars are seen more or less aggregated
i^G^mm?
Fig. 16. — Section through a superficial acne lesion (acne simplex).
(Author's drawing.)
together without order or regularity, the whole
constituting the condition known under the name of
"pimply skin" or "pimples."
The lesions of acne simplex present no especial
subjective symptoms, though when handled the
inflamed ones are sometimes slightly painful. Occa-
sionally a burning sensation or itching is complained of.
The scars and stains resulting from the lesions vary
in degree, in number, and in size. In many cases, no
scars are produced and the subsidence of the inflam-
matory symptoms marks the end of the lesions.
Others, however, leave decided stains and scars.
The stains may remain for a few weeks only; but the
writer has seen them persist for months with scarcely
any change. As a rule, they gradually fade and
ultimately disappear without leaving any pigmenta-
tion or trace. In the cases in which scarring takc^
place, the scars often remain for all time, though
occasionally the skin seems to smooth out entirely
after a few years. These differences in the results of
the lesions are naturally dependent upon the tissues
of the individual affected, the formation of scars
being commonly found in strumous subjects and in
those suffering from malnutrition of various origin.
When an acne lesion is opened and its contents
evacuated, these will be found to consist of pus, blood,
sebaceous matter, and the comedo, when this latter is
present. After evacuation, the lesion heals rapidly
and the process is at an end. Still just next to that
gland, another may become attacked, and in that way
the disease constantly renews itself, lesions appearing
every day and the same train of symptoms repeating
themselves for a varying period of time. Acne
always runs a chronic course; that is, a limit of
existence within which it ceases to recur cannot be
made, and the comforting assurance so often given
to young patients that when they reach legal age
their affliction will disappear, is based upon fancy and
not at all upon fact. The simple variety of acne may
be present during the entire course of the affection, or it
may become of the severer type — the indurate form —
or it may be complicated by the development of a
rosacea. The simple and indurate forms, however,
very commonly coexist, one or the other preponderat-
ing from time to time.
Acne Indurata.— The deeper-seated variety of acne
— the indurate form — presents clinical symptoms
differing in degree and extent from those which occur
in the type just described. Comedones are often
present, but they do not constitute an essential
portion of the process, nor do the lesions have their
origin in connection with them. The efflorescences of
acne indurata vary in size from a pea to a small nut.
They originate deep in the tissues and enlarge slow-ly
or rapidly, requiring some days and even a week be-
fore softening. The inflammatory reaction is not
limited to the gland alone, but affects the surrounding
tissues, and while in cases in which the lesions arise
acutely their color may be a bright red, in others it may
be dull red and even purplish. In shape, great
variations are seen, and the inflamed lesion may be
rounded, or elongated, or irregular, and it may also,
by the implication of several contiguous glands, give
origin to a furuncular or abscess-like formation. The
Fig. 17. — Section through an acne indurata pustule.
(Author's drawing.)
occurrence of the suppurative change is in some cases
very active, and there is a rapid transformation of the
indurated area into a pus cavity; but in others, only a
small amount of pus forms in the central portion, and
the hard and tense condition of the original lesion
persists. Spontaneous rupture does not occur, and
unless its contents are evacuated mechanically, the
lesion may remain for days and even weeks, slowly
undergoing involution. After it has been opened, it
may refill again, and even many times, or until thor-
ough evacuation of all its contents has taken place.
Acne indurata is much more apt to leave scars than
acne simplex. The scarring, however, occurs most
readily in subjects of lax fiber, or who have strumous
antecedents, or who are accustomed to empty the
lesions by hard squeezing or other irregular mechani-
cal means. The scars produced have no charac-
80
REFERENCE HANDBOOK
OF THE
MEDICAL SCIENCES
PLATE IV
- *
- :
: -
-- a
<
* r ~
- ^ £
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Acne
teristics and are generally at first purplish and livid,
but finally they become white in color. Keloidal or
fibroid degeneration has been seen by the writer as a
Bequela. This form of the disease attacks the same
localities as have been mentioned for acne simplex,
but it occurs on the trunk more frequently than the
latter. The lesions may occur singly, discrete, and
only few in number, or they maybe very numerous and
more or less aggregated together. In fact, patches
may occur on which they are so crowded that it is
difficult to make out the separate lesions.
\rne indurata tends to run a chronic course and to
persist for a number of years. Only a few lesions may
appear from time to time, or there may be severe out-
breaks, and crop aftercrop may arise until the affected
surface is covered with the manifestations of the process
— papules, pustules, crusts, and scars — and every stage
of evolution and involution of the disease be present at
tin- same time. It is doubtful if spontaneous disappear-
ance of the indurate form ever takes place, though
Fig. IS. — Acne Cachecticorum of the Face. (From a photo-
graph taken by Dr. George H. Fox.)
such is not infrequent for the simple variety. In
connection with both the simple and the indurate
type of acne, seborrhcea oleosa occurs very commonly,
the skin then presenting a greasy, oily aspect, being
yellowish in color, with most usually the follicular
orifices dilated, giving the surface a sieve-like ap-
pearance. The process known as seborrhoic eczema
{dermatitis seborrheica) is also a frequent com-
plication, the skin then presenting, in addition to the
acne lesions, scaly patches of irregular outline or
patches covered with thin greasy squamae or even
fatty crusts. It is in such eases that itching is
generally complained of. Besides these, any other
cutaneous disease may coexist with an acne.
Acne Cachecticorum. — The form of cutaneous
eruption to which the name of acne cachecticorum is
given occurs in poorly nourished, marasmic, strumous
individuals, though cases have been recorded which
developed in those perfectly healthy. The process is
Vol. I.— 6
generally associated with tuberculous glands of the
neck and with lichen scrofulosum. The trunk and
lower extremities tire must commonly the- seat of the
eruption, though the arms may be affected and like-
wise the face. The Lesions are of large size — pea to a
nut ; they are dark red, purplish, and even livid in
color; they are not tense or prominent, but fla' ened
and flaccid. No sebaceous plugs are present, and the
contents are scanty, consisting of a seropurulent fluid.
They form crusts, and underneath these ulceration
occurs. In some cases, the lesions become hemor-
rhagic. After healing has taken place, a livid and
purplish scar of irregular shape persists for a long time,
finally becoming white. Occasionally, the hands are
affected and become edematous and bluish-red, and
covered with nodules and pustules. It is doubtful
to-day whether this process should be regarded as an
acne at all. In its course and general symptoms it
differs greatly from acne indurata, though it is
possible that the differences are due more to the soil
Fig. 19. — Acne Cachecticorum of the Back. (From a photo-
graph taken by Dr. George H. Fox. J
conditions in which the process occurs than, to any
special pathological causative factor. Still, owing to
the presence of the tuberculous glands and the coexist-
ence of lichen scrofulosorum, a tendency exists to
regard it as a form of "scrophuloderma" and of
tuberculous origin.
Iodide acne and bromide acne are eruptions caused by
these drugs when taken internally. The iodic acne
occupies the same regions as acne in general, though
it is very apt to be more disseminated over the surface.
There are no comedones, but the lesions appear as an
acute eruption of hard papules, which may enlarge
and become pustular. General symptoms of iodism are
usually coexistent. The bromide acne appears
often on the face, but has a predilection for the hairy
surfaces — scalp and eyebrows. The lesions are
papules, pustules, and tubercles. They often form
around the hair follicle and the lesion is pierced by a
hair. Both of these may be caused by any iodine or
81
Acne
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
bromine compound, and though the eruption generally
ceases with the cessation of the drug, it may, however,
persist for months afterward.
Acne picea, tar acne, occurs in those regions upon
which tar has been used. The orifices of the sebaceous
glands become blocked up with the tarry plug, which
acts in a similar manner as the comedo and leads to
perifollicular inflammation and the formation of a
papule. Pustulation also takes place at times. The
same condition may result from the use of chry-
sarobin. The application of ointments, particularly
in those regions in more or less constant contact with
each other — the inguinal and the axillary regions, for
instance — very often produces a follicular disturbance
analogous to an acne, in so far that the lesions
implicate the sebaceous glands and consist of papules
which become, later, pustules. There may also be
referred to here the folliculitis of the face and arms of
flax spinners (Purdon), and the eruption occurring
on the thighs, which is due to the oils and grease used
by spinners in their vocation (Leloir).
Pathology. — The pathological changes in acne
are constituted by inflammation of a sebaceous gland,
the occurrence of suppuration, and in a greater or
lesser degree the destruction of the gland and the
surrounding tissue. The cause of these changes may
be of various origin and is certainly not a single specific
one. It may be the comedo or other agent blocking
up the follicular orifice, and acting as a foreign body
causing perifollicular congestion and inflammation
through some chemical change. The causal agent
may, moreover, be some pathogenic microorganism
present in the follicle prior to its closure, or carried to
it through the circulation. The fact that certain
microorganisms have been found to be especially
associated with the production of pus has suggested
that the acne pustule was the result of infection of the
sebaceous follicle by some one or other of these pyo-
genic germs. Most text-books on diseases of the
skin give Staphylococcus albus as the cause of acne
vulgaris in addition to the predisposing causes.
Many investigators could get only Staphylococcus
albus in cultures from acne lesions and this organism
is undoubtedly an active factor in some, if not all
stages of the disease. Unna in 1893 found a small
bacillus in smears and sections from comedones
together with the bottle bacillus and several forms of
cocci. Only poorly nourished plate cultures of the
bacillus could be obtained — no subcultures. Unna
thought these bacilli were the cause of acne. Hodara
in 1894 confirmed Unna's observations and grew the
bacilli in mixed cultures but did not get any pure
culture. Sabouraud in 1894 published his first com-
munication upon his microbacillus of seborrhea but
did not believe the organism to be the direct cause of
acne. Gilchrist in 1899 isolated a bacillus in pure
culture from acne vulgaris lesions which be believed
to be the cause of the disease. In 1903 Gilchrist
confirmed his previous work by finding the Bacillus
acnes present in 240 smears from 86 patients; and
pure cultures of the organisms were obtained from
62 lesions. He also found that the sera from patients
suffering from severe acne caused clumping or agglu-
tination of the Baccillus acnes even when diluted 1-100,
which led him to think that the anemia, coated tongue,
and constipation were probably the result of acne and
not predisposing causes of the disease. Engman con-
siders the organisms described by Unna, Sabouraud,
Gilchrist, and himself to be identical. He found the
organism was grown only with the greatest difficulty
and was unable to obtain subcultures. Fleming,
Western, and Lovejoy have since noted the constant
presence of Bacillus acnes in the lesions of acne.
Smiley reports 100 cases of acne vulgaris in which the
acne bacillus was present in all. In eighty-six per
cent, of his cases the accompanying organism was the
Staphylococcus albus; in ten per cent, he found the
Staphylococcus albus and aureus together; in three per
82
cent, the Staphylococcus aureus alone; and in one per
cent, the Staphylococcus citreus and albus together.
In the writer's opinion Bacillus acnes may be the
cause of the acne lesion, but it certainly is not
the only cause. The bacillus can frequently be iso-
lated from the sebaceous follicles of the nose of people
who have never had acne. Experience and the ob-
servation of a great many cases nave shown that the
various functional and pathological conditions men-
tioned in the paragraph on etiology play a most
important part in the production of the eruption.
Under the influence of these various etiological factors
the resisting power of the skin is lowered. As a
result the acne bacillus is enabled to assume patho-
genic properties where before it had existed as a
harmless saprophyte of the skin.
Pathological Anatomy. — According to many
writers the starting-point of the inflammatory change
is around the follicle of the lanugo hair attached to
the gland, the latter becoming only secondarily impli-
cated in the process. The writer has, however,
frequently found the hair follicle absolutely intact
and not concerned in the pustular formation. The
inflammatory changes always begin around the
follicle — that is, it is primarily a perifolliculitis.
The tissues are infiltrated with round cells which
are located at first around the network of blood-
vessels supplying the sebaceous gland attacked.
Unna states that the infiltration consists of plasma,
large fusiform " mast " and a few giant cells, leucocytes
being found only when suppuration has occurred.
The degree of infiltration varies in different lesions
and cases. The writer has found that in acne simplex
lesions, infiltration is more superficial and located
about the duct and upper part of the gland, while
in the indurate form it is deeper and around the
body of the gland especially. It may also extend
widely throughout the cutis; and several contiguous
glands becoming affected, they melt together into
one inflammatory and suppurating area. The peri-
follicular inflammation having extended to the gland,
its parenchyma becomes infiltrated, its cavity is
distended, and its walls ruptured in places. Its con-
tents are then composed of serofibrinous fluid,
sebaceous debris and leucocytes, some intact glandular
epithelium, and often the comedo. In acne simplex
the gland is not always destroyed, but in acne indu-
rata it generally is. The same changes may affect
the follicle of the lanugo hair attached to the
gland.
Etiology. — The etiological causes active in the
production of acne, whether of the simple or indurate
variety are manifold, and the process cannot in any
sense of the term be regarded as of specific origin.
Whether the many disturbances or systemic condi-
tions found in connection with these cases are to be
estimated as of causative importance, or as simply of
predisposing effect, is a question which will be deter-
mined when the pathological origin of the disease is
absolutely established. Until then it can only be
said that without their proper valuation and con-
sideration, no case of acne can be understood or its
needs correctly estimated, for it is more upon these
etiological factors that treatment should be based
than upon any other feature presented by the proc-
ess. Age plays an important part, as the inception
of the disease in the large majority of cases is at or
about the time of puberty. Still it occurs at other
ages, and the writer has seen it develop at every
period of life between puberty and the climacteric,
and even later. In youth, acne simplex is most
common, but acne indurata occurs most frequently
after twenty-five. That it tends to disappear at the
age of twenty-one — a belief so current among the
laity and unfortunately the general medical profes-
sion also— is an unwarranted assumption, due to the
fact that many patients have at that age recovered
from one or another disturbance of nutrition incident
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Arnr
to their development, and occurring during the pe-
riod in which stability of their tissues was in a stage of
transition; that is, major etiological causes of the
disease had by that time been removed by nature, by
general treatment for other systemic condition':, nr
by greater care of the functional and general health
on the part of the individual afflicted, through educa-
tion and possibly observation of the relation existing
between the eruption and some deviation from normal
health.
Menstrual and uterine disorders are frequently
accused as predisposing factors in the production of
acne, but still too much stress should not be laid upon
them alone, since the cause of the menstrual disturb-
ance may more properly be the important factor.
At any rate, an aggravation of an existing acne will
commonly occur before, during, or after a menstrual
epoch. And yet the abnormal conditions which
affect this function may be entirely removed, but
the eruption will persist; or the acne may be radically
eured, "hile 'he functional or other disturbances of
the uterine organs remain unchanged. In assocation
with the process, all other forms of functional and nutri-
tive disturbance are also met with. Constipation is
very frequent and not uncommonly chronic catarrhal
forms of diarrhea. Chlorosis or anemia of variable
grades and debility of various origin are often the
basic factors. Gastric and intestinal dyspepsia are
common, though in my experience it is most usually
fermentative intestinal indigestion which is of impor-
tance. Dilatation of the stomach has been stated to
be particularly common in these cases, but it is
undoubtedly exceptional. Mental and physical ex-
haustion, excesses of any and every kind, masturba-
tion, urethral irritation, a sedentary life, excessive
exercise, the gouty, rheumatic, or strumous consti-
tution, all must be mentioned as causes of acne in
themselves or through their influence upon the systemic
health. But if analysis is applied to all of these, it
cannot be evident that the whole may be comprised
in the category of lowered or debased nutrition, as all
are productive of more or less marked nutritive disturb-
ance of the organism. In consequence, the etiology
of acne can be briefly stated to depend especially
upon some disturbance occurring in the functional
or systemic health of an individual, which results in
disordered or lowered nutrition. External and local
causes, however, also play a certain part in the pro-
duction of the disease. Among these, there may be
mentioned exposure to cold winds, to irritation of
various kinds, inattention to cleanliness, etc. The
face, the locality most generally affected, is that
surface especially and constantly exposed to such
factors as changes of temperature, to dust and drift
of every description carried by the winds, to irritating
influences of many kinds, and the fact that it is
attacked so disproportionately in frequence to other
surfaces equally or almost as rich in sebaceous glands
would suggest that these various external agents
and causes have an influence in developing or at
least in aggravating many, if not all, cases of the
disease.
As particular causes of acne, the atrophic form
of rhinitis has been mentioned, and recently a German
colleague has claimed that all cases of the process
owe their origin primarily to some slight or severe
ulcerative or erosive process in the nasal cavities,
which allows entrance of pyogenic germs into the
lymphatic circulation.
The acne due to the use of iodine and bromine
compounds has as its direct inducing cause one of
those substances, and is a drug eruption; not an acne
in a strict sense, but one of artificial origin. The
same may be stated in regard to the folliculitis due
to the closure of the follicle by tar — after use of a
tar ointment — and known as acne picea; while the
many other processes dubbed acne of one kind or
other, having nothing in common etiologically with
acne simplex and indurata, should all be strictly
disassociated from these.
The effect of diet upon the disease is of some
importance, since it may originate the process, through
the functional disturbances which it may create, or
it may aggravate an already existing acne. Among
the articles of diet which may be particularly men-
tioned are sweets of all kinds, pastries, oatmeal,
cheese, nuts, highly seasoned and rich foods, shell-
fish, etc. Milk in certain individuals appears to
have the effect of causing an outbreak of lesions;
so also has cream, fermented drinks, such as beer,
etc., champagne, and syrups with soda or natural
waters.
Diagnosis. — There should be no difficulty in
making the diagnosis of a case of acne. Popularly
known as "pimples" or a "pimply face" or an attack
of "blackheads," it is so common that its recognition
should be immediate. Especially is this the case
with acne simplex, in which the comedo plays so
important a role; but acne indurata may at times
offer some points of doubt. The papular form of
eczema may be differentiated by its occurrence on
the extremities as well as on the face, and it is never
limited to the latter. Its lesions are smaller, often
crowned with a minute vesicle, and they tend to
coalesce into patches; they are very itchy, and when
opened do not contain sebaceous debris. The
vesicular or pustular elevation is superficial and
results in the formation of epidermic scales and small
exudation crusts. The pustular syphilide may be
mistaken for acne, and vice versa; and so much is
this the case that one form of syphilitic eruption has
been named acneiform. These lesions may be limited
to the face, but they are more often coincident with
syphilitic manifestations on other parts of the body
or on the mucous membranes. They tend to form
groups, to dry and become covered with crusts; and
when these are removed, a punched-out ulceration
filled with seropurulent fluid and bounded by a more
or less infiltrated wall is found. Many mistakes
in diagnosis are made between an indurate acne and the
superficial gummatous syphilide — the so-called tuberc-
ular syphilide — especially when the latter is situated
on the nose. But the error should not occur when
it is borne in mind that the syphilide as a rule is
circumscribed in its occurrence, its lesions are grouped,
indolent, undergo softening and crust formation,
and beneath the latter ulceration occurs. The
process very usually extends slowly in an excentric
or serpiginous manner, leaving more or less marked
cicatrices. Acne indurata, on the other hand, runs
a more acute course, is painful and furuncular in
aspect, occurs here and there without reference to
preexisting lesions, does not tend to form groups,
heals up rapidly after evacuation, does not ulcerate
nor tend to progress in a serpiginous manner, and
frequently leaves no scar, or at the most one superficial
and ill defined.
There is a papular form of erythema occurring at the
menstrual epoch in women which is very usually con-
founded with acne. It is papular in character,
though occasionally a pustule occurs. It appears
on the face especially, but sometimes over the neck
and shoulders. Its appearance is brusk, a few days
before, during, or just after the menstrual epoch.
It may consist of a few or of many lesions, which are
frankly inflammatory and about the size of a small
pea. They do not contain any comedo or sebaceous
matter; they itch and burn, persist for a few days to
a week, and then subside, to reappear, however,
at the time of the next period. This eruption, purely
a reflex papular erythema, is usually regarded as
an acne, but it should be strictly separated from it.
Prognosis. — The prognosis of an acne is favorable,
and it can be said that all cases of the disease are
curable, provided that the etiological factors existing
in any given case are correctly estimated, and that
83
Acne
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
the therapeutic efforts are carried out carefully and
systematically by the patient. Acne also may and
does disappear spontaneously, but that is the case
when the one or other cause of the process has also
been removed by course of time, improvement of
general somatic conditions, etc.; but in view of the
disfigurement, scarring, and changes which may occur
in the skin from the disease, it is not advisable to
wait for a spontaneous involution and to leave the
patient without such proper care as will keep the
process within bounds or gradually cause its entire
cessation. In giving to a patient the prognosis of
his or her acne, it should also be borne in mind that
the same causes can produce the same effects, and that
the complete or lasting cure of the eruption will
therefore depend upon the individual's avoidance of
the particular cause or causes or factors which have
been found to be the basis for the existence of the
disease in any given case. As to the length of time
needed to cure a case, definite statements should
not be made, since the duration of treatment will
have to depend upon the response of the patient to the
remedial agents made use of, the care and system
with which the orders of the physician are carried out,
the age of the patient, and particularly upon the pos-
sibility of removing the etiological factor or factors.
Still, if not absolutely cured, no case should be
dismissed as incuraDle, as all can be very materially
benefited by proper care.
Treatment. — The methods, procedures, and reme-
dies pertaining to the treatment of acne are mani-
fold and various, being such as have to do with the
general systemic health, and such as are local and
applicable to the lesions themselves. In no sense of
the term is there any specific medication in vogue or
any drugs which can be regarded as specific, but every
case has to receive such treatment as is indicated by
the conditions found to exist. The statement just
made refers especially to the internal and general
systemic care, and in these particulars there is no
disease in which, as it may be put, " individualiza-
tion" of treatment is so necessary and called for.
As a rule, no two cases can be treated alike, but each
must receive such special advice as may be judged
to be required, after a thorough investigation into
the bodily and functional health of the patient, his
habits, mode of life, diet, etc. Under these circum-
stances, should constipation be the factor in the case,
it should be relieved by cascara sagrada, aloin, or
some other remedy affecting the bowels, or by means
of diet, proper exercise, cold douches, etc. Gastric
or intestinal indigestion, fermentative processes,
should be appropriately combated by dietary measures,
the mineral acids, pepsin, etc., or by intestinal an-
tiseptics — resorcin, sulphocarbolate of soda, salicin,
charcoal, etc., and by such other measures as are in-
dicated for these conditions. If debility or anemia
exists, then tonics are called for: iron, mix vomica,
mercury, the vegetable bitters, feeding up, general
hygienic methods, etc. The ferrum reduetum, the
carbonate, and the dry sulphate of iron have proved
the best in my experience; hemogallol is particularly
good when the stomach rebels against the other
forms or when constipation exists. Except to
tuberculous subjects, the iodide of iron should not be
given, owing to the possibility of the iodine causing
an eruption. When administering iron in cases of
acne, the blood should be tested at the beginning of
its use for the percentage of hemoglobin, and retested
every two to three weeks. Only in this way can
certainty be had that the iron given is being assimilated
and the blood state is or is not improving. Practi-
cally, Fleischl's hemometer answers all requirements
for testing. For strumous subjects, cod-liver oil.
the hypopnosphites, and the malt preparations are
e pecially valuable. If, on the other hand, the acne
occurs in gouty subjects, in those who are rheumatic
or plethoric, who show evidences of deficient elimina-
84
tion, then alkaline mixtures, the potassium salts — ex-
cept the iodide and bromide — lithia, saline purgatives,
colchicum, the salicylates, strict regimen, etc., are of
the greatest service. In other words, every indica-
tion obtained from investigation of the patient's
history should be duly estimated and receive such
attention as it requires. It is useless to take up each
seriatim, but all should be considered together in order
to obtain as rapid progress as possible. The effects
of calcium sulphide are illusory: none when given
alone; but when exhibited together with dietary
regulations, with other internal and local treatment,
then improvement is seen in the case. But the
result is obtained by those same measures when no
calcium sulphide is administered. Arsenic is of use
under certain conditions, but should not be regarded
as a specific. As a rule, more harm than benefit
is done by it. It is of value in certain cases in which
anemia or debility is present. In acute examples
of the disease it is contraindicated, but it may be of
benefit in those which are chronic in type. In those
acnes which are complicated by a seborrhea oleosa,
or in which the process is sluggish and the lesions
are indolent and leave congested stains, ichthyol
internally is frequently of value. Beginning with
five-grain doses three times a day, the amount may
gradually be increased until gr. xv. ter in die are
being taken. The drug is harmless, and for its best
effects should be continued for several months. The
question of diet is of some importance, but yet it
should not be carried to an extreme, nor be regarded
as the keynote of the treatment. In general, it may
be stated that the diet should be composed of nutri-
tious and easily digested food, and the various arti-
cles chosen or forbidden should depend to the greatest
extent upon the digestive conditions in existence
in the individual case under care. As a rule, I have
found that it is advisable to forbid in all cases such
articles as are comprised under the heading of sweets
— desserts, candies, jams, preserves, pies, rich pud-
dings, etc. — and also oatmeal, cheese, and nuts.
Besides these, the diet should exclude stimulating,
highly seasoned, and indigestible foods of all kinds.
Oysters are allowable, but lobsters and crabs will be
found injurious. Clear soups, plainly cooked fish,
roast and broiled and boiled meats, poultry and game,
vegetables of all kinds, salads with plain vinegar and
oil dressing are perfectly allowable for all cases, but
at the same time the diet in these as well as in all
particulars will have to be varied according to the
necessities of the individual case. In may thus be
found that in one milk, cream, butter, and fats will
be beneficial, while in others they will be injurious;
in some, a light claret or Rhine wine with the meals
is distinctly beneficial, but in others all wines will
be harmful. The same remarks are pertinent as
regards beer, alcohol, tea and coffee; and on the
whole, it may be stated that so far as diet is concerned,
the same rule should be followed as has been laid down
for the internal medication of acne — that is, it should
be made to conform to the needs and the require-
ments of the individual afflicted, and not with a
view of furnishing a specific regimen which shall of
itself remove the affliction.
General hygienic laws should also be enforced.
Exercise in moderation, but not, however, to the
excessive point it is carried to-day, is of value, and
so also is a change from a sedentary to an active life.
Attention to personal cleanliness, to bathing, to
early hours is clearly indicated, and dissipation and
excesses of all kinds should be avoided.
The local treatment of acne is of equal importance
with the internal and with the general care of the
patient, for by these means the lesions of the disease
ran be removed and a healthy action of the skin
can be brought about, and that even before the pre-
disposing causes have been entirely disposed of.
Many cases, moreover, can be cured by external
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Acne
treatment alone, but the writer has failed so far to
obtain such a result from exclusively internal care.
Both, in reality, should go hand-in-hand in order to
get the best and most rapid cure of the process.
The first requisite in the local treatment is the use
of soap and water. The surface of the skin, the seat
of an acne, should be thoroughly washed night and
morning. Any good toilet soap is all that is neces-
sary, but a marble or sand soap has been recom-
mended, as well as the Tr. saponis viridis. Super-
fatted soaps containing resorein, ichthyol, sulphur, or
mercuric chloride are also advised and used, but unless
left on the surface over night, for instance, they
offer little advantage over a plain, pure soap. Tar
soaps are decidedly injurious in these cases, particu-
larly if rubbed info and left on the skin, inasmuch
as the tar may lead to the development of an acne
picea. The water should be fresh and cool — about
the temperature of the room; and in the writer's
opinion and experience, hot water is injurious. Still,
it is recommended by many as of value when applied
for a number of minutes every night at as high a
temperature as can be borne by the patient. Face
straining is also advised by some, the external
remedy ordered being afterward rubbed into the skin.
The writer certainly cannot vouch for the value of
either one of these procedures, as he himself has never
found them other than objectionable, increasing the
amount of the eruption, inducing often a seborrhoea
oleosa, accompanied by a relaxed condition of the
skin and dilated follicular orifices, and causing the
skin to have a sieve-like appearance. He has also
found that these procedures were liable to cause a
persistence of the process and to occasion frequent
relapses. The same statements he would also make
in regard to facial massage, so frequently recom-
mended and used to-day, as in his experience he
has found that it often causes an outbreak of acne
and invariably aggravates a preexisting one. Still
these may in some cases be beneficial, but they
certainly are not adapted for all, and should not be
made use of as regular modes of treatment.
The comedones should be dealt with according to
the directions given under that section. Curetting,
both for them and the acne lesions, has been recom-
mended by various writers — Hebra, Jr., Fox, Brocq; a
dermal curette is used, and the face is gone over and
thoroughly scraped once every week or ten days.
The operation is rather painful, and though at times
there may be rapid improvement, yet unless the pa-
tient is treated locally and internally at the same
time, the relief is only temporary and a marked
relapse is apt to follow. I wish to emphasize this
statement because in a large number of cases which
have come under my observation the previous treat-
ment consisted solely of repeated curetting, and yet
the relief afforded had been only temporary. Inci-
sion of all the lesions with a sharp-pointed bistoury
and complete evacuation of their contents constitute
very desirable steps. When the acne lesion has been
quite large, or a veritable abscess has formed (through
the coalescence of several lesions), or such an abscess
has reformed despite repeated openings with the
knife, it is advisable to swab out the cavity with
pure carbolic acid or with pure or fifty per cent,
ichthyol. An ordinary match slightly sharpened
is all that is necessary for conveying the antiseptic
into the cavity. For lesions which are indurate,
indolent, and obstinate, not containing pus, linear
scarification has been recommended by Vidal and
electrolysis by Brocq. The latter procedure invar-
iably, however, causes more or less marked scars.
For the obstinate lesions, the writer has obtained
good results from the emplastrum hydrargyri, or
from pure ichthyol, or from the unguentum hydrar-
gyri nitratis diluted one-half or more. The local
agents and remedies which have been used and
recommended for the treatment of acne are innu-
merable and of the urn I various kinds. Yet all
which will be found beneficial possess some degree
of antiseptic action. The application chosen should
vary according as the process is acute in character,
or partakes rather of the indolent and chronic type.
For the former, soothing applications should be
used, and for the latter those which are stimulating
and capable of causing a certain amount of active
reaction in the tissues. In all cases, liquid agents,
solutions, etc., are far preferable, and only occasion-
ally are salves and greases advisable. When the
eruption is acutely inflamed, there can be used a
lotion of R Magnesias carbonatis, Zinei oxidi, aa, gr.
xv.; Acidi carbolici, gr. x. (or Acidi borici, gr. xv.j
or resorcini, gr. v., etc.); Aquae rosae, gi. M. Cala-
mine may be substituted for the magnesia in the
lotion, or aqua calcis can be used instead of the rose
water. Other lotions suitable for these cases are:
Liquor plumbi subacetatis diluti, or R Bismuthi sub-
nitratis, 3ij.; Ichthyoli, gr. xv.; Aqua; rosae, aqua?
calcis, aa 5 ss. M. If the patient's skin is a dry and
harsh one and a seborrhea oleosa does not complicate
the acne, then an ointment can be used. Suitable
ones would be: R Acidi salicylici, gr. xv.; Zinci oxidi,
gr. xl.; Unguenti aquae rosae, 5i.; or a two per
cent, ichthyol ointment, or one containing boric
acid, three to five per cent., etc. The remedy
chosen should be kept more or less constantly on the
affected surface, in order to obtain the best results,
and if possible it should therefore be used both day
and night.
The large majority of acne cases being, however,
of the chronic type, a greater choice of remedies is
needed, and they are also required when the acute
stage of the disease has subsided and the case has
also become indolent in character and course. Of
especial value are applications containing sulphur.
It may be used in powder form mixed with starch
in the proportion of one to four, or as high as one to
one, that is, equal parts, But it is in lotions that
sulphur is most useful, though many recommend it
in the form of a ten-per-cent. ointment or paste. R
Sulphuris sublimati, gr. 1. to 5%; Crete pra?parate,
kaolini, aa_5 ij-; Unguenti aquae rosae, §i. M. Apply
freely at night and remove with soap and water next
morning, and then rub in well a two-per-cent. salicylic
or other mild ointment, or apply a three- to five-per-
cent, boric-acid lotion several times through the day.
A very strong resorein paste is also of benefit at times.
Its strength may be from ten to twenty-five per cent.
or even more according to the indolent nature of the
case. It should be applied by the physician and its
effects closely watched, as resorein has a very power-
ful reactionary effect on the skin, and will cause a
diffuse peeling off of the epidermis. The reaction
produced may give some very undesirable results,
but when the procedure is carried out with care it is
usually of great benefit. The number of applications
necessary will vary in each case, and the paste should
be discontinued when the epidermis has a seared,
yellow look, and exfoliation is imminent; a mild,
soothing salve should then be substituted for it. The
process may be repeated a number of times, but a
milder resorein paste should be used after the first
peeling has occurred. This method, which is rather
heroic, necessitating the patient's confinement to the
house, is of great value, but necessarily of restricted
use, and, the same results being obtainable by milder
measures, it should be reserved for obstinate and
rebellious cases. In the severe forms of acne indurata
and acne pustulosa Bier's hyperemic treatment may
be found useful. Suitable cupping glasses may be
applied or an elastic bandage round the neck may
be worn.
There are a large number of lotions in use for acne,
which, together with other ingredients, contain some
proportion of sulphur. Of these, there may be men-
tioned: R Sulphuris sublimati, 5 ij.; JStheris, spir-
85
Acne
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
itus vini, glycerini, aa .> ij.; Aqua calcis, aquas rosas,
aa 5 iv. M. (Crocker). R Sulphuris lactis, 5 iv.;
Tineturae saponis viridis, 5 x.; Glycerini, 5 vi.; Spir-
itus vini, 3i. M. (Elliot). R Sulphuris lactis,
S iss.; Glycerini, 5 i.; Spiritis vini camphorati, 5 x.;
Aquas rosae, q.s. M. (Besnier). These various
combinations owe their efficacy for the most part to
the sulphur they contain, and may be varied according
to the physician's wishes. One of the most useful
will be found to be: R Zinci sulphatis, potassii sul-
phidi, aa gr. xv.; Sulphuris lactis, gr. xx.; Aquas
rosae, Si. M. When made with fresh drugs and
properly prepared, this lotion is of very great value.
It should be applied at night after the face has been
thoroughly washed with soap and water, and allowed
to remain all night. If irritation is produced, cold
cream can be used during the day. It is wise,
however, to keep up the effect of the treatment even
during the day, and for this purpose a lotion of boric
acid can be used or a one- to three-per-cent. solution
of resorcin in water, but preferably in alcohol and
water, equal parts. A very beneficial lotion is R
Acidi borici, gr. xv.; Resorcini, gr. x.; Acidi acetici
ililnti, 5 ij; Spiritus vini, 5 vi. M. Potassium sul-
phide, o i., in rose water, 5 iv., is also recommended.
The mercuric salt is often of value, but it should
never be used in conjunction with sulphur prepara-
tions, owing to the probable formation of sulphurct
of mercury on the surface. Authors recommend P»
Hydrargyri bichloridi, gr. xv.; Ammonii chloridi,
gr. xxx. to lxx.; Alcoholi, 5 iv.; Aquas, Oi. M. The
formula of the "Oriental Lotion" as given by Hebra
is: R Hydrargyri bichloridi, 3 i.; Aquae destillatas,
5 iv.; Ovorum iij albumen; Succi citri recentis, oiij-l
Sacchari, oi- M. Another formula recommended
by the writer is: R Hydrargyri bichloridi, gr. iij.
to vi.; Acidi salicylici, gr. xxx.; Acidi acetici diluti,
5 iss.; Spiritus vini, o iiss. M. When using any
of these lotions, it should be remembered that more
or less desquamation and peeling of the horny layer
takes place, and it is advisable to warn patients of
the fact. When this occurs, it is wise to discontinue
the application and to use an indifferent salve until
the reaction has subsided, and then to begin anew
with the lotion.
Ichthyol as an external agent is most valuable in
certain cases. It may be used in watery solution —
five to fifty per cent. — or it may be added to any of
the foregoing formulae, with the exception of those
containing mercuric chloride. The writer has found
it of especial benefit in cases in which pustulation was
a marked feature; and in full strength or in a fifty-
per-cent. dilution it has very commonly served the
purpose of aborting a beginning lesion. In those
instances of acne in which from time to time one or
two papules begin to develop, the ichthyol applica-
tion, as mentioned, has been a most valuable agent
in cutting short the career of such fresh lesions.
In the case of patients in whom there is no complica-
tion of a seborrhea oleosa, but who have a natural
dryness of the integument, ointments are especially
of use. When indicated, they should be such as
possess antiseptic properties, and may contain various
remedial agents. Among the many recommended,
the unguentum hydrargyri ammoniati, five to ten per
cent., may be mentioned, and also one made with
the red or yellow oxide of mercury — three to ten per
cent. A ten-per-cent. sulphur ointment may be of
value, or the hypochloride of sulphur may be used —
ten to fifteen per cent., or the iodide of sulphur —
three to ten per cent. At times the following for-
mula will be found a good one: R Unguenti hydrar-
gyri oxidi rubri, oij.; Unguenti sulphuris (U. S. P.),
7> iij.; Unguenti aquas rosae, q.s. ad 5i- M. In ordi-
nary cases the writer would advise: R Acidi borici,
gr. x.; Resorcini, gr. x.; Acidi acetici diluti, o iij- ;
Lanolini, ,~vi.; Unguenti aquas rosae, oij. M. In
addition to these, there may be mentioned calomel
ointment, three to ten per cent., /3-naphthol oint-
ment, five per cent., or one containing dermatol,
or oxychlorate of bismuth, etc. In cases character-
ized by indolence, the unguentum hydrargyri nitratis,
diluted (1 to 8, 1 to 4, or 1 to 2), is of benefit. Chrys-
arobin, pure carbolic acid, tincture of iodine, have
also been used in individual instances with benefit.
That is, there is a host of external remedies or "cures"
for acne embodied in literature, but when dealing
with a case of the disease it should always be kept
in mind that each case represents an individual, and
whatever line of treatment is instituted it should
involve the use of an antiseptic, should be adapted
to the peculiarities of each individual patient's skin,
and should be adjusted in accordance with the inten-
sity of the lesions existing in each case.
Vaccine Therapy. — The vaccine therapy of acne
has received considerable attention of late and nu-
merous articles are to be found in the literature advo-
cating its use. At first it was thought necessary to
use the opsonic index as a guide to the size of the dose
and the frequency of repetition. Experience, how-
ever, has shown that the opsonic index is unreliable
and impracticable and that the clinical effect upon the
patient is the best guide as to the size and frequency
of the dose. As a result the use of the opsonic index
as a guide in vaccine therapy has been almost uni-
versally discontinued. Stoner in 1911 collected 139
cases of acne from the literature which had been
treated by bacterial injections. Practically all had
received injections of Staphylococcus albus alone.
Of these 139 cases seventy-nine were reported as
cured, forty-eight as improved, nine as not bene-
fited, seven had discontinued treatment, and one was
still under treatment.
Gilchrist considers that Staphylococcus albus vac-
cine is very helpful in cases of acne of the superficial
pustular type, that is, when the Staphylococcus
albus as a secondary invader predominates. Engman
considers that albus vaccine alone is of little value
in the treatment of acne vulgaris. He, in fact,
rarely uses it as he looks upon the Staphylococcus
albus as a secondary factor of no therapeutic impor-
tance. Fleming in 1909 was the first to present any
convincing demonstration of the use of acne bacillus
vaccine. He treated three cases with a mixed vac-
cine of Staphylococcus albus and Bacillus acnes,
Fleming claimed that while the staphylococci are
always associated with the pustular lesions of acne,
the acne bacillus is the true etiological factor and, in
order to produce an immunity to the disease, vaccines
of both organisms must be used. Engman claims
that treatment with acne bacillus vaccine, provided
a proper technique is adopted, yields most brilliant
results. He considers that indifferent results are the
fault of the technique and not the fault of the method.
He recommends small doses sufficient to cause a
short negative phase. His initial dose is three to
five million and he rarely finds it necessary to give
as high as seven to ten million. The dose is repeated
at five- to seven-day intervals and the treatment is
supplemented by means to produce local hyperemia,
thus bringing an increased quantity of immune serum
to the part. He finds stock vaccines very reliable
and can be used in most instances. Gilchrist recom-
mends an initial dose of five million of the Bacillus
acnes, and increases gradually each week to thirty
million unless the negative phase becomes pronounced.,
which indicates that too much vaccine is being given.
He uses the Bacillus acnes vaccine alone, unless the
secondary invader predominates markedly. King-
Smith found in cases due to the acne bacillus that
treatment with Bacillus acnes vaccine alone was
rather disappointing; in cases where the acne bacillus
and Staphylococcus albus were both present in large
numbers treatment with vaccines made from these
organisms gave good results — at least fifty per cent,
showed marked improvement; in cases in which
86
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
\t nc Necrotica
Staphylococcus albus alone was found the correspond-
ing vaccine gave excellent results. Lovejoy reports
fifty cases treated with acne bacillus and a polyvalent
staphylococcus vaccine with very satisfactory results.
He gave from three to five million of the acne bacillus
at a dose and from 150 to 2.30 million of the staphy-
lococcus vaccine. Stock vaccines seemed to give as
good results as autogenous. Smiley treated 100
eases of acne vulgaris with autogenous mixed vaccines
with such uniformly good results that when one
can control the patient a cure of the condition can
be promised in every case. The associated symptoms,
such as headache, constipation, anemia, mental and
phvsical lassitude, etc., were greatly modified or
entirely disappeared in those patients thus treated.
In consequence Smiley believes with Gilchrist, that
the acne bacillus or its toxins are responsible for the
associated symptoms and conditions occurring in
acne infections. Treatment with a stock vaccine
was not satisfactory in regard to clearing up the
sequel* or complications.
It will be seen from the foregoing that the more
recent workers are unanimous in reporting beneficial
results in the treatment of acne vulgaris with Bacillus
acnes vaccine. They all recommend small increasing
• repeated at a five- to seven-day interval. The
initial dose is usually three to five million and only
Gilchrist finds it necessary to increase beyond ten
million at a dose. He occasionally gives thirty
million. Opinions vary as to the value of staphy-
lococcus vaccine in the treatment of acne vulgaris.
Most reports show that it is of benefit only in the dis-
tinctly pustular cases.
The writer cannot agree with the opinion of Gil-
christ and Smiley that the headache, anemia, con-
stipation, etc., so often associated with acne are due
to the absorption of the toxins of Bacillus arms
from the local lesions. If these symptoms are treated
with appropriate remedies as outlined when dis-
cussing the internal treatment he thinks the possibil-
ities of success will be much greater than if vaccine
treatment alone is relied upon.
X-ray Treatment. — Many authorities claim that
the most rapidly effective local treatment for acne is
found in the skilful use of the z-rays. Recurrences
are said to happen less often. Many cases, however,
can be managed just as well without it and it would
seem best to reserve its use for persistent rebellious
cases, especially of the indurated type. The use of
such a powerful and at times dangerous remedy as
z-rays for such a simple condition as acne, which can
usually be successfully treated by other simple and
perfectly safe methods, seems unjustifiable. More-
over, when relapses occur they are much more rebel-
lious to x-ray or any other form of treatment. If
used at all its use should be limited to acne indurata
of the back and shoulders. Frequently one sees the
development of an atrophic wrinkled skin with tel-
angiectases even under the most careful use of the
x-rays, and this condition would of course be of less
moment on the back than on the face. It is not
necessary to produce a dermatitis to get good results.
In fact, it is better if possible to attempt to get the
curative effects without producing the slightest
erythema as in this way the possibility of producing
future atrophy is much lessened. The exposures
should always be made most carefully. A soft to
medium tube should be used at ten to fifteen inches
distance and for three to four minutes duration twice
weekly. If improvement is shown it is best to adhere
to such cautious technique. Geoege T. Elliot.
Acne Necrotica. — Si/nonyms: Acne frontalis, seu
varioliformis; acne pilaris; acne rodens; acne atro-
phica; folliculitis varioliformis, etc. Perhaps no affec-
tion has so many different designations in actual daily
use. It is very desirable that some term acceptable
to dermatologists of all countries be selected by
agreement, for our knowledge of this disease cannot
but be retarded by this lack of consensus. At
present the tendency appears to be toward the use
of the terms acne varioliformis, and folliculitis varioli-
formis despite the fact that some of the others are
more logical.
Definition. — A chronic, recurrent, papulo-pustular
affection, having its seat about the hair follicles, lead-
ing to necrosis of the involved tissues and terminating
in a variola-like scar.
Symptomatology. — The site of predilection is the
forehead, at the margin of the hair, and it is this fact
which gave rise to the name acne frontalis. A wider
acquaintance with the affection, however, has shown
that it involves other regions. It may extend to the
hairy scalp, the face, the neck, and the interscapular
and intermammary regions. Cases of more or less
generalized eruptions of papulo-pustules terminating
in necrosis and scar formation have been described,
which present many of the clinical features of this
malady.
The primary lesion is generally stated to be a
papule which soon becomes encrusted and covers an
underlying ulceration. Sabouraud describes the
elementary lesion as an umbilicated vesicle always
seated about a hair. Within two or three days it
attains its full dimensions, about three millimeters
in diameter. Its central portion then sinks below
the level of the surrounding integument, becomes
harder, encrusted, and gives to the observer the
impression that it is mortised into the skin. The
color of the crust, at first a yellow or brownish yellow,
darkens with age. The lesion may remain in this
state for several weeks; exceptionally two or more
pustules may become confluent.
On removing the crust or after its spontaneous
separation, a red, moist, or dry depression is left
which eventually because white like the variola scar.
Superficial lesions healing with shallow depressions,
and deeper ones leading to depressed scars, are
generally encountered in every case (Unna).
The presence of lesions in various stages of evolu-
tion, with pigmented and non-pigmented scars of
older ones, makes up the peculiar clinical picture
of the disease.
Pathology and Morbid Anatomy. — It is now gen-
erally conceded that acne necrotica is a perifolliculitis
probably of locally infectious origin.
Sabouraud insists that the affection demands for
its development hair follicles previously infected with
his microbacillus of fatty seborrhea. It is not
possible to have acne necrotica, according to this
writer, unless these infected follicles are invaded by
the yellow staphylococci which are the essential
agents in producing the disease. The infection takes
place at the follicular opening, and from this point
invades the epidermis in a circular manner, giving
rise, as the process increases, to an intense leucoeytosis
in the papillary and subpapillary dermal regions.
The final stage is characterized by a dry necrosis of
all the involved tissues.
Sabouraud w T as unable to differentiate the yellow
staphylococcus, which he found in all lesions of acne
necrotica, from ordinary Staphylococcus aureus from
other sources. The distinct clinical lesion to which
it is supposed here to give rise may be due to the
previous damage to the follicle by the microbacillus
of seborrhea, to its admixture with this organism,
to a change in the virulency of the staphylococcus,
or to other causes which we are at present unable to
determine.
Microorganisms had been previously described in
these lesions by Touton, Unna, myself, and others.
Touton was not inclined to attribute to them any
pathogenic importance. Unna, however, considers
the affection due to a mixed infection with a small
bacillus and his diplococci of seborrhoic eczema.
In lesions examined by myself, staphylococci
87
Acne Necrotlca
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
were found which are probably identical with those
described by Sabouraud.
In substance it may be stated that acne variolifor-
mis (Hebra) is an inflammation of the pilo-sebaceous
system, probably microbic in origin, leading to
destruction of these organs and the surrounding
derma, and that Bazin was correct in naming the
disease acne pilaris.
Etiology. — Acne necrotica is essentially a disease
of adult life. It is rarely seen before the age of thirty,
and may develop late in life. Men are more frequently
affected than women.
Some of the older dermatological writers attributed
it to syphilis. Although sometimes mistaken for a
grouped papulo-pustular syphilide on the forehead or
at the sites of acne necrotica, it does not owe its
existence to that infection.
Its more frequent occurrence among those in the
low T er walks of life, and its location in the majority of
instances on the forehead, exposed to the pressure of
unclean hat bands, lend weight to the theory of local
infection. A pre-existing fatty seborrhea is, according
to Sabouraud, an absolutely essential condition for
the development of an acne necrotica by affording a
locus minoris resistentitc, and determining the clinical
features of the eruption.
Diagnosis. — The absence of comedones and the
sites affected, together with the depressed encrusted
lesions, intermingled with white and pigmented scars,
easily enables one to differentiate this variety of
folliculitis from acne vulgaris. Its differential
diagnosis from a papulo-pustular or a grouped pustulo-
tubercular syphilide is more difficult. The history
of frequent recurrences extending over months or
years, which patients with acne necrotica give us,
together with the absence of concomitant manifesta-
tions of syphilis, should enable one to separate the
two diseases. Syphilis again shows no predilection
for the hairy parts of the face which the former affec-
tion does in a striking manner.
Other varieties of pustular affections of the follicles
do not give rise to the peculiar and rapid tissue
necrosis with its resulting variola-like scar. It is
questionable whether the generalized eruption of
papulo-pustules resulting in scar formation like that
of acne necrotica of the face should be included
with this disease in a single group.
This disseminated eruption, to which various names
have been given, as hydradenitis suppurativa, acnitis,
necrotizing granuloma, etc., frequently begins as a
deep-seated papule about the coil glands or in the con-
nective tissue of the derma independently of the gland-
ular structures. While the two diseases present many
similar clinical features, it is quite probable that they
depend on different infectious agents. Boeck claims for
the generalized eruption a close relationship with lupus
erythematosus, and believes that both affections are
due to the toxic products of the tubercle bacillus ab-
sorbed from a focus in some part of the body.
Prognosis. — It is not difficult to cure a single
attack of the eruption, but recurrences are the rule.
and we have no certain means of preventing them or
of limiting their frequency.
Treatment. — The various internal remedies recom-
mended by dermatological writers have probably no
value in curing the attacks or preventing relapses.
The lesions are quite readily healed by ointments
containing sulphur, resorcin, /3 naphthol, salicylic acid,
ammoniated mercury, or calomel. These drugs may
be used in the strength of two to five per cent, or
stronger.
Careful attention should be paid to the h}'giene of the
scalp and to personal cleanliness, as the agent pro-
ducing the infection is probably widely scattered.
The scalp should be frequently washed with the
ordinary tincture of green soap, followed by lotions
containing bichloride of mercury, 1:1,000, to insure
its disinfection. Resorcin lotions (two to ten per
88
cent, in alcohol and water, equal parts), with the
occasional use of sulphur or salicylic-acid ointment,
may be used alternately with the bichloride lotion.
It is only by the persistent use of local antiseptic
applications, not only to the eruption itself, but to the
surrounding skin, that we may hope to prevent or
delay relapses. J. A. Fordyce.
Literature.
Pick: Archiv f. Dermat. u. Syph., p. 551, 1SS9.
Touton: Verhand. der Deutsch. dermatol. Gesellschaft. Zweiter
u. Drifter Congress, p. 2S7, 1S92.
Unna: Histopathology of Skin Diseases; English translation, p.
366.
Fordyce: Journal of Cutaneous and Genito-Urinary Diseases, voL
xii., p. 152. 1S94.
Sabouraud: Ann. de derinat. et de syph., tome x., p. 841, 1899.
Acne Rosacea. — Synonyms: Acne erythematosa,
gutta rosacea; acn6 rosee; Couperose; Kupfernase.
Definition. — Acne rosacea represents not one
disease, but a rosacea with a superimposed acne.
Rosacea is a congestive disturbance affecting the nose
and portions of the face, transitory at first, but after-
ward becoming permanent, and represented by red-
ness, dilatation of the cutaneous blood-vessels, the
formation of a telangiectasis, and in some instances
by more or less hypertrophy of the connective tissue
Fig.
20. — Acne Rosacea. Showing Dilated Blood-vessels.
(Author's drawing.)
and the glandular elements of the skin. The acne
lesions developing in the course of the process are
secondary products, and are expressions of an inflam-
matory process affecting the sebaceous glands.
Symptomatology. — Rosacea attacks especially the
nose and the neighboring portions of the cheeks, though
it may extend laterally to the malar prominences, or
even implicate the forehead and the chin, and in
some eases the entire face, with the exception of the
orbital spaces. The symptoms characterizing the
process vary in degree and in intensity according
to the stage and the grade of the affection. In the
earlier stages, there is only more or less marked
hyperemia or congestion of the nose and cheeks,
occurring after eating or drinking, or after exposure
to cold, or at the time of menstruation. The symp-
toms are usually transitory, and, remaining in exis-
tence for a short space of time, disappear without
leaving a trace. The patients generally complain
that there is at the time a sensation of heat or of
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Acne Rosacea
burning, but yet the skin itself is cold to the touch.
This recurrent congestion may take place for a variable
length of time, alternating with a return to normal
conditions; but sooner or later the hyperemia occurs
more often and apparently without cause or induce-
ment, and gradually the redness becomes a stable
and permanent fact, varying only in degree from
time to time. The congestive disturbance, when
permanent, is diffuse and sluggish in character, with-
out definite outlines, and the redness returns only
slowly after pressure. At times, however, it may be
active and may simulate an erysipelas or acute der-
matitis. When exposed to the cold, the affected
surfaces are liable to become bluish and cyanotic in
appearance.
The stage of permanent congestion may persist
for a variable length of time without any further
change occurring in the skin. But sooner or later
there develops upon the nose and other surfaces a
condition of telangiectasia, represented by fine,
tortuous, dilated blood-vessels. These vary in size,
being usually more prominent and larger on the alae
nasi, and they sometimes present in their course dis-
tinct varicosities. The telangiectatic condition may be
slight or severe, and in some cases attains such a
height that the entire nose and cheeks are covered
with distinctly evident tortuous vascular dilata-
tions, varying in color from bright red to purplish
red, according to the temperature and the somatic
condition of the affected individual.
The process, as a rule, does not progress beyond this
stage, but occasionally and after long existence, a
fibriod degeneration of the surface attacked takes
place. It is the nose, however, which, as a rule, is the
seat of this change, the other portions of the face being
affected only to a slight degree and moderately thick-
ened. The nose under these conditions becomes hyper-
trophied as a whole, and on portions of its superficies
there may in addition arise lobulated or peduncu-
lated, firm growths of various sizes, which sometimes
attain enormous development (rhinophyma).
In all of the stages of rosacea a seborrhea oleosa
generally coexists. The affected surface is greasy,
the orifices of the sebaceous glands are dilated, and
minute drops of oil can be seen exuding from them
after the flushing has subsided, and even independ-
ently of the hyperemia. When the congestion has
become permanent, these orifices may be so exces-
sively dilated that the skin has a sieve-like appearance,
but it is in the hypertrophic form of rosacea that the
greatest degree of dilatation is found. In other
eases, the affected surface is scaly and dry or covered
with small, thin, yellowish scales, or with larger
greasy, soft crusts. The patients complain of itching
and burning, and these symptoms are invariably
associated with a yellow, scaly discoloration of the
interpalpebral space and with a certain grade of what
is generally called pityriasis, or seborrhea sicca capi-
tis. The clinical picture presented by these cases
is quite distinct from that of the others described and
represents a complication of rosacea and dermatitis
seborrhoica. In fact, the presence of the latter
process alone may and frequently does lead to the
same congestive and hyperemic objective appearances
as originate from other and different internal causes.
A further and very common complication of a
rosacea is acne, which, in the majority of cases, sooner
or later arises on the congested surface. It is when
the two processes are combined that an acne rosa-
cea may be said to exist. The lesions may be either
of the superficial (simplex) variety or of the deeper
(indurata), or both may be present. They will be
found on the nose and cheeks, singly or very numerous,
and occurring in numbers on the nose, in which
organ they frequently cause considerable defor-
mity and also very marked pain. In themselves,
the lesions differ in no wise from those others which
occur independently of rosacea.
The course of the process is always a slow one. and,
having developed, it persists in varying degree for an
indefinite period of time, or until its inducing cause or
causes have been removed by appropriate cure or
treatment. Slight subsidences of the congestive
disturbance and of the acne lesions are generally
seen to alternate with exacerbations.
Pathology and Morbid Anatomy. — Rosacea is
primarily a vasomotor neurosis, resulting in retarda-
tion of the circulation in the superficial capillary
plexus. Although at first transitory, this paretic
condition of the blood-vessels becomes, through fre-
quent repetition, somewhat fixed. In consequence
the congestive redness becomes permanently estab-
lished, and the telangiectases and varicosities gradu-
ally become evident. The implication of the blood-
vessels is not limited to the superficial ones, but may
extend to the deeper plexus, and so all the vessels
throughout the skin may be affected. In conse-
quence of the congestion, the sebaceous glands are
influenced and the seborrhea oleosa arises. The
acne lesions owe their origin to the resulting debased
nutrition of the skin. In some cases new connective
tissue forms about the blood-vessels and the folli-
cles, thus producing a thickening of the corium and
causing ultimately either the hypertrophic form of the
disease, or, in very severe cases, rhinophyma. On the
other hand, one form of the hypertrophic stage is
attributed to an increase in size of the sebaceous
follicles.
The histological anatomy of the first stage of rosa-
cea has been found by the writer to be represented by
a dilatation of the blood-vessels in the upper portion
of the cutis and by a few collections of round cells
about them. In the second stage, there was an
increase in degree in these features, many dilated
vessels having thin walls, and large lumina being
found widely distributed throughout the corium,
which was also slightly thickened and edematous.
In the third stage (rhinophyma), marked hyper-
plasia of the connective-tissue elements of the skin
had taken place, and the sebaceous glands were also
somewhat enlarged. The blood-vessels were large
and tortuous and their coats were thickened. Sub-
stantially the same changes have been found by others,
but Unna also ascribes the formation of the growths
in some cases to an enlargement and multiplication
of the sebaceous glands, which thus constitute the
major part of the rhinophymatous change. In other
cases he states that the connective-tissue hypertrophy
predominates, though the glandular change may
also be a prominent feature. The investigations of
Hans Hebra led to practically the same conclusions.
The histopathology of the acne lesions occurring in
connection with rosacea does not differ from that
of the same efflorescences wdiich arise independently.
Etiology". — Rosacea develops more frequently in
women than in men, and while occurring especially
after the age of thirty and in older people, yet it also is
not infrequently seen in younger persons. It arises
in women very commonly in association with pu-
berty, with menstrual and utero-ovarian irritation, and
especially at the menopause. It also is liable to
appear during pregnancy, in sterile women, and very
frequently among those others who come in the cate-
gory of old maids. In both sexes, disorders of the
gastrointestinal canal are potent factors in the pro-
duction of the congestive disturbance, and in indi-
vidual cases there will therefore be found such dis-
turbances as constipation, gastric or intestinal indiges-
tion, fermentative processes, etc. Anemia is often
the basis of the cutaneous disease, and so also is
plethora. The gouty and rheumatic diatheses are
prone to favor the development of the disease both
directly and through those functional and other dis-
turbances which are so liable to occur in those who
are subjects of these constitutional conditions. Sed-
entary habits strongly predispose to the process, and
89
Acne Rosacea
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
hence rosacea and its accompanying feature, acne,
very commonly affect seamstresses, sewing girls, and
others obliged by their occupation to forego outdoor or
physical exercise. In connection, however, with their
confining occupations, it should also be mentioned that
these same individuals are usually subjects of func-
tional bodily disturbances, due to their diet and poor
hygiene. The morphine habit has been claimed to
produce the disease, and it has also been attributed
to various intranasal processes, such as atrophic and
hypertrophic rhinitis, chronic catarrhal inflammations
of various degrees, and sycosis of the vibrissa. Seb-
orrheic dermatitis is claimed by Unna to be a most
important cause of rosacea in women. It would be
more correct, however, to regard its effects when
located on the nose as in the line of producing a red-
ness similar to rosacea, through the inflammatory
congestion incident to its presence, than to claim
that it causes that latter disease itself. Exposure to
cold and bad weather is an external factor in the
etiology of the process. The writer has seen sun-
burn determine its existence, and in a number of
cases a slight chilblain condition of the nose led to
objective symptoms simulating accurately a mild
rosacea. Face steaming, use of very hot water, con-
tinual exposure to the heat of a fire — all enter into
this category. The effect of diet and abuse of spir-
ituous liquors is generally very well known. The
articles of diet which are injurious are practically
the same as have been mentioned for acne, and their
effects are not so much in themselves, as in the gastro-
intestinal and other disturbances which they may
bring about. When used in excess, all liquors may
lead to the development of a rosacea, but the most
pernicious are fermented drinks, such as ale, beer,
porter, and also sweet wines and liquors, port, etc.
Tea, when improperly used, may have a similar
influence, owing to the injurious effect of the tannin
on the gastrointestinal canal. The influence of smok-
ing in itself is certainly remote, though it possibly
may indirectly operate through the production of a
catarrhal or other intranasal irritation. In many
cases, however, no definite etiological cause can be
discovered.
Diagnosis. — The diagnosis of rosacea will be
obtained from the history of its development, as well
as from the clinical symptoms presented by it. As
the disease occupies, as a rule, the nose and neighbor-
ing portions of the cheeks, it will be found that the
persistent redness was preceded by intermittent
flushing, and was followed by superficial capillary
dilatation and the formation of telangiectases and
varicosites. Lupus erythematosus, which commonly
occupies the same surfaces, may be differen-
tiated from a rosacea by the distinct delimitation
of the patches constituting it. The outlines,
though irregular, are sharply defined, the edges are
usually elevated and enclose a scaly area. The
patches tend to enlarge by peripheral extension, and
as a rule atrophic changes occur over the affected
area.
Erythematous eczema should also be differentiated
from rosacea. It occurrence is not limited, however, to
the same localities, but it appears anywhere on the
face, or neck, or- other surface. It appears bruskly
as an acute process, which in time may become
chronic in character. The affected portions are some-
what swollen from serous exudation; they are scaly
and rough to the touch, or have a glazed, varnished
appearance, and there is much burning and itching.
When syphilis exists on the nose, either in the form
of the papulo-pustular grouped syphilide or when
there are cutaneous gummata, errors in diagnosis
are not only possible, but are not infrequent. If
attention, however, is paid to the history of the
development of the redness and of the lesions dis-
cretely located or aggregated together in groups upon
it; if it is noted that beneath the crusts distinct ulcer-
ation with subsequent scarring occurs, and that there
is a tendency as regards the gummatous lesions to
serpiginous extension with consecutive cicatrization,
then the diagnostic difficulty should give no trouble.
The term erysipelas is used very loosely both by
medical men and by patients, and it is a most common
fact to hear the latter complain of an erysipelas,
which in reality is a rosacea of several months' or
years' standing. They often state that their diagnosis
was that made by their physician. It should, how-
ever, be remembered that, though erysipelas does
frequently affect the nose primarily, yet it is an acute
process,, begins with slight or marked chills, and is
accompanied by elevation of temperature and such
other somatic disturbances as are never associated
with a rosacea.
Prognosis. — The prognosis of this cutaneous
affection will depend to a great extent upon the possi-
bility of removing its inducing cause or causes in any
given case and upon the ability to prevent their
recurrence. An entire and absolute cure is obtain-
able and can be effected, or if not this much, at any
rate a most decided amelioration of the symptoms.
Treatment. — In the treatment of rosacea or acne
rosacea, very much the same procedures are called
for as have been detailed for acne simplex and
acne indurata. The cases require both internal and
external care, the former being such as will remove or
modify that defect in functional or physical health
which may be found in the case under consideration at
the time, and the latter being such as will bring back
tone and vasomotor control to the paretic blood-ves-
sels, or will destroy them, or, in the severest grades of
the disease, will remove the disfiguring growths which
have arisen. In general it may be said that all inter-
nal medication should be such as will correct the exist-
ing constipation or gastrointestinal disturbance
present in the case. If uterine or ovarian irritation
exists, it should be attended to; and also gout, rheuma-
tism, and lithemic conditions should receive proper
attention. Anemia or plethora, the tuberculous
diathesis, and every other factor should be properly
estimated and seen to, and all matters pertaining to
errors of diet should be diligently investigated. As a
rule, cheese, oatmeal, sweets, pastries, nuts, ferment-
able articles, and such as are highly seasoned, stimu-
lating, and liable to tax the digestive powers, should
be forbidden. Beer and alcohol and all sweet bever-
ages should be stopped, though a light claret with
water or a dry Moselle wine may be allowed at meals.
Coffee without milk is perfectly allowable, but tea
should be cut off, unless it is very weak and freshly
made. With these exceptions, the diet should be of a
simple, easily digested, and nutritious character.
The needs and digestive capabilities of each patient
should be studied, and the food taken should be such
as is found appropriate.
So far as drugs are concerned, it may be stated that
in many of the cases in which the process is in its
inception, in which the redness has not become
persistent, but is represented by periods of flushing
and of retrogression, the mineral acids are particularly
useful. Especially is this the case with the dilute
nitric, muriatic, or nitromuriatic acid. Another
class, however, may require alkaline remedies and
diuretics, the citrate and acetate of potassium, or some
of the more recent ones, uricedin, urotropin, aspirin,
etc., or it may be saline purgatives that are called
for. By means of these it is possible, in the early
cases, to divert the blood current from the face to
some other part of the body. When the congestive
disturbance of the nose and face has become a stable
fact, then a very useful remedy is ichthyol. Begin-
ing with doses of gr. v., it should be increased until gr.
xv. are taken t.i.d. It may be given in pill or capsule
form, or simply diluted with water or coffee. Toler-
ance to its peculiar taste is quickly established, and
only rarely have I found the remedy to be objection-
90
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Aconite
able or distressing to the patient. Resides these
particular remedies — and they should be given in
conjunction with those others demanded by the
necessities of the individual case — ergot and ergotin
have been recommended, as well as belladonna,
digitalis, quinine, codliver oil, etc. But all of these are
intended to meet indications furnished by certain
cases, and should not be regarded as of general or
extended value. Arsenic may be said to be al\v:i\ -
injurious in rosacea. The local treatment is of the
utmost importance, and some, if not many, instances
of the disease may be relieved by it alone. In acute
cases, characterized by active hyperemia and burning,
soothing applications are to be used. The magnesium
carbonate and zinc oxide, or the calamine and zinc
lotin referred to in the article on Acne, is indicated;
or a lotion of R Bismuthi subnitratis, gr. xxx.;
Bismuthi oxychloratis, gr. xl. ; Magnesia? carbonatis,
gr. xx. ; Aqua; rosa;, 5 i., or the Liquor soda;, chlorinata;,
diluted 1 :20, or less, or more, may be applied. A
very thin boiled starch poultice is frequently of great
value, as is also the official liquor calcis.
The majority of the cases of rosacea coming
under treatment are, however, of the chronic type,
have passed beyond the primary stage, and require a
very different order of local treatment — one which is
stimulating in its effects and which is intended to
improve the vasomotor tone of the paretic vessels.
For this purpose, stronger applications than are needed
in acne in general are called for, and a stiff paste is
often useful — R Resorcin, gr. 1. to cl.; Kaolin, zinci
oxidi, aa 5 ij.; Unguent, aqua? rosa;, g i. M. In place
of the resorcin, ichthyol may be substituted in the
strength of ten to fifty per cent., or the ichthyol
may be used pure. The pastes are applied every
night until a decided reaction has been produced
and the horny layer has a glazed appearance and is
beginning to exfoliate. The paste used should then
be replaced by a mild, soothing ointment, R Acidi
salicylici, gr. x.; Zinci oxidi. '.) ij.; Unguent, aqua;
rosa;, o i-J or an > r other similar salve. When the
exfoliation has ceased, the surface will be found
much improved in all probability, and the same paste,
or a weaker one, may again be applied and the same
course followed. This procedure may be kept up
until all the redness has disappeared, or toward the end
the lotion given under Acne — R Zinci sulphatis,
Potassii sulphidi, aa. 5 ss.; Sulphuris lactis, 5 i-,'
Aqua; rosa;, o i- — may be applied. To obtain the
same result, caustic potash solutions (two to ten per
cent.) have been recommended, or vigorous washing
with green soap. Likewise Vleminckx's solution in
full strength or diluted one-half, or even weaker, is at
times ot benefit. Chrysarobin has been advised and
used, but the danger of conjunctivitis from its appli-
cation on the face renders it of doubtful service.
When seborrhoic dermatitis is the cause of the rosacea,
resorcin and sulphur are particularly called for.
They may be used either in ointment form or in
water, or in alcohol and water, equal parts.
The acne lesions which may be coincident with the
rosacea do not require any special treatment, but the
telangiectasia and dilated blood-vessels remaining
after subsidence of the congestive disturbance have
to be dealt with. They may be destroyed by multiple
scarification, care being taken to split the vessel
longitudinally with a fine-pointed knife and then to
make transverse incisions. It has been recommended
to touch the open vessel along its length with nitrate
of silver, but that usually leaves a scar as a result.
Iodine and pure carbolic acid have also been advised,
but when the scarification has been properly done,
none of these measures is necessary. Excellent
results are obtained from electrolysis, and also from
the use of the thermocautery. As regards the former,
the needle used for electrolytic destruction of super-
fluous hair is all that is necessary. The needle at-
tached to the negative pole of a galvanic battery
should penetrate the vessel before the circuit is closed
— that is, before the electric current is turned on. The
positive pole — sponge moistened with water or salt
solution — is grasped by the patient after the needle
has been introduced into the vessel. The procedure
IS very painful and requires much time, and scarring
is very liable to result. The thermocautery acts
on the same principle, but it is neither as painful
nor as liable to cause scars. A needle point should
be used, such as is furnished with the Mikrobrenner
introduced into practice by Unna of Hamburg.
Much the same result may, however, be obtained if
an ordinary sewing needle grasped by a needle holder
be heated in an alcohol flame and made use of to
puncture the dilated blood-vessels in their course.
The method is simple, and I have found it absolutely
as efficacious as the more showy and impressive
ones previously mentioned.
When the case is one of hypertrophic rosacea, in
which the development of connective-tissue growths
in greater or lesser degree has occurred, surgical
interference is called for. Ablation of the excrescences
is necessary and may be done with the knife or the
galvanocautery. Electrolysis has been recommended,
but is of uncertain value, if not entirely without
result.
For a discussion of the value of vaccine and i-ray
treatment the reader is referred to the article on acne
where these questions are taken up fully. In acne,
rosacea Staphylococcus albus vaccine is more generally
called for, as the lesions are more usually of the
pustular type. George T. Elliot.
Acoin. — A synthetic hydrochloride of dipara-
anisylmonophenethyl-guanidine, introduced by
Trolldenier, in ls.99, as a safe and efficient local
anesthetic substitute for cocaine. It occurs as a
white crystalline powder, soluble in about fifteen
parts of water. Instilled into the conjunctiva it
produces anesthesia without increasing intraocular
pressure or exerting any cycloplegic effect, but is
somewhat irritating and is therefore not recommended
when inflammation is present. It is said to be free
from the systemic effects of cocaine. It is also used
in one per cent, solution for subconjunctival injection,
in which use it is less painful than cocaine. It is
recommended in 1-1000 solution in physiological
salt solution for the production of infiltration anes-
thesia by the Schleich method. In one-per-cent.
solution it has been employed as a local anesthetic
in dentistry.
Aconite, Aconittjm. — (Monkshood, Wolfsbane.)
"The dried tuberous root of Aeon Hum Napellus L.
(fam. Ranunculacece) collected in autumn; yielding,
when assayed by the process given below, not less
than 0.5 per cent, of aconitine." (IT. S. P.) This
definition will probably be amended in the forthcom-
ing revision by omitting the requirement of autumn
collection, and permitting a short piece of the stem-
base to be attached to the tuber.
Aconitum L. is a genus of some sixty species, dis-
tributed almost throughout the Northern hemisphere.
Many of the species resemble one another so closely
that even from the examination of complete speci-
mens, with flower and fruit, botanists have reached
diverse conclusions regarding their identity or dis-
tinctness. It is therefore not remarkable that the
detached medicinal portions should be found difficult
of differentiation, or that various species should have
been found mixed in commerce. As the chemical
and medicinal properties of the different species vary
greatly in degree, the tubers of at least one species
being used for food, these mixtures become serious
in the case of such an important drug. Of late, much
more care has been exercised than formerly, so that
this adulteration, intentional or accidental, has be-
come infrequent. Partly because of this element, and
91
Aconite
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
■ r
f
f ^i Y p.
partly because experiment has proven the activity
of the drug to increase under cultivation, the British
Pharmacopoeia now requires that only the cultivated
English tuber shall be supplied. It is also cultivated
in various continental localities. These cultivated
products are much more expensive than the ordinary
drug, but their specification appears fully justified,
except when a standardized drug or preparation (see
Constituents) is employed.
The official species occurs abundantly in the moun-
tainous districts of Central Europe, extending up the
mountain sides to a very
high elevation, as well as
deep into the valleys. The
plant is cultivated as an
ornamental flower in the
United States, where occa-
sionally it escapes. The
tubers used in medicine are
collected in Europe.
Since the herb, although
unofficial, is much used in
medicine, the entire plant
is here described. The
simple, stiff, upright stem
of aconite rises from 50 to
100 cm. (20 to 40 inches)
from the ground, bearing
numerous alternate leaves,
and a long, close, terminal,
spike-like, raceme (Fig. 21).
The leaves are sub-
rotund, from 5 to 20 cm.
in diameter (2 to 8 inches),
rather stiff and thick,
smooth, shining, and dark
Fig. 21. — Aconitum napellus L. green above and paler be-
low. The blade is pal-
mately three-parted; the lateral segments are again
divided nearly to the base. The narrowly wedge-
shaped divisions are further three or two lobed, and
these lobes are again incised, or cleft, with linear
and pointed tips. The leaves become less compound
toward the upper part of the stem, and are finally
reduced to three- or several-cleft bracts. They have
no marked odor, but upon being chewed produce, like
the tuber, a persistent stinging sensation in the mouth.
They are poisonous and contain a small and uncertain
amount of aconitine and considerable aconitic arid,
the latter of no therapeutic importance. The flowers
are of striking appearance; the corolla is nearly want-
ing, and its place is taken by a large colored calyx,
of which the upper sepal is developed into a deep cup-
shaped helmet, that sits upon
the rest of the flower like a
bonnet (Fig. 22). The pistils
are three, containing numerous
small ovules.
The form of the mature tuber
gives the specific name to the
plant (napellus, a little turnip).
It is a simple, conical, tapering
tuber, ending in a long, slender,
cylindrical tap-root, and bearing
numerous rootlets upon its sides
(see Fig. 23). From its scaly
crown arises the flowering stem,
and at the base of this stem a
short stolon extends horizontally under the ground,
and bears on its extremity a young tuber, more or
less developed according to the season, and destined
to produce the plant of the succeeding year. There
may also remain upon the other side of the crown a
similar but dead connection between the present tuber
and the remains of that of the preceding year. This
habit of growth well enables us to determine the sea-
sun when the tuber was collected. When it shall be-
come positively determined at what season it is most
Fig. 22. — Entire Flower
of Aconitum napellus.
active, this knowledge will doubtless prove of the
greatest value to us.
Fresh aconite tuber is brown externally, white within,
and has a biting benumbing "taste," which has
caused it to be occasionally stupidly mistaken for
horseradish.
The dried tuber, which constitutes the usual drug
{Aconitum, U. S. P.; Aconiti Radix, B. P.; Tubera
Aetiniti, P. G.; Racine d'aconit impel, Codex Med.,
etc.), is from 1 to 2 cm. in diameter at the base, and
from 5 to 7 cm. in length (two-fifths to four-fifths
inch, by 2 to 3 inches) ; more or less shrivelled and
wrinkled longitudinally especially below; often curved
and twisted, or broken. The external color is dark
brown; internally it is grayish, showing, after being
soaked up, in a transverse section, a distinct, five to
eight pointed stellate cambium ring, in each angle of
which is a well-developed fibrovascular bundle. Fre-
quently the tubers are attached in pairs; when not,
the scar where they
were broken apart can
be seen. The taste is
similar to that of the
fresh root, but the
stinging sensation
may be a little de-
layed. Spanish aco-
nite is large, stout,
and of a light dirty-
brown color. It is
usually deficient in
strength.
Aconite, even when
coming solely from
Aconitum napellus, is
variable in quality.
The age of the root
has much to do with
this. Grown in differ-
ent countries, or un-
der varying circum-
stances, it is subject
to considerable varia-
\ tion in quality.
Composition. — Its
active constituent is
the alkaloid Aconi-
tine, described below.
The determination of
its aconitine percent-
age therefore constitutes a perfect method of esti-
mating its quality. Owing to difficulties in its extrac-
tion, this determination was formerly impracticable,
but a reliable method of assay is now given in the
Pharmacopoeia. It has also been proposed to deter-
mine the presence of the normal percentage of alka-
loid by securing the tingling effect upon the tongue
and lips by the use of a solution of a specific degree
of dilution; but the personal equation is so great, and
the effects of training so important, that this method
has not found favor. The amount of aconitine, in a
first-class sample, will be about seven one-hundredths
of one per cent. In addition to the aconitine, there
is a small quantity of picraconitine or isaconitine.
Besides the alkaloid, a large amount of aconitic acid,
combined with calcium, is present. Resin and slight
amounts of fat and sugar are also found.
The aconites were known to the ancients, both in
Europe and Asia, as poisons, and are said to be still
used by some of the hill tribes of India to envenom
their arrows. They were employed as medicines in
Germany in the twelfth, and on the islands of
Great Britain in the thirteenth centuries, but after-
ward fell into disuse until 1762, when Stoerck of
Vienna again introduced them to the medical pro-
fession, since which time they have been constantly
used.
Physiological Action. — There is nothing in the
Fig.
23. — Tubers and Roots of
Aconitum napellus.
92
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
AronlCic Acid
composition of aconite which materially modifies the
action of the aconitine.
Primary Effects. — It sharply stimulates certain of
the nerve endings on coming into contact with them,
as well as certain of the encephalic centers. These
effects upon the nerve endings are evidenced by a
tingling sensation in the skin, whether the aconite be
directly applied or be carried there in the circulation.
A similar tingling is produced upon contact with the
mucous membrane, ami this becomes a severe irrita-
tion when the drug is applied in concentrated form,
as when the dust of the alkaloid is inhaled or reaches
tin- eyes. This effect of aconite upon the mouth is
markedly to increase the salivary and mucous secre-
tion. It produces some increase of perspiration in
the same directly stimulating manner on being carried
to the skin. Under careful observation, spasmodic
contractions of voluntary muscular fiber can be seen,
while stimulation of the vasomotor mechanism
(whether central or peripheral is not certainly known)
results in arterial constriction, when other and antago-
nistic influences resulting from the drug's action are
excluded. At the same time, the pupil is temporarily
contracted. Under the same conditions of control,
increased cardiac action is observed. A slight diu-
retic effect, in spite of decreased blood-pressure, is
probably due to direct renal stimulation. Stimu-
lation of the medullary centers is plainly evidenced by
the strong cardiac inhibitory action which is the most
prominent effect of the drug, and by convulsions,
which in poisoning often occur before the respiration
has failed sufficiently to produce them. There is a
powerful stimulation of the respiratory center,
though the action is temporary, irregular, and spas-
modic. The vomiting which is often present may
also be due in part to the same central stimulating
cause. When nausea is present, the diaphoresis is
increased. The powerful action on the vagus results
in a marked slowing of the heart, and as the systole is
much the more abbreviated, the heart is weak as well
as slow, and blood-pressure is reduced. The tempera-
ture falls, partly owing to this cause, partly to the
perspiration, and, some think, partly by reason of the
disturbance of the heat centers.
Secondary Effects. — The secondary effect of aconite
i- to paralyze the parts at first stimulated, though
these are affected in very different degrees as to both
strength and promptness. Failure of the sensory
nerve endings produces anesthesia where tingling
before existed, so that a sensation of numbni'- is
experienced. The stimulated respiration changes to
a depressed one, and convulsions from this cause
frequently ensue in poisoning. Vasomotor con-
striction disappears, as does secretion due to pe-
ripheral stimulation. The pupil often becomes dilated.
The promptness with which these secondary
symptoms appear is proportional to the size and con-
centration of the dose, so that the primary symptoms
may be almost altogether wanting. In all cases, they
supervene so soon, and are so much more pronounced
and continuous, that they, rather than the primary,
constitute the medicinal effects of the drug. Of all,
the cardiac depression and lowered arterial pressure,
which are continuous, are the most prominent
effects.
In poisoning, conspicuous modifications of the
medicinal effects occur. The tingling in the ex-
tremities may become extreme. Constriction of the
throat, with a sensation of strangling is also severe
and alarming. Salivation and vomiting are prompt,
the latter being violent, convulsive in character, and
persistent. The heart becomes very erratic, although
upon the whole weakness is rapidly progressive.
The respiration is painfully depressed and convulsive.
Muscular weakness, which may be quite persistent
even after recovery, is added to nerve depression.
After a very brief period of cardiac stimulation the
pulse becomes slower, more feeble, irregular, and
dicrotic, then flickering, ami finally imperceptible;
respiration is shallow and hurried; there are chills and
subnormal temperature. There is great weakness
and prostration; slight exertion provokes sym
and sometimes cardiac pain. The patient is in fear
of death, restless: the face is pale, the lips arc blue,
and the surface is covered with cold perspiration.
The extremities are cold, sometimes paralyzed, and
sometimes affected with pains in the joints. The
eyes arc staring, glistening, and the pupils usually
dilated, with more or less complete loss of sight or
diplopia. In some instances the patient becomes
delirious, though generally perfectly conscious to the
last; sometimes he is attacked with cramps and con-
vulsions, and sometimes he is comatose. The urine
is generally retained. Respiratory failure is the
usual cause of death. This, with cardiac paralysis, is
sometimes almost instantaneous when large quant i
of a liquid preparation are swallowed.
Otherwise, the above-described symptoms come on
successively. The tingling and numbness of the
mouth are very characteristic, and are succeeded by
similar sensations over the surface of the body,
especially in the hands and feet. The skin soon
becomes cold, though there is more or less perspiration.
There is dilatation of the pupils. There is progressive
muscular weakness, accompanied by feebleness and
ultimately, in fatal cases, paralysis of respiration.
Although some aconitine is excreted, especially by
the urine, it is for the most part quickly burned up in
the system, so that if a fatal result is not prompt,
recovery is apt to occur. Vomiting should be en-
couraged, warm water containing iodine in potassium
iodide solution being used to wash out the stomach.
Atropine is a physiological antidote, as is digitalis.
External heat is very important. Alcohol should be
used cautiously. Artificial respiration may save the
patient even when death seems to be impending.
Aconite is one of the most useful drugs of the Phar-
macopoeia. It works especially well with children,
and even very small doses often work satisfactorily.
Because of the rapidity with which it is destroyed in
the system, doses should be small and often repeated.
The "special cases in which it is useful are those of
sthenic character, in the relief of congestions. It is a
very safe and moderate agent for lowering the tempera-
ture, as well as for relieving tension. It tends to
lessen inflammation and is especially useful in many
forms of sore throat. All forms of throbbing pain,
such as earache, toothache, and headache, are likely
to be relieved, as are painful disorders of the respira-
tory organs, such as pleurisy. Great relief is often
experienced from its use in inflammatory rheumatism.
Scarlet fever and the fever of measles and similar
diseases are often markedly benefited by aconite, but
care should be taken to avoid excessive depression.
Neuralgic pains are often benefited by local applica-
tions, preferably by inunction. It must never be
overlooked, however, that fatal absorption may thus
take place.
The official preparations and their doses are as fol-
lows: Fluid extract, one to two minims; tincture (of
ten-per-eent. strength), five to fifteen minims. The
extract, no longer official, is still considerably used, in
doses of one-half to one grain. (See also Aconitine.)
Other species of aconitum having similar properties
in marked degree are A.ferox Wall, of India, contain-
ing pseudaconitine, and A. Jiachcri of Japan, con-
taining apparently aconitine, but which has been
called japaconitine. H. H. Rushy.
Aconitic Acid, C,H e 6l occurs in large amount in
combination with calcium in aconite, also in adonis
and other plants of the Ranunciilacecv and elsewhere.
Either water or alcohol will dissolve it. It deposits in
thin plates. This acid is also yielded upon heating
citric acid. It has no special medicinal properties.
II H. R.
03
Aconitina
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Aconitina. — Aconitine. " An alkaloid obtained from
aconite (C 34 H„NO u =640.55). As the Pharma-
copoeia defines aconite as proceeding from A. napellus
L., the above definition is equivalent to a require-
ment that the alkaloid be obtained from that
species. The percentage is variable, and should be
stated in connection with every lot and preparation
of the drug. Aconitine occurs in white, flat or pris-
matic crystals and is soluble in twenty-two parts of
alcohol, and in 3200 parts of water. When heated
rapidly, it melts at 195° C. (3S3° F.), but when heated
slowly, it decomposes and melts at 182° C. (359.6° F.).
It is a compound of acetic acid with the alkaloid
benzoyl-aconine, the latter being a compound of
benzoic acid with the alkaloid aconine. Both of the
two last-named occur to a greater or less extent in
aconite, as derivatives of the first. Neither possesses
the properties of aconitine, nor are they poisonous.
To the incompatibilities of alkaloids in general,
aconitine adds that of being decomposed by alka-
lies, owing to its peculiar composition, as above
described.
The properties and uses of the alkaloid are fully
stated under the title Aconite. Its activity is, how-
ever, so intense that it has to be used and handled
with the most extreme caution, as will be appreciated
when it is considered that there is but a half pound of it
in a ton of aconite, yet the safe dose of the root
is limited to about five grains.
Its external use is for the relief of rheumatic and
neuralgic pain. The ordinary commercial alkaloid
has been used in ointment up to two-per-cent.
strength, but that of the pure crystalline alkaloid
should be limited to 0.2 of one per cent. There is
great danger of absorption, and it should be applied
only to the unbroken skin. Internally, it may be
used in pill form or in freshly made solution, in doses
of gram 0.0001 to 0.0003 (^ to ^ grain), and not
more than ten times these amounts per day.
Pseudaconitine, from Nepaul or Indian aconite (.4.
ferox Wall.), is equally poisonous. Its properties are
under investigation, and it is not unlikely that it
may be found worthy of introduction.
H. H. Rusbt.
Acormus. — See Teratology.
Acoustic nerve. — See Ear, Anatomy and Physiology
of the.
Acrochordon. — From &Kpov, extremity, and yopS-fi,
cord. A small fibrous growth, usually peduncular,
of the skin, especially of the neck or eyelids. It may
occur at any period of life but is more common in the
aged. See Fibroma of the Skin, under Fibroma.
Acrodermatitis Chronica Atrophicans. — This term
was applied by Herxheimer and Hartmann to a type
of affection previously included under idiopathic
atrophy of the skin. It is also held to be a form of
dermatitis atrophicans diffusa, limited to the extrem-
ities; somewhat as sclerodactyl is a local type of
scleroderma. Some dermatologists have insisted
that these forms of atrophy of the skin must be
minimal forms of scleroderma, a possibility barely
mentioned by others, who merely state that the two
processes show at times some points of resemblance.
The initial stage shows a soft, doughy infiltration
having a bluish-red hue, which is a prelude to the
atrophic stage, in which the skin becomes smooth,
shiny and tense. These lesions do not as a rule
appear in the fingers as the name suggests, but are
prone to arise in the course of the limbs, especially
on the knees and elbows. Authors mention especially
the "ulnar strip," a narrow atrophic band which
Occupies the ulnar side of the arm. Other favorite
Idealities are the face and soles of the feet. Some
cases terminate in spontaneous recovery in a few
weeks, while in others the affection may last for
many years, yet leave no permanent atrophy. About
sixty cases are on record (see also Atrophia cutis
idiopathica). Edward Preble.
Acrodynia. — Epidemic erythema, a somewhat
obscure disease, said to bear considerable analogy to
pellagra. It was first observed at Paris in 1828,
occurring there as an outbreak in one of the infirma-
ries for old men. The epidemic subsided during the
winter months to break out again in the spring, but
was considered to have been extinguished during the
severe winter of 1S29-30. A few cases, however,
were noted from time to time during the years 1830
and 1831, since when the affection has not again been
observed in Paris. In Mexico, in 1866, during March
and April, an epidemic said to be acrodynia broke
out among the Mexican and Algerian soldiers at
Zitocuaro.
On the Continent it had been observed on a small
scale since 1831, chiefly among Belgian and French
soldiers and prisoners, the last occasion being in a
French regiment stationed at Satory, near Versailles,
in 1874. This epidemic was not very clearly demon-
strated, however, to have been one of acrodynia, and
of late the existence of such a disease has even been
questioned. The general symptoms are said to be in
some respects similar to those of chronic arsenical
poisoning. Commencing with gastrointestinal irri-
tation, redness of the conjunctiva, edema of the face
or limbs, there are soon added formication, pains in
the fingers and toes, a burning sensation, and pricking
or shooting pains in the palms and soles, and a feeling
of weight in the extremities, especially the lower.
Hyperesthesia of these parts, especially the soles of
the feet, and sometimes anesthesia, are present.
Cramps, spasms, and tetanic contractures are almost
always constant symptoms. There is no fever, and
the disease is rarely fatal, except in the old and feeble
or from the diarrhea which is present in all cases,
recovery taking place in a few weeks or months.
The chief cutaneous manifestations of the disease
are erythematous and pigmentary.
The erythema makes its appearance early in the
course of the disease and may be very general,
affecting, however, chiefly the extremities, more
particularly the hands and feet, and here especially
their palmar and plantar surfaces. It may be pre-
ceded or accompanied by the formation, chiefly on
the hands and feet, of vesicles or bullae filled with a
clear or at times more or less sanguinolent effusion,
and is followed by desquamation or exfoliation of the
epidermis, while a dark brown or blackish pigmenta-
tion spreads itself over the abdomen, chest, axilla?,
and other parts, being more pronounced in the warm
regions of the body. Alibert, in his description, the
only one coming from a dermatologist, says (" Mono-
graphic des dermatoses," Paris, 1S33, p. 12) that what
particularly attracted his attention in most of those
afflicted with the disease was this black color which
affected the integument, nearly all who presented
themselves for treatment having the tint of a chimney
sweep.
The pathology of the disease is obscure; there are no
special postmortem changes, but in several cases in-
flammation of the pia mater and spinal arachnoid was
found. Though the disease bears a close resemblance
to pellagra, the general and cutaneous symptoms are
more varied in acrodynia than in pellagra; and while
in the latter the backs of the hands and feet are
attacked, it is the palms and soles that are affected
in the former. The disease was regarded (Chomel,
Recamier, etc.) in Paris as being due to spoiled
cereals, but nothing positive on the score has been
proven. The most efficient treatment was claimed
to consist in counterirritation of the spine.
Charles Townshend Dade.
94
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Acronwualy
Acromegaly. — Synonyms: Megalacria, acromegalia,
pachyacria, Mane's disease.
Definition. — Acromegaly, from inpov, extremity,
and uiyat (fiej-aX-), great, is a chronic disease, charac-
terized by an abnormal increase in the size of the
extremities, viz., hands, feet, and generally head,
due to an hypertrophy of the bones and soft parts
of these regions.
History. — The first to recognize this disease as a
Separate entity was P. Marie, who wrote upon the
subject in the Revue de Medecine, vi., 297, 1886,
describing two cases which he had discovered while
assistant to Professor Charcot. The first cases dis-
covered and reported as acromegaly (in 1885 Wads-
worth reported a case as myxedema which was un-
doubtedly acromegaly) in America were those of
O'Connor and Adler, both of which were published
in 1888.
For the early bibliography the following may be
consulted: New Sydenham Society Reports, London,
1891; Joseph Collins' articles in the Journal of
Nervous and Mental Diseases, December, 1892, and
January, 1S93, the alphabetical bibliography in the
writer's article in the Yale Medical Journal, Decem-
ber, 1S97; Guy Hinsdale's monograph in Medicine,
1898; and the chronological bibliography of Harlow
Brooks in the Archives of Neurology and Psycho-
Pathology, vol. i., No. 4, 1S9S. The later bibli-
ography is given in the monograph of Bernhard
Fischer, "Hypophysis, Akromegalie und Fettsucht,"
Wiesbaden, 1910.
Symptomatology. — General Condition. — The acro-
megalic patient comes to the physician complaining
of headache, disturbances of vision, severe joint pains,
and sometimes ringing in the ears; or the condition is
discovered while the patient is under treatment for an
entirely different disease. The pain in the head is the
most frequent subjective symptom, and is often
severe and even terrific. There may be, and fre-
quently are, pains referred to various parts of the
body, often to the joints, which are more or less per-
sistent but neuralgic in character. Frequently there
is tingling of the hands, feet, or ears, often with
numbness of the fingers, but with no great loss of
sensibility. There are generally increased and often
ravenous appetite, increased thirst, dyspepsia and
polyuria, and generally constipation. As a rule, in
women menstruation is absent and in men the
sexual appetite is diminished.
The weight during the developing period of the
disease always increases, and so does the height to a
certain extent, at least till the period when kyphosis
develops, when more or less loss of height takes
place The gradual increase in the size of the hats,
shirts, gloves, and shoes worn affords evidence of the
enlargement of the head and extremities. In women
the increase in the size of the fingers, as shown by the
inability to wear the wedding ring, is a positive evi-
dence of growth. In most cases earlier photographs
of the patient can be obtained and compared with the
present condition.
Clinical Inspection. — In acromegaly all of the pro-
jecting portions of the body are greatly enlarged —
hands, feet, chin, lips, nose, tongue, ears, and often
the genitalia. Of these parts the bones, cartilages,
and soft tissues are all hypertrophied. The face is
oval, the cheeks are flattened, the forehead is retreat-
ing and low, the nose enlarged and often massive, and
exophthalmos may be present. The ears are gener-
ally enlarged and the hair of the head is strong and
thick. The intellectual faculties may or may not be
impaired, and somnolency is sometimes present.
Taste and smell are rarely affected, while hearing is
occasionally disturbed and sight is frequently im-
paired. The voice is loud and deep. The reflexes
are generally normal, at least not markedly impaired,
and the electrical reactions are normal.
lhiul. — The forehead is low and retreating, due to
the growth forward of the superciliary ridges, which,
with the elongation and forward projection of the
lower jaw, gives the oval or elliptical face so charac-
teristic of this disease. The hair is thick and strong,
and the eyebrows are often heavy. The face is
entirely too large, being out of all proportion to the
cranium proper. The skin of the face is thickened and
of a yellowish-brown color, most marked on the eyelids,
with perhaps here and there a molluscous growth.
The skin of the forehead is often redundant and
thrown into many transverse wrinkles and folds.
The cheeks are flattened, and appear sunken, largely
due to the prominence and projection of the malar
bones. The circumferences of the orbits are promi-
nent, and the eyelids are large, due to the thickening
and widening of the tarsal cartilages, with more or
less hypertrophy of the skin, especially of the lower
lid, where it may fall in folds, with occasionally the
appearance of edema. The eyeballs are large and
generally more or less prominent, even to the con-
dition of exophthalmos.
The nose, even for the size of the face, is too large,
often immense, due to the thickening of the nasal
cartilages and to the great hypertrophy of the soft
parts. It is wide, thick, and may be pugged. The
mucous membrane is often thickened.
The superior maxillary bones may or may not be
enlarged, but are frequently lengthened from above
downward; however, they are never enlarged to the
same extent as is the lower jaw. The upper lip is
generally thick and projecting, but never attains the
size of the lower lip. The lower lip is almost in-
variably thick, everted, and projecting, and is a
characteristic feature.
The enlargement of the lower jaw is one of the
characteristic changes in this disease, although acro-
megaly can occur without it. Sooner or later prog-
nathism generally occurs; it is due not only to the
growth of the body of the lower jaw, but also to the
widening of the angle and the changes in the glenoid
fossa.
The external ear is generally increased in size.
The cartilages and the soft parts both take part in the
growth, and the former may become in places as hard
as bone, while the external auditory canal may be
lengthened by the growth of its cartilage and nar-
rowed by exostoses from the bony wall.
The tongue is broad and thick and frequently
double its normal size, almost entirely filling the
cavity of the mouth, so that the sides show indenta-
tions from the teeth. The upper surface of the tongue
is often deeply corrugated and marked by deep lines
and fissures, and the papilla? may be prominent and
projecting. The speech is rendered thick, heavy,
and slow by the massive tongue, while the prog-
nathism allows the labial and dental sounds to be but
poorly articulated. The tongue is generally clean,
but may be covered with a grayish-yellow coating.
The soft palate is often thickened, the uvula may be
wide and long, even as large as a little finger, and the
epiglottis has been found considerably thickened.
The larynx is enlarged, either as a whole or in one or
more sets of its cartilages. The aryepiglottic liga-
ments may be thickened and the vocal cords hyper-
trophied. These laryngeal enlargements cause the
voice to be loud and" harsh, while the pitch is much
lowered in men and made masculine in women. The
submaxillary and the lymphatic glands of the neck
may be enlarged. The thyroid gland nvay be normal
in size, hypertrophied, cystic, or so atrophied that it
cannot be found.
The neck is short and thick, and the head leans
forward, while the cervicodorsal kyphosis causes the
long projecting chin almost to rest on the sternum.
Body. — Sooner or later the irregular growth of bone
in the spinal column causes deformity of the spine.
This deformity is almost constantly a cervicodorsal
95
Acromegaly
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
kyphosis, giving a humpback appearance which is
very characteristic of this disease. Occasionally
scoliosis is also present, and sometimes there is a
compensatory lumbar or dorsolumbar lordosis. The
spinous processes of the vertebrae may be abnor-
mally prominent, especially the lower cervical.
The size of the chest is greatly increased, especially
at the level of the ensiform cartilage, where it reaches
its o-reatest circumference. Laterally the chest
Flu. 24. — Acromegaly. (Author's Case.)
appears flattened, while the anteroposterior diameter
is often enormous, due to the forward projection of the
lower end of the sternum. The sternum is generally
widened and thickened, with prominent transverse
ridges. The xiphoid cartilage is hard, wide, ami
projecting. The clavicles are most enlarged at the
sternal extremity, but the acromial end is also thick-
ened. The ribs are wide and very oblique, and al
their junction with the more or less enlarged and
ossified costal cartilages are found bony nodules, not
unlike the rachitic rosary, and nodosities may appear
on the ribs themselves. The hardening of the liga-
ments iiiid cartilages of the chest causes a peculiar
stiff and constrained up-and-down or out-and-in
96
motion of the lower part of the thorax during respira-
tion, and the abdominal respiration is increased.
The abdomen is generally flattened and even ap-
pears retracted from the forward projection of the
sternum and costal cartilages, though rarely it may
be large and pendant.
The pelvis is enlarged, the ilia are wide apart, the
crests broad and prominent, and the pubic bones are
especially hypertrophied at the symphysis.
The external genitals may or may not be enlarged.
The clitoris may be hypertrophied, and the vagina
may be lengthened, but the uterus is generally small
and atrophied.
Upper Extremity. — The shoulder joint may be, but
rarely is, much enlarged; the elbow joint may be in-
creased in size; the forearm is often enlarged at its
lower third, especially just above and at the wrist;
the wrist joint is almost always large. The hand,
widened, thickened, and often lengthened, is massive
and enormous, and appears heavy and cumbersome
for the relatively small arm to carry. The ends of
Fig. 25. — Typical Hand in Acromegaly. (Author's Case. )
the metacarpal bones and phalanges are enlarged,
giving prominent joints. The skin of the hand and
the subcutaneous tissues are greatly hypertrophied,
so that the normal lines of the palm are greatly
deepened. At the upper part of the hand, and over
the metacarpal bone of the thumb, and on the ulnar
border, the hypertrophy of the soft parts is excessive.
The fingers, by the growth of phalanges and soft
parts, become of the same width and thickness at the
tips as at the bases, giving the appearance called "sau-
sage-shape," which is a characteristic feature of this
disease. The fingers may appear somewhat flattened,
unci, according to Marie, there is often a swelling at the
articulation of the first and second phalanges. The
nails are flattened, short, and sometimes widened,
but always appear too small for the enlarged fingers,
whose redundant flesh laps over them at the sides.
There are strongly marked longitudinal striatums,
sometimes even with ridges, and there may be trans-
verse striations on the nails. They are often brittle,
breaking off or cracking easily.
REFERENCE HANDBOOK
OF THE
MEDICAL SCIENCES
PLATE V
Fig. 1. Fig. 2. Fig. 4.
Acromegalic Skeleton (Osborne's Case) At the Yale Medical School
Fig. 1. — Normal skeleton.
Fig. 2. — Skeleton of Acromegaly showing Kyphosis, enormous
anteroposterior diameter of thorax, great obliquity of the ribs,
long arms reaching almost to the knees, large feet, great project-
ing os calcis, etc. (author's case).
Fig. 3. — Spine of Fig. 2; shows co-ossification of bodies oi
dorsal vertebrae and many bony unions of spinous and transverse
processes.
Fig. 4. — Skull of Fig. 2, showing enormous inferior maxilla,
prognathism, projecting supraorbital ridges, large and prominent
malar bones, etc.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Acromegaly
Lower Extremity. — The thighs are generally not in-
creased in size, although the condyles of the femurs
may be prominent and enlarged, which with the hy-
pertrophy of the patellar causes a marked enlarge-
ment of tin' knees. The upper ends of the tibiae and
fibulae may or may not be enlarged, but the lower ends
of the leg bones are generally found hypertrophied,
causing prominent malleoli and large ankle joints.
The tendo Achillis is frequently prominent and hard-
ened. The bones of the feet are all enlarged, especially
the os calcis, which projects backward, giving a
marked prominence to the heel. The foot is thick and
broad, with a prominent cushion of thickened skin
and subcutaneous tissue on the external border, a
characteristic feature of the foot in acromegaly. The
toes are all large, but more especially the big toe,
which is immense, and crowds the other toes together.
The skin of the foot is redundant, hypertrophied, and
thickened, especially on the toes. The nails of the toes
present appearances similar to those of the fingers.
Acromegaly is primarily a symmetrical disease,
one part enlarging correspondingly with its fellow on
the other side; but exceptionally one side of the body,
more often the right, is larger than the other. Be-
sides this slight asymmetry of the two sides of the
body, some atypical cases have occurred in which one
or several toes or fingers were found to be larger than
their fellows, or one side of the face and head was
much larger than the other side.
Muscles. — At first the muscle growth and muscular
power are increased, and sometimes the development
of the muscles may be very great. Sooner or later,
however, the muscles become atrophied in greater or
less degree, and the muscular power is greatly dimin-
ished, even to the point of compelling the patient to
remain in a sitting or reclining posture, or in bed.
There may be intermittent attacks of great loss of
muscular power, followed by periods of improved
strength.
Skin. — The subcutaneous fat may be increased or
diminished, but later it is generally found diminished,
except perhaps on the diseased portions of the body.
The skin on the affected parts is hypertrophied, and
where exposed is olive brown or yellowish in color.
This yellow color is most marked on the face, and
here most noticeably on the eyelids. The face may,
however, be pale, or the nose may be red, and the skin
may be dry and harsh from diminished sebaceous
secretion. There is frequently increased perspiration,
coming on with slight exercise, or even without ex-
ercise, either general or local on the diseased portion
of the body, and especially frequent on the legs.
This perspiration may have a disagreeable odor. The
growth of the hair all over the body is increased,
especially on the legs, and on the head it is thick,
strong, and coarse. There may be pigmentations on
the skin, and pendulous growths of molluscum fibro-
sum frequently occur on the face, especially on the
eyelids, and on the chest or back. Multiple fibro-
mata of the skin may occur, of the size of a millet-
seed, and fatty nodules may be found beneath the
skin.
Blood-Vessels . — There are always vasomotor dis-
turbances of the affected portions of the body, as
shown by the tingling, flushing, and local sweating.
The flushing is often accompanied by a "burning
pain." Besides these signs, which denote the dilata-
tion of the small blood-vessels, there is a marked
tendency to a dilated and varicose condition of the
Superficial veins, especially of the legs. Hemorrhoids
are often present, varicocele may be, and profuse
epistaxis may occur, while the arteries may show
signs of beginning atheroma.
Albuminuria or peptonuria may be present, while
polyuria is a frequent symptom. Glycosuria has
been so many times present as to suggest some
metabolic connection between pituitary disease and
disturbances of the sugar mechanism.
Vol. I.— 7
Sight. — .More than half of all cases of acromegaly
show deranged vision or optic signs during some stage
of the disease. The physical cause of the ocular
disorder is largely the pressure of the enlarged
hypophysis on the optic chiasm. That in some
cases one eye, in others both, and in still others the
ears alone are affected can be explained by the con-
dition of the bony environments of the sella turcica
in the individual skull, the enlarging pituitary body
tending to escape in the direction of least resistance.
If the middle clinoid processes are small, the pressure
will be exerted early on the optic commissure; or if
one of these processes is smaller than the other, the
pressure will first be exerted on that side, and but one
eye may be affected. Exophthalmos is often present,
due both to actual enlargement of the eyeballs and to
bony growth in the orbital cavities, or perhaps to
associated thyroid disease. The pupils are generally
normal in size, but may be dilated, and the reaction
may be slow to light but normal to accommodation.
Nystagmus, both rotary and vertical, has been present,
and divergent strabismus has been noted in a few
cases. Narrowing of the visual fields has been found
in all degrees, even to bitemporal hemianopsia, and
signs of optic neuritis due to pressure may be found
even before the vision is much impaired. Optic
atrophy, partial or complete, of one or both eyes, is of
frequent occurrence. The retina? may show venous
congestion, and the arteries may be small or they may
appear pale, or a congestion as of a neuroretinitis
may be present.
Hearing. — The hearing is not generally affected, but
occasionally there has been decided deafness, and in
several cases there has been continuous and unceasing
tinnitus aurium. When this is constantly present
there is either pressure on the cavernous sinuses by
the enlarged pituitary or an actual growth into them
of the pituitary tumor. The ringing is often in-
creased on lying down, so that the patient cannot
sleep except in the sitting position, and anything that
increases the blood pressure even momentarily will
increase the tinnitus and often give it a pulsating
character. The drum membrane may be hardened,
thickened, and almost immovable.
Smell and Taste. — These are but rarely affected.
Nervous Phenomena. — A most constant symptom
is pain in the head, which may be referred to any
region, but is generally frontal or vertical; in one of the
writer's cases it was located in a small circumscribed
spot, tender to pressure, over the region of the anterior
fontanelle. This pain may be so mild that it is hardly
complained of, or so violent as almost to render the
patient insane. The headache is often, like the
tinnitus aurium, made worse on lying down or by
anything that increases the cerebral blood pressure.
Pain may be present in the joints, especially the knees,
and is often severe in the fingers. Pain is frequently
complained of in the chest or abdomen, shooting
around the body or confined to one side, or it may be
lumbar or sacral. Almost every subject of acrome-
galy has pain, more or less constant and severe, in
some part of the body, often without any local cause.
Crepitations may be found in some of the joints,
which, of course, would account for the pain there,
though there is no swelling or any evidence of acute
inflammation.
Sometimes a peculiar nervous sensation is com-
plained of, a sensation as of a nervous discharge or
electric shower, starting from the top of the head and
passing quickly over the body to the feet. This is
sometimes described as giving the sensation of the
rolling of shot; hence it has been termed the "shot
feel."
There are no marked or constant paresthesias in
acromegaly, though slight numbness or prickling of
the affected parts is often complained of, most fre-
quently in the fingers. The tactile sense of the
fingers may be impaired, so that small objects can-
97
Acromegaly
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
not be readily handled, and sewing, knitting, or even
dressing becomes difficult. Sometimes an inter-
mittent vasomotor spasm in the fingers has been
noted, causing localized anemia with severe pain,
while formication or hyperesthesia of the hyper-
trophied parts may occur. General numbness anes-
thesia, analgesia, and impaired perception of heat or
cold, are rare conditions in this disease.
The electrical responses of the muscles and nerves
are rarely abnormal, and the reflexes, both deep and
superficial, are generally unimpaired. Occasionally
the patellar reflex is diminished, and rarely it is
absent on one or both sides.
The mental faculties in the majority of cases are not
affected, but loss of memory, dulness or sluggishness
of the mind, apathy, and depression have all been
recorded. Marie says that there may be a state of
gnat good humor, but, on the contrary, melancholia
is more frequent. There may be great irritability,
while there may be delusions, and the patient may
be refractory and suspicious; he may develop de-
cided insanity, and may even show suicidal and
homicidal tendencies. This condition may be persis-
tent or intermittent, or may last for a short time and
not recur. Another interesting condition which
seems quite frequently to occur in acromegaly is a
persistent drowsiness even to somnolency. Vertigo
may occasionally occur and be severe enough to
cause the patient to grasp something for support. At-
tacks of syncope are sometimes a frequent symptom.
It is probable that the conditions showing sudden
and serious brain trouble, all of which point to cere-
bral tumor, are due to the first sharp pressure which
the enlarged pituitary body exerts upon the brain,
having perhaps suddenly burst from its bony
moorings.
Pathological Anatomy. — Hypophysis Cerebri. —
A lesion of the anterior lobe of this structure is
probably always present in cases of acromegaly..
Fia. 26. — Section of Parenchyma of the Thyroid filand. The
whole gland weighed 101 grams. (Author's Case.)
Usually there is a distinct enlargement, or hyperplasia
(adenoma), of the anterior lobe, but it may be normal
in size or there may be cystic or other form of de-
generation, the latter being probably always second-
ary. The changes found here will be discussed in
the section on Pathogenesis.
98
Thyroid. — The thyroid gland is not infrequently ab-
normal in acromegaly. It may In- hypertrophied and
give a hypersecretion and all of the symptoms of
exophthalmic goiter, or it may be atrophied and
cause some myxedematous symptoms, or, which is
probably most frequently the case, the gland is first
hypertrophied and then connective-tissue growth
displaces the glandular parenchyma, and though the
gland is actually enlarged, it is producing a diminished
secretion, and a partial myxedema occurs. This
accords with the symptoms of a long-continued acro-
megalic case, and with the frequent autopsical
"
' -V*
-
' • ■ .
■ • .
9 *f iu>
N % 1
■ ft )
Fig. 27. — Section of Thoracic Thyroid Gland. The whole gland
weighed 36.5 grams and contained a large amount of iodine. (Au-
thor's Case.)
finding of an enlarged and heavy thyroid gland
sometimes containing a greatly diminished amount of
iodine. This gland may also show cystic degenera-
tion. In one of my cases a large supernumerary
thyroid gland was found in the upper part of the
thoracic cavity, which contained a large amount of
iodine.
Thymus. — The thymus gland has several times
been found enlarged and in one instance a fatty growth
in the region of the thymus has been reported. In
these cases instead of thymus glands they may have
been supernumerary thyroids. A thymus gland
contains no iodine (Mendel).
Brain. — The brain has frequently been found en-
larged, but may not be, even in cases which show
increase in size of almost every other organ of the
body. The pineal gland has been found double its
ordinary size, and little tumor growths have been
found attached to the base of the brain.
Calcified and even ossified plates have been found in
the dura mater, and its attachments to the skull may
be ossified. The arteries at the base of the brain
may be enlarged and thickened, especially some one
artery in the circle of Willis, while another artery or
another part of the same artery may be distinctly
narrowed. The arteries may become distorted and
tortuous, and the posterior cerebral has been found
knotted and imperforate. The cranial nerves have
been found either normal or enlarged. The nerve
changes in the brain and cord, if there are any, are
probably secondary to the Vascular changes. As in
this disease we find the blood-vessels almost con-
stantly changed, we may expect to find all kinds of
changes due to a greatly modified blood supply, be
it in an organ or in nervous tissue.
Spinal Cord and Nerves. — The medulla and spinal
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Acromegaly
cord are generally normal, but the pia of the cord has
b een found I hickened, and some of the columns of the
,.,,i,l may be degenerated. Probably, however, as
above stated, all nerve degenerations of the brain or
spinal cord are due to foregoing vascular changes.
The nerves of the body, and especially of the
extremities, may be enlarged generally, this change
being due to an increase in the interstitial connects e
tisane. They may show sclerosis in some places and
fat tv changes in others, and their vessels may show
hyaline degeneration.
flu i -*''
<
Fig. 2S. — Section of the Pituitary Body. (Author's Case.)
The ganglia and nerves of the sympathetic system
show no special changes, though they may beenlarged,
and from the same cause as in the case of the spinal
nerves, viz., from connective-tissue growth.
Heart. — The heart is probably always enlarged in
acromegaly, by reason of an actual hypertrophy,
especially of the left ventricle; this being due to the
increased work which it must perform in overcoming
the resistance offered by the thickened blood-vessels.
Later the heart, though hypertrophied, becomes
weakened by the impaired action of its muscle fibers
due to connective-tissue formation or perhaps to the
presence of fat globules, or else to the impaired blood
supply of its walls, which in turn is due to thickening
of the intima of its own nutrient blood-vessels.
Blood-Vessels. — The vascular changes are a con-
stant feature of acromegaly, the intensity of these
changes or their localization causing the many
variations of symptoms or conditions seen in different
cases of acromegaly. More or less generally all over
the body the coats of the arterioles are thickened,
the intima being the most affected. This may also
be true of the veins, although in many places the vein
walls seem to be thinned, allowing varicose conditions
to take place. This may occur in the lower extremi-
ties, or as hemorrhoids, or in the large veins of the
arms and neck. The epistaxis noticed in some cases
is probably due to this weakening of the blood-vessels.
The blood is normal, or late in the disease it may
show simple anemia.
Lungs. — The lungs are not often affected, but
many times, both in autopsical reports and in clinical
accounts of cases of acromegaly, "phthisis" has been
mentioned, or tuberculous consolidation has been
found. Chronic bronchitis, edema, or passive con-
gestion can develop from a weak heart action in the
later stages.
The Digestive System. — The stomach and intestines
present no specific abnormalities. The pancreas
often shows changes, especially in those cases in
which glycosuria has been present. The liver is
generally enlarged, sometimes very greatly, and mav
show a great increase in connective-tissue growth
(hypertrophic cirrhosis). There may be a passive
congestion or fatty degeneration of the liver. The
spleen may be enlarged by passive congestion and an
increase in its connective tissue.
Genito-Urinary System. — The kidneys are often
found diseased (chronic nephritis), or I hey may be
cystic. They and the suprarenal glands may be
increased in size.
Microscopical examination of the genitals shows an
increase in connective-tissue growth and even al
limes the formation of fibrous tissue; these I'li.r
being accompanied by a gradual diminution of all
functional activity.
Skin. — The skin is hypertrophied over the affected
portions of the body, sometimes in a marked degree.
This is especially true of the scalp, hands, and feet,
all of the layers of the skin taking part in this thicken-
ing. The sweat glands may have a double layer of
epithelium. Fibromata, neuromata, and elephantia-
sis of the skin have been observed, and molluscous
growths are of frequent occurrence. The sub-
cutaneous fat may be increased or decreased in
thickness, but in the later stages it is probably nearly
always decreased.
Muscles. — Many of the muscles at the time of death,
unless I he patient dies early in the disease from some
intercurrent affection, are found atrophied, and yet
there may be many local hypertrophies. Certain
muscles, especially the deltoid or the supraspinatus,
may become greatly hypertrophied, forming veritable
muscle tumors.
Fir,. 29. — Section of Branches of Vessels near the Posterior
Tibial Artery, Showing Thickened Intima. (Author's Case.)
Skeleton. — In well-marked cases nearly all of the
bones of the body are enlarged, although a few
individual bones may not take part in this increased
growth. The long bones undoubtedly show the
greatest enlargement and growth at their extremities,
due to the tendency of the articular cartilages to
ossify; still in many instances the shafts of the bones
are also decidedly enlarged. The spongy bones of
the skeleton are all more or less thickened, and all
articular surfaces, whether of long or spongy bones,
show a tendency to spread out, widen, and grow more
prominent. The flat, thin bones, while increasing in
extent show a tendency to become thinner in their
plates. This is not true of the cranial bones, because
the spongy tissue in the diploe increases in thickness.
We sometimes find a thinning at the ends of the long
bones, just back of the articular surfaces, while they
are at the same time extending their articular sur-
faces. This growth of bone is an hypertrophy, the
99
Acromegaly
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
new bone growing from the periosteum and also
"within the medullary spongy tissue at the ends of the
long bones. In the early part of the disease this
growth seems to be more especially confined to the
periosteum; later the apophyses and epiphyses
become affected. The crests, tuberosities, and
eminences are enlarged and grow in the direction of
the muscular action, a portion of the tendons of the
muscles becoming ossified. The tendons of the
muscles are often found in deep grooves or bony
canals, and the foramina for the nutrient arteries, and
especially for the articular arteries, are often enlarged.
Osteophytes may be found in the joints, especially
over the wrist and ankle joints, or pieces of calcareous
material may be found loose in a joint. The spongy
ends of the long bones may become more compact,
through eburnation and a change in the architecture
of the part. The ends of the bones in some cases have
shown condensing osteitis. This laying on of bone
at the extremities, the articular surfaces, may lengthen
a long bone without the shaft being at all affected.
Head. — The bones of the cranium are always more
or less thickened, this change being due largely to an
increase of the diploe. The ridges and crests for the
attachment of the muscles and fascia? are more promi-
nent, while the occipital protuberance has been found
as a spicula-like outgrowth, an exostosis. The
parietal eminences are sometimes abnormally promi-
nent, as are always the superciliary ridges. The sella
turcica is always enlarged and deepened, probably
because the enlargement of the pituitary body causes
the surrounding bone to undergo absorption.
The lengthening of the face is largely due to the
increase in the vertical diameters of the superior and
inferior maxilla?. The maxillary bones and the
sphenoid bones contribute the principal part of the
total enlargement of the bones of the skull.
Many of the sutures of the cranium and of the face
are obliterated by complete co-ossification. The
enlarging malar processes, orbital processes, and nasal
processes of the superior maxillary bones cause the
pushing outward of the malar bones, the lateral widen-
ing of the orbital cavities, and the pushing upward of
the nasal bones, thus causing the prominence of the
malar bones, the quadrilateral appearance of the
orbital cavities, and the wide nasal openings seen in
skulls of acromegaly.
The lower jaw is massive, the chief growth being in
the body, which is found lengthened and widened,
especially at the symphysis, while the mental process
stands out with undue prominence. The alveolar
process is widened and thickened, and the rami also
may take part in the growth, while the angle formed
by the junction of the body and the rami becomes
more obtuse. The coronoid processes are often
greatly enlarged. The growth of the alveolar process
is rarely participated in by the teeth, they remaining
normal in size, so that while the alveolar cavities
undergo enlargement we frequently have spontaneous
falling out of the teeth.
The hyoid bone may be enlarged with all of its
ridges very prominent, and the laryngeal cartilages
may al>u I nlarged.
Spine. — Marked changes are always found in the
spine, the degree being due to the age of the disease.
The bodies of the vertebra? are enlarged, especially
from the laying on of bone on the anterior part in the
cervical and dorsal regions. The increase of bone in
this region is often restricted to the upper part of the
interarticular cartilages, while in the lumbar region
the increase of the bone is more general.
The irregular thickening of the intervertebral carti-
lages, with the irregular growth of the bodies of the
vertebra?, sooner or later causes deformities of the
spine, namely, kyphosis, lordosis, or scoliosis, or more
than one deformity. An absorption of the inter-
vertebral discs, especially on the anterior borders.
with bony union of the anterior parts of the bodies,
and ossification of the anterior ligaments, which often
occurs, may cause an enormous kyphosis, the anterior
part of the spine appearing, under these circumstances,
as if formed of a single bone.
The transverse processes probably always are
enlarged, and may be joined together by the ossifica-
tion of their connecting ligaments. This ossification
may take place along the interspinous ligaments, or
we may find ossification of the posterior intervertebral
ligaments. The lumbar vertebra? are sometimes of
great size, and the sacrum may have its lateral masses
much enlarged.
Thorax. — The sternum is enlarged and thickened,
and the ensiform cartilage is ossified and generally
projects outward. Large transverse ridges are often
found on the sternum; also a hollow or depression
may be seen at the upper part, due to the manu-
brium not enlarging relatively as much as the body of
the sternum.
The costal cartilages are large and more or less
ossified, and often show prominent nodes at their
points of junction with the ribs, thus simulating the
rachitic rosary. The ribs are wide and thick, and
by the faster growth of the costal cartilages they
become abnormally oblique, while the sternum itself
is pushed forward, giving an enormous anteroposterior
diameter to the chest.
Upper Extremity. — The clavicles are always en-
larged, often enormously so, most marked at their
extremities, and especially at their sternal ends.
Their ridges and tubercles are very prominent. The
scapula? are generally enlarged, especially in their
transverse diameters, and the spines may be enor-
mous in size.
Fir,. 30. — .Skiagram of the Right Forearm and \\ rist. (Author's
Case i
The articular surfaces of all the long bones are en-
larged, due to ossification of the articular cartilages or
ligaments, and they are often roughened. There
may be exostoses, spongy growths, osteophytes, or
calcareous deposits in and around the joints.
The humerus is frequently not increased in size,
though its extremities, especially the head, may be.
The radius and ulna, if the case is of long standing,
are found enlarged, especially at their articular sur-
faces, and more especially at their lower extremities.
100
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Acromegaly
The carpal bones are always more of less enlarged,
md may all be very markedly so. The metacarpal
bones and phalanges are widened and thickened; the
former especially at their heads, and the latter at each
jxtremity, thus rendering the joints prominent. The
listal phalanges are generally the most affected, and
nay show an increase of spongy tissue at their ungual
•IK is.
/', (,-;*. — The pelvis is always enlarged, with the
symphysis of the pubic bones often wide and deep,
while the crests of the ilia are wide apart, by reason of
Fig. 31. — Skiagram of Part of an Acromegalic Hand, Showing Hy-
>ertrophy of the Soft Parts and Increase of Spongy Tissue at the
Jngual Ends of the Distal Phalanges. (Author's Case.)
i spreading out of the ilia. Though the pubic bones
tnd the iliac bones may be enlarged, with their ridges
md eminences increased in size, and with the obtura-
tor foramina enlarged, the substance of the bones
hemselves may be considerably thinner than normal.
rhe acetabular cavities may be enlarged and rough-
;ned by partial ossification of the cotyloid ligaments.
Lower Extremity. — The femurs maybe enlarged at
X)th extremities, as may also be the heads of the
ibia? and fibulae. The patella are often hypertrophied
uid may present abnormal spinous processes. The
nalleoli are large. All of the tarsal bones may be
enlarged; especially is the os calcis often enormous,
m account of the laying on of bone at the attachment
if the tendo Achillis. The metatarsal bones and the
Dhalanges of the toes are all enlarged similarly to
;hose of the hands. Thompson found several of the
phalanges of the toes ossified together. The distal
phalanges may show spongy enlargements at both
extremities, and there may be spongy spicules of bone
which reach around from one extremity to the other,
forming foramina or incomplete notches on the sides
of the bones.
Pathogenesis. — Some of the earlier theories of the
pathogeny of this condition may be mentioned, but
they are purely of historical interest, being no longer
accepted as true or even probable.
Marie's theory was that acromegaly is dependent
upon a diminished pituitary secretion, this resulting
from more or less destruction of the gland by a new
growth. The new growth, however, is usually an
adenoma with increased secretion, and when it is not,
it is a secondary degenerative lesion occurring late in
the course of the disease after the mischief has been
done.
Freund and also Campbell suggested that acromegaly
was a disease of puberty, an atavistic anomaly of
development manifesting itself at this period, the
body in its entire development at this time harking
back to the anthropoid apes. There is, however, only
the very faintest superficial resemblance between the
p-athological anatomy in acromegaly and the normal
anatomy of the ape.
Von Recklinghausen, Lancereaux, and others have
inclined to the view that acromegaly is a trophoneu-
rosis. It is true that vasomotor disturbances, neu-
roses, and trophic changes are present in acromegaly,
but they are dependent immediately upon the hypo-
physeal overgrowth or oversecretion, and only
remotely, if at all, upon central nerve lesions.
Klebs believed that the underlying lesion was an
angiomatosis, basing his theory on the undoubted
fact that signs of vascular disturbance are present in
acromegaly. The blood-vessels are increased, it is
true, but only, as a rule, in proportion to the general
hypertrophy of the bones and soft parts.
Other writers have ascribed the presence of acro-
megaly to lesions of the thyroid gland, or to a per-
sistent thymus. The thymus is seldom persistent
in acromegaly, however, and many cases occur with-
out any evidences of thyroid lesions.
Spitzer offered the suggestion that the disease was
due to an error in development, viz., an inclusion and
subsequent growth of spinal cord rests in the hypo-
physis cerebri. This theory is of course in the highest
degree fanciful and unsupported by anatomical
findings.
Another fanciful suggestion is that of Yu Kon that
the changes in acromegaly are due to pressure upon
some as yet undiscovered trophic center at the base
of the brain by the pituitary tumor. Aside from the
gratuitous assumption of the existence of an unknown
center here, the fact that cases of acromegaly un-
doubtedly occur without any enlargement of the
hypophysis would seem to dispose of this theory.
It has been asserted by more than one writer that
acromegaly is due to an aplasia or degeneration of
the sexual glands, this view being supported by a
supposed resemblance of the skeleton in a castrated
person to that in the disease in question, and also
by the undoubted fact that there is frequently more
or less loss of the sexual function in the subjects of
acromegaly. In such a theory the consequence in
mistaken for the cause, for there can be little question
that the sexual disturbance is a secondary condition.
At the present time it is quite generally accepted
that acromegaly is due to some perversion of secretion
of the hypophysis cerebri, but what this perversion
is, whether hyperpituitarism or hypopituitarism, is
even yet a subject of dispute. Because of the fre-
quent association of a tumor of the anterior lobe of
the hypophysis, Marie believed, as above noted, that
the condition was one of lessened secretion; but
opinion inclines now rather to the opposite view,
101
Acromegaly
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
namely that there is a supersecretion of this portion
of the gland. A more careful study of the so-called
tumors of the anterior lobe in these cases has shown
that the condition is one rather of hyperplasia than
of degenerative neoformation; the secreting cells are
not displaced by a cystic growth or neoplasm, but
are increased by reason of an adenomatous develop-
ment. In some instances, it is true, there is no tumor
or hypertrophy of the anterior lobe and there may
even be an apparent atrophy. In order to reconcile
such findings with the theory of supersecretion three
explanations have been offered. The first is that
though no gross changes are evident there may
nevertheless be found microscopically an increase in
number of the specific secreting (eosinophile) cells,
or there may possibly be a more active secretion
without increase in number. Another theory is that
of Tamburini that there is a primary hypertrophy of
the anterior lobe, which after having produced the
mischief, is succeeded by atrophy. The third
hypothesis rests upon the recent discovery of acces-
sory hypophyseal glands in the vault of the pharynx.
Killian (1888) and Eidheim (1904) noted the presence
of hypophyseal tissue in the vault of the pharynx in
the newborn, and Civalleri (1907) and Haberfeld
(1909) showed that an accessory pituitary gland may
exist in this situation in the adult. Moreover, hypo-
physeal rests have been noted by Eidheim and Levi
in recesses in the sphenoid bone in connection with
a persistent craniopharyngeal canal. It is possible
therefore that these accessory glands, acting with a
normal pituitary body, may produce an excess of
secretion and so cause acromegaly.
While either one or all of these hypotheses may be
alleged in support of the view that acromegaly is the
result of a superfunctioning of the hypophyseal cells,
it must be admitted that the problem is not yet
satisfactorily solved, even though the weight of
evidence is in support of supersecretion rather than of
subsecretion. One of the strongest arguments
against this is the fact that there may be a true
adenoma of the hypophysis without any signs of
acromegaly. The explanation of such cases, if the
theory of supersecretion is accepted, is difficult. It
has been suggested that the increase in pituitary
secretion may here be counteracted by a coincident
increase in the internal secretion of the sexual or
some other glands; but this is a supposition only,
not an explanation, and is no more satisfactory than
a simple denial of the fact.
For a discussion of the physiology and pathology
of the pituitary, body, the reader is referred to the
article on Hypophysis Cerebri.
Diagnosis. — This disease must be diagnosed from
myxedema, gigantism, erythromelalgia, elephantiasis,
leontiasis ossea, chronic rheumatism, syringomyelia,
rachitis, osteitis deformans, arthritis deformans,
pulmonary hypertrophic osteoarthropathy, local
hypertorphies, and adiposis dolorosa.
The principal- clinical differences between myxe-
dema and acromegaly are as follows:
Acromegaly.
1. Both sexes are about equally
affected.
2. Begins most frequently be-
tween the ages of twenty and
forty.
3. Bones are always enlarged.
4. Face is oval or elliptical.
5. The ends of the fingers are
of the same size as the bases, i.e.
they are "sausage-shaped."
6. The skin is yellowish,
wrinkled, and hairy.
Myxedema.
1. About eighty per cent, of
all cases are women.
2. Occurs most frequently be-
tween the ages of forty and fifty.
3. Bones are never enlarged.
4. Face is round and full.
5. The ends of the fingers are
swollen and clubbed.
6. The skin is pale, waxy,
puffy, boggy, and shiny.
Gigantism, or giant growth, is distinguished from
acromegaly by the fact that in the former there is
symmetrical and general growth all over the body; the
cranium grows as much as the facial bones, and the
face does not look too large for the head, nor the head
too large for the body, as is the case in acromegaly.
In gigantism the ends of the bones are not enlarged
out of proportion to the size of the shaft, and the
hands and feet are not enlarged out of proportion to
the arms and legs. The bones increase in length as
well as in width and thickness, and that symmetrically,
and the whole growth of the body is in proportion,
as in a normal individual, all of which is quite the
contrary of what is observed in acromegaly.
In erythromelalgia, a vasomotor neurosis of the
extremities, there may be some increase in the size
of the hands and feet with severe pain, and there is
always an impaired blood flow, giving burning sen-
sations, local redness, and even cyanosis, often in
patches or spots. There is, however, no enlargement of
the bones or soft parts of the face, no eye symptoms,
no marked change in the speech, and the hand itself
is unlike the acromegalic hand; the fingers are not
sausage-shaped, but smaller at the tip than at the base.
Elephantiasis Arabum is a hypertrophic disease of
the skin and subcutaneous tissue, located generally in
one, occasionally in two extremities of the body.
There is generally a history of several attacks of local
inflammation of the part affected, followed by a con-
tinuous growth and hypertroph}' of the skin, until an
enormous size is reached. In elephantiasis the
bones are not enlarged, the skeleton is not affected,
and the nervous, facial, and cerebral phenomena of
acromegaly are not present.
Leontiasis ossea is the name given by Virchow to the
condition in which osteophytes, or bony tumors, are
formed on the face and cranium. These bony tumors
are of irregular distribution, and produce great
deformity and asymmetry. There is no hypertrophy
of the extremities.
During the first stages of acromegaly one of the fre-
quent symptoms, and often a prominent one, is joint
pain, which at this stage might lead one to mistake
the disease for chronic rheumatism. The joints at this
time are tender to the touch, but are not reddened or
swollen. The pain is not permanent in any one or
two joints, and ankylosis does not take place, although
later crepitations are often present, and some con-
tractures of the fingers may be found, due to the flexor
tendons not growing as rapidly as the bones. As
soon as the hands, feet, or face begin to enlarge, the
diagnosis from chronic rheumatism becomes plain.
Syringomyelia is a disease of the nervous system
which generally begins before twenty, or in early
adult life, and in its slow development and long dura-
tion simulates acromegaly. After the complete
development of either disease, however, the amyo-
trophic paralysis, with retention of tactile and loss of
thermic and painful sensation in the case of the
syringomyelia, and the enlarged extremities in the
case of the acromegaly, render the diagnosis easy.
Several cases of acromegaly have shown coincident
symptoms of syringomyelia, and autopsical examina-
tions have revealed gliomata in the spinal cord.
Rachitis is a disease of childhood, or rather baby-
hood, occurring most frequently in -children under
three years of age. This alone would exclude the
possibility of confusion with acromegaly. The ends
of the bones, especially the epiphyses of the wrist, are
enlarged in rickets, while the hands and feet may be
flattened and apparently widened, but there is no in-
crease in the thickness of the hands or feet. The
bones of the head show no malformation, except
flattening and lengthening of the cranium with pro-
jection of the occiput and the softened spots. This
causes the cranium in rickets to appear too large for
the face, while in acromegaly the face appears too
large for the cranium. Softening of the ribs causes a
sinking in just before the junction with the cartilages,
giving the formation of the rachitic rosary, which
from another cause we also find in acromegaly. Ky-
Hi:
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Acromegaly
phosis, when it occurs in rachitis, is in the dorsal
region, while in acromegaly it is almost invariably in
the cervicodorsal region.
The diagnosis between the osteitis deformans of
Paget and acromegaly is shown in the following
table:
Ostein* Deformans.
1. Rarely occurs before fifty,
never before forty years of age.
2. The long bones are the
ones primarily affected; rarely
arc (he hands or feet affected.
3. The long bones are often
curved, giving great deformity.
4. Often one lirub or one bone
is affected long before another
limb or bone.
5. The cranial hones are af-
fected, rarely the facial.
6. The lower part of the face
id narrow, giving it a triangular
appearance.
Acromegaly.
1. Very generally begins before
forty years of age, almost never
after fifty.
2. The hands and feet are
enormous; long bones are gener-
ally not affected much.
3. The long bones are normal
in shape, possibly thickened at
the extremities, but are never
curved.
4. The hands, feet, arms, and
legs are generally nearly sym-
metrical.
.",. The facial bones are affected,
rarely the cranial.
6. The lower part of the f is
broad, giving it an elliptical ap-
pearance.
In arthritis deformans decided changes take place
in the articular tissues, and are accompanied by pain,
with sooner or later great deformity and ankylosis
of the joints. Tender nodules may appear in the
muscles, while the muscles themselves become
atrophied. The disease is apt to attack the same
joints on both sides of the body symmetrically, but
soon spreads to all of the joints. The hands are
thin from the wasting of the fat and muscles, but the
ends of the phalanges and metacarpal bones may be
enlarged and nodular. The fingers are more or less
flexed and turned toward the ulnar side of the arm,
while the joints of the hand are all stiff and more
or less completely ankylosed. Schulz has re-
ported a case of acromegaly associated with arthritis
deformans.
Pulmonary hypertrophic osteoarthropathy is subse-
quent to, or consequent on, some affection of the lungs,
which may be a bronchitis, an empyema, or perhaps
most frequently some new growth located primarily
or secondarily somewhere in the respiratory tract.
The hands are enlarged, but principally in the joints
and the ends of the fingers, the middle of the hand not
being attacked. The elbow, shoulder, and knee joints
are all affected, and there is always more or less im-
paired motion. The wrist joint is large, the hand
proper not much enlarged, while the fingers are in-
creased in size, especially the last phalanx, but the
soft parts are not hypertrophied. The appearance
of the finger nails is also quite characteristic of this
disease. They appear too large for the fingers, spread-
ing out at the sides, and even curving over the ends of
the fingers, often giving the appearance of the beak of
a bird, while the enlarged ends of the fingers have
caused them to be likened to "drum-sticks."
Local hypertrophies are not instances of partial acro-
megaly. These local enlargements of one extremity,
or one finger, or one toe are generally congenital,
though they may increase in size at the time of
puberty. One side of the face may be affected, in-
volving the bones and soft parts, including the tongue,
tonsil, and palate on that side, but whatever the
enlargement there is no symmetry.
Adiposis dolorosa is characterized by an enormous
deposit of fat, first in the form of nodules, either in one
location or in corresponding places on the upper or
lower extremities. These deposits soon cause pain,
diminished sensibility, and muscular weakness, and
the muscles may show the reaction of degeneration.
The absence of any marked enlargement of the hands,
feet, and face, as well as the absence of increased
bone growth, excludes confusion with acromegaly.
Prognosis. — The duration of acromegaly is vari-
ously estimated from ten to twenty years. The
patient may die of some intercurrent disease, or may
live for years with but a slow progression of the
disease, but no case of complete recovery has yet
been reported.
This disease is one of continuous progression, espe-
cially in the growth of the bones. Under treatment, or
without treatment, periods of apparent quiescence or
periods of cessation of symptoms occur, and the soft
parts of the hypertrophied portions of the body not
only may not enlarge, but may actually appear to
be diminished in size. Yet even in such cases the
bones apparently continue to grow. These periods,
when the patient may say that he feels well, are sooner
or later followed by marked exacerbations of all the
symptoms, often coming on suddenly.
Finally, little by little the patient falls into a con-
dition of progressive cachexia, with partial or nearly
complete loss of muscular power. This condition
may last for several years, and then death occurs
unexpectedly and suddenly from syncope.
It is possible that an enlarged pituitary body may
cause coma and death. Most subjects of acromegaly,
however, die of some intercurrent affection, the most
frequent of which are cardiac disease, nephritis, or
diabetes, all of which are the results of the connective-
tissue hyperplasia of the involved organs, viz., heart,
kidney, or pancreas respectively.
Treatment. — This disease is incurable, but in any
given case we can safely expect to ameliorate many
of the nervous symptoms. When there is an exacer-
bation of symptoms, of all treatment rest is the most
important, under which all the phenomena, except
those produced by actual lesions, will improve. Pain,
the most frequent cause of complaint, has been vari-
ously treated by all of the analgesics, but with only
temporary and varied success. The bromides are
often of service in relieving the headache and the
feeling of pressure in the head.
The constipation should be treated, while dyspepsia,
when present, can be best helped by a diet that re-
quires but little mastication, as prognathism, which
is so frequently present, is one constant cause of the
dyspepsia.
Any tonic treatment, combined with rest, will often
cause a cessation of the acute symptoms and an appa-
rent pause in the disease, except in the last stages.
If there is atrophy of the muscles with great loss of
muscular power, strychnine, given by the mouth or
hypodermically, is of value, especially when com-
bined with faradism.
Cardiac insufficiency and renal insufficiency should
be treated as though they were primary diseases,
without regard to the acromegalic condition.
The treatment of glycosuria should be cautious,
i.e. the true diabetic diet should be assumed with
care, if at all. If diabetes is present, the patient
might be fed on pancreas, as in acromegaly diabetes
seems to be generally, if not always, of pancreatic
origin.
The specific treatment of acromegaly undoubtedly
must bear some relation to the secretion of the pitui-
tary gland. During the stage of almost imperceptible,
gradual, and perhaps symmetrical growth of the bones,
pituitary feeding would probably be of no benefit, and
might even aggravate or precipitate unpleasant
symptoms, such as headache. But when a case of
acromegaly comes into our hands for treatment the
hypophysis disease has progressed far enough to give
nervous symptoms and selective enlargements so
typical of the disease. At this time we are probably
having a diminished amount of normal secretion or a
wholly or partially perverted secretion from the
hypophysis. At this time pituitary substance will,
I believe, often be found of marked benefit.
In a case of acromegaly I have obtained good results
from pituitary tablets, the dose varying from six to
103
Acromegaly
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
twelve grains a day. In this case the headache,
which had been continuous for two years, was mark-
edly relieved. While under the treatment the appe-
tite improved, the muscular weakness disappeared,
the nervous restlessness subsided, and the patient was
able to do her usual work, which she was not able
(o do before the use of the pituitary substance. Also,
tin' hypertrophy of the soft parts of the face, hands,
and feet greatly diminished. On stopping the treat-
ment, the headaches and muscular weakness again
developed.
In cases in which the thyroid gland is pathologically
so changed that it cannot furnish its normal secretion,
as denoted by mild myxedematous symptoms, the
feeding of thyroid extract has been of some benefit.
Little benefit has been derived from drugs. Arse-
nic has been given without effect, but apparent im-
provement has been noted in a few cases under
treatment with potassium iodide; possibly there was
a luetic element present in these instances.
Oliver T. Osborne.
Actinomycosis. — This disease is a combination of
abscess formation and new growth of connective
tissue. In most cases the disease has the character
of a subacute or chronic suppurative process, but in
some cases the new growth of connective tissue may
be so marked a feature of the process that it may
present the character of a tumor or neoplasm. The
disease affects man and certain domestic animals,
particularly cattle, in which it is probably best known.
It has a wide geographical distribution.
In cattle it most commonly affects the jaw bones,
where it may take origin in the medulla or the peri-
osteum, and may lead to the tumor-like conditions
which have been long known as medullary sarcoma or
osteosarcoma of the jaw, or as "lumpy jaw," etc.
The external soft parts about the jaws and face, the
tongue, the peripharyngeal tissue, the stomach, the
skin, and the subcutaneous tissues in various places,
may also be the seat of the disease. Anatomically,
the lesions consist in general of an overgrowth of
granulation and connective tissues, throughout which
are distributed, more or less numerously, small,
yellowish, soft suppurative areas or abscesses. If the
seat of the lesions be the jaw, there is usually more or
less new growth of bone as well.
In swine the mamma?, the peripharyngeal tissues,
the vertebra', and the spleen have been observed to
be the seat of the disease. In horses the disease may
occur in the spermatic cord after castration, as well
as in the jaw bones and in the bones of the extremities.
A few cases of the disease have been observed in
dogs.
In man the disease is probably more common than
is generally supposed. It most frequently affects the
tissues in and about the oral cavity, the pharynx, and
the neck. It also frequently affects the lungs, the
bones of the thorax, and the intestinal tract. Almost
any organ or part of the body may become the seat of
the disease. Anatomically, actinomycosis in man is
essentially a destructive suppurative process accom-
panied by a new growth of connective tissue which
in general is not as abundantly developed as in the
disease in cattle, so that in man the tumor-like lesions
are less frequent.
Pathology — The disease is due to the action of a
vegetable parasite upon tissues which are suitably sus-
ceptible. This parasite is an organism closely allied to
the bacteria, but belonging to a higher class. Itoccurs
in the lesions, and in the discharges from them, as
small aggregations or colonies, of variable size, which
in most cases are visible to the naked eye as grayish
or yellowish granules or lobulated bodies, less than one
millimeter in diameter. The presence of the peculiar
granules in the lesion or in the pus is characteristic
and diagnostic of the disease. As a rule they are soft,
and when placed on a slide and covered with a cover
104
glass, they are flattened or crushed by the weight of
the latter. In some instances, especially in cases in
cattle, they may be more or less calcified. Under a low
magnifying power a granule crushed beneath a cover
glass will appear as an aggregation of lobulated
hyaline masses, with rounded, finely serrated borders
which may have a slightly brownish tint. In some
instances a fine radial striation may be made out at
the margins. As a rule masses of pus cells will be
found surrounding the hyaline masses and making
up a portion of the bulk of the granules. Under
a higher magnifying power the hyaline material in
places will have the appearances of being made up of
a dense feltwork of delicate filaments having the
Fig. 32. — Portion of the Margin of an Actinomycotic Granule
crushed under a cover glass, as it appeared under a moderately
high magnifying power. Various forms and appearances of the
"clubs" are shown.
«
diameter of bacilli of moderate size and closely packed
together. At the margins these filaments" usually
have a radial arrangement, and some of them project
beyond the limits of the hyaline mass. In the case of
some granules, the margin of the hyaline mass may
be formed of a row of closely set, elongated, finger-
shaped, or club-shaped, or bulb-shaped bodies, com-
posed of a hyaline substance and arranged radially
(Figs. 32 and 33). These bodies constitute the so-
called "clubs" or "rays" on account of which the
name "ray fungus" has been applied to the parasite.
They are of variable size and width, often being three
or four times the width of the filaments. In stained
preparations a stained filament may often be seen in
the median portions of the "clubs" or "rays," which
for this and other reasons are regarded as modifica-
tions of the marginal filaments (Fig. 29). These
bodies are usually better developed in granules from
old than from recent lesions. If one of the granules
be broken up on a cover glass and suitably stained
there will be seen on microscopical examination,
tion, besides long filaments which branch, short rod-
like or bacillus-like or coccus-like forms (Fig. 30).
These forms may be fragments of filaments or true
bacilli and cocci growing in intimate association with
the specific microorganism as secondary infecting
elements. Such secondary infection of the lesions by
bacteria is quite common.
Microscopically, the lesions consist of larger or
smaller abscesses, each containing one or two of the
granules or colonies, and bounded by connective
tissue, in all grades of development (Fig. 3(i). In the
latter, giant cells may be present. A granule in a
section stained by Gram's method appears as a mass
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
AcromcKaly
of filaments embedded in a hyaline material and .-.bow-
ing at tlic margin more or less radially arranged fila-
ments, or the ••clubs" or " rays" previously described
(Figs. 33 and 36). The hyaline material seems to be
composed in many instances of non-staining degener-
ated filaments. In other instances the nature of this
hyaline material is not clear, but it is very probably
the result of degenerative processes in the colony.
It is not uncommon to see bacillus-like fragments of
the organism in or among the pus cells surrounding
the colony.
jr.
•
f
% •
*
M
-.
^
§
^.
•
&
m
''fa**
•>
f '^ J*.H
ft . *
Fig. 33. — A < rranule or Colony of Actinomyces, in a section about
two micromilli meters thick, showing the "clubs" with central fil-
aments at the margin. The general structure of the colony is
shown also. From an abscess in the heart in a human case.
X750.
The pathological significance of the granules in the
lesions of the disease was first clearly shown by
Bollinger in 1877, although their presence had been
noted previously by several observers whose work was
incomplete and did not receive general recognition.
Bollinger regarded the granules as growths of a fungus
and as the essential cause of the disease. Harz, a bota-
nist, confirmed Bollinger's ideas of their fungous nature
and called the organism ''Actinomyces bovis," a
name that has clung to it ever since. The disease
in man was first recognized and identified as due to
the same cause as that found in the disease in cattle
by Ponfick a short time after Bollinger's publication.
The granules, however, had been seen in a suppura-
tive process in the neighborhood of the vertebrae in
man by Langenbeck in 1845, and had been described
and figured by Lebert in his " Atlas of Pathological
Anatomy," published in 1856.
Many untrustworthy observations have been
published concerning the cultural peculiarities of
Actinomyces bovis. It is commonly stated in text-
books that culture methods have shown that various
pathogenic species of this parasite are known, but
the writer considers that the observations upon
which these statements are based are open to serious
question.
It is the writer's opinion based upon his own obser-
vations and those of others, that but one species of
Actinomyces is the specific infectious agent of actinomy-
cosis. This microorganism was first described by Woltf
and Israel in 1891 and has been isolated from many
cases of the disease since thai time l>y various workers
[vide V. Harbitz and N li. Grondahl, Am. ./. Med. Sci.,
September, 1911). It grows on certain of the ordinary
culture media in the form of masses or colonies of
closely [lacked branching filaments resembling its
colonies in the tissues. It grows best al body tem-
perature but does not grow at all at ordinary tem-
peratures. The characteristic "clubs" may be de
veloped in colonies placed in sterile blood serum, as
has been shown by the writer.
By the inoculation of guinea-pigs and rabbits in
the peritoneal cavity with cultures of the micro-
organism, nodular lesions may be produced which
have the characteristic microscopical appearances of
the lesions of actinomycosis and the inoculated cul-
ture material forms the characteristic "club-" bearing
colonies or granules. It is not known whether the
disease can be produced experimentally in cattle and
other animals.
This species of branching microorganism has been
confused with certain other similar microorganisms
which are widely distributed in the outer world and
some of which occasionally have been found in
inflammatory processes. These differ from it so
markedly in certain ways that the writer thinks
that the}' should be classed in a separate genus, and
that cases of infection by them should not be called
actinomycosis.
Fig. 34. — A Cover-glass Preparation Made from a Granule.
Some rods and branching filaments in association with pus
cell are shown. X 1,000.
The most frequent seat of primary actinomycosis in
man is the tissues about the buccal cavity and the
neck. Primary actinomycosis of these parts forms
more than half of all the recorded cases. Next_ in
frequency is primary actinomycosis of the digestive
tract and of the lungs. Primary actinomycosis of the
outer skin, exclusive of the skin of the face and neck,
is less frequent. Various cases have also been recorded
of actinomycosis of various organs, including the brain,
105
Acromegaly
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
without any demonstrable primary lesion in the situa-
tions above mentioned.
The infecting organism is probably frequently
carried into the tissues along with foreign bodies,
especially such as occur in food material in the ease
of cattle. The not infrequent finding of such foreign
bodies in or near the lesions of the disease, and the
observations of the increase of the disease in herds of
cattle when a change has been made in their food, as
also the very frequent localization in the neighbor-
US
. ■'•<
Fig. 35. — Section of a Portion of an Actinomycotic Lesion in
the Liver of the Same Case as That Mentioned in Fig. 29. The
abscess, containing a "colony" or "granule," and the surround-
ing connective-tissue growth extending into the liver sub-
stance, are shown. The "colony" appears as a rounded, dark
mass in the right upper quadrant of the figure. Low magnifying
power.
hood of the mouth, pharynx, etc., support this idea.
The facts that it does not grow at the ordinary tem-
perature of the air but best at body temperature and
that no one has ever satisfactorily demonstrated its
occurrence outside of the body, suggest that it is a
natural inhabitant of the gastrointestinal tract as are
certain of the pathogenic bacteria such as the pneu-
mococcus. The demonstration by F. T. Lord of the
frequent occurrence in carious teeth and in tonsillar
crypts of microorganisms very closely resembling it,
is strongly in favor of this view. The widely accepted
teaching that its natural habitat is on grains and
grasses is based on faulty knowledge of its biological
characters and is erroneous. There is no satisfactory
evidence that the infection may be transmitted from
animals to man or from one individual to another.
Actinomycosis in man is distinguished from the
disease in cattle not only by a less extensive new
formation of connective tissue, but also by its greater
tendency to the formation of fistula? and sinuses, by
which the disease may extend widely from one organ
to another. Such sinuses may extend from the tissues
about the mouth or pharyngeal cavities deeply into
the thorax and along the spinal column (prevertebral
phlegmon). In actinomycosis of the lungs fistula)
may perforate the chest wall or go through the dia-
phragm into the abdominal cavity. In actinomycosis
of the intestines fistulae may form which usually perfo-
rate the anterior abdominal wall; they may, however,
extend through the lumbar region or into the rectum
or bladder. The disease may also extend metastat-
ically through invasion of the blood stream by the
organism, and in this way various organs at a distance,
such as the heart, brain, kidneys, etc., may become
the seat of the disease. Only rarely does it spread by
the way of the lymphatics. Secondary infections
with pyogenetic cocci may occur.
The clinical course and prognosis of the disease
depend upon its extent and localization, and upon the
occurrence of secondary infections with the pyogenic
cocci. The last mentioned is an unfavorable com-
plication. In extensive involvement of internal
organs there may be fever and marked disturbance of
nutrition. The cases in which it is localized about the
buccal cavity or neck may be cured by surgical treat-
ment, but recurrences after apparent cures are
frequent. The bones of the jaw are rarely affected in
man. The occurrence, in the soft parts of the neck
or cheek near the jaw, of hard swellings which have
arisen painlessly and present a fluctuating or suppu-
rating focus, should excite suspicion of actinomycosis.
Actinomycosis of the lungs in general resembles
chronic pulmonary tuberculosis. The affection may
last for months or years. It is characterized by cough,
■ ■ -
^»" V y ;
■T&t- ^£ jE» -* &$*?^£t» ,•$& ' ,
Fig. 36. — A Colony of Actinomyces in a Section of the Same
Lesion as in Fig. 29. This is a colony composed of filaments and
hyaline substance. There are no "clubs." X 500.
by much sputum, which is often fetid or bloody, and
by marked pains in the breast and back. There are
also irregular fever and progressive emaciation.
Fistula? perforating the chest wall and involving the
sternum or ribs are not infrequent. In this the disease
differs radically from tuberculosis of the lungs. The
prognosis is generally bad. Remissions with appear-
ances of healing occur. The process may be localized
in any part of the lungs. It usually appears as small
abscesses or bronchopneumonia patches, from which
106
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Active Constituents of Plants
cavities may be formed accompanied by new growth
of connective tissue.
Actinomycosis of the intestines is characterized by
extensive induration due to a marked development of
peritoneal adhesions and to the extension of the proc-
ess to the abdominal wall and neighboring organs.
\, before mentioned, the tendency to the formation of
the fistula' is marked. Metastatic involvement of the
liver is not unusual. The prognosis must be regarded
as unfavorable in general.
Actinomycosis of the skin, according to Leser
(Archil* f. klin. Chir., 1899, xxxix.), may appear as a
circumscribed ulcerated lesion or as a nodular forma-
tion with central cicatrizations. The subcutaneous
tissue may also be affected and a chronic phlegmonous
condition be produced.
I ine of the forms of the disease known as "Madura
foot" is very probably actinomycosis of the part.
This is the so-called "white" or "ochroid" variety, in
which the characteristic granules in the lesions are of
this color. The "black" or "melanoid" variety of
"Madura foot" is due to an altogether different
vegetable parasite, which is a hyphomycete (Wright:
Transactions of the Association of American Physi-
cians, 1S9S, Journal of Experimental Medicine, vol.
Hi., 1898).
The diagnosis of actinomycosis is made by finding
the characteristic granules or colonies of the organism
in the lesions or in the discharges from the same.
These in some instances may be so obscure as to escape
observation with the naked eye. Microscopic exami-
nation is necessary to distinguish the colonies or
granules from small pieces of necrotic tissue and masses
of pus cells. The pus or suspected material should be
spread on a piece of glass. In this way the granules
will be more easily seen. In actinomycosis of the
lungs the organism may be found in the sputa and in
the discharges from fistulas in the wall of the thorax.
In the sputum the parasite is to be distinguished from
the common leptothrix of the mouth by the fact that
the filaments of the latter are larger, straighter, and
thicker and do not branch as do the filaments of
actinomycosis. The leptothrix filaments are also
frequently adherent to epithelial cells.
The treatment of actinomycosis should be operative
if the extent of the disease admits of it.
In internal treatment good results are said to have
been obtained from the use of potassium iodide.
The photographs which accompany this article were made by Mr.
L. S. Brown and the writer, in the Clinico-Pathological Laboratory
of the Massachusetts General Hospital.
James Homer Wright.
Actinomyxida. — An order of protozoans in the
class Sporozoa. These animals consist of a double
cellular envelope, three polar capsules, and eight
spores arranged in ternary symmetry. There are
four genera, mostly parasitic in annelid worms.
See Protozoa. A. S. P.
Active Constituents of Plants. — If this term were
strictly interpreted, we should omit from consideration
all but those constituents which produce positive
physiological effects, other than nutritive, upon the
animal system. As this treatment would exclude
some substances having important medical and phar-
maceutical relations, especially the latter, it is deemed
better to consider briefly all plant constituents which
affect the properties or uses of drugs or medicines.
_ Of the nutrients proper, the albuminoids may be
dismissed as of neither medicinal nor pharmaceutical
importance in the department of materia medica.
The sugars, inulin, starch, and cellulose, as well as the
more important plant acids, are considered in their
respective alphabetical order.
The other principles of interest to us may be
conveniently divided into the inorganic and the
organic.
The inorganics from this source are not treated as
of importance in tin- modern materia medica. The
vegetable compounds of iron, being readily assimi-
lated are probably worthy of much more study and
rational employment than has been accorded thorn
heretofore. Sea, weeds have long been a well-known
source of iodine, ami some vegetable drugs apparently
owe their properties largely to this element. For
the rest, the value of the inorganics in drugs depends
chiefly upon the presence, especially in such fruits as
prunes and tamarinds, of the well-known laxatives
salts, the properties of which do not differ from
those of inorganic origin. It is possible to obtain
important cutaneous stimulant effects from the use
of many vegetable substances rich in needles of cal-
cium oxalate, although the fact has never been duly
appreciated.
The organic constituents which here require atten-
tion are the vegetable acids, gums, fixed oils, resins,
volatile oils, amaroids, glucosides, alkaloids, and en-
zymes, together with such mixtures as oleoresins,
gum-resins, and balsams.
Vegetable Acids. — The number of vegetable acids
which have been extracted from plants is very great,
though only a few are found widely distributed among
different plants. In the plant they serve a variety of
useful purposes. Some of them, at least, act as
reserve foods, being manufactured during darkness
and consumed in the light, while the reverse is true of
starch. They combine with organic and inorganic
bases, which are thus rendered soluble and trans-
portable. They render many fruits more palatable,
thus influencing dissemination, and, on the other
hand and in other cases, by their irritating or anti-
septic properties they protect the plant against its
enemies. Those which are of a resinous nature are
thus particularly useful in preventing fermentation
and decay (see Resins). Another class form an
essential element in the composition of fats and are
known as fatty acids (see Fixed Oils). Some of the
vegetable acids, as tannic, citric, benzoic, and hydro-
cyanic, are of direct use as medicinal agents, while
others are of pharmaceutical interest, as influencing
the extraction of the associated .substances. It has
been claimed in numerous instances that a basic
organic substance is more efficient when administered
in combination with its iiatural acid. Many of the
natural compounds of these acids are with the
inorganic constituents, and it is these salts which
chiefly render some fruits and vegetables laxative.
The antiseptic properties which render many acids
of value to the plant are made to render a similar
service to man.
The acid properties of the vegetable acids are much
weaker than those of the inorganic acids, so that they
yield up their bases to the latter. They are also less
corrosive and irritating than the latter, and they often
cannot perform the same service in digestion. Taken
continuously or in excess, they can impair digestion
or cause gastritis, and they are supposed to favor a
rheumatic diathesis. Their salts are commonly more
soluble than those of the inorganic acids. Their in-
compatibilities are in general the same as those of
the latter.
Gums are supposed to exist as waste substances in
the plant. They usually form in successive layers
upon the inside of the cell wall — the process known to
botanists as "mucilaginous degeneration." While
these statements are true of those gums which are
collected as such for medical and pharmaceutical
uses, another class, occurring in such drugs as
althaea, apparently act as reserve foods. These are of
interest as affecting pharmaceutically the prepara-
tions of drugs. The gums are insipid, insoluble in
alcohol or ether, but soluble in water to form a
107
Active Constituents of Plants
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
mucilage or an adhesive jelly. They differ in their
precipitation tests, but are mostly precipitated by
lead acetate and by alcohol. Their presence in an
alkaloidal solution will very often prevent the pre-
cipitation of the latter by tannin and by weak solu-
tions of metallic salts. Chemically, the gums are
compounds of special acids with potassium, calcium,
and magnesium. Medicinally the gums are inert, but
they serve to form a protective covering in many
cases, thus guarding against irritation, as in corrosive
poisoning. When used externally for this purpose,
some antiseptic substance should be added. Muci-
laginous substances are highly prized in the making
of poultices, because of their marked power to retain
heat and moisture. Here, also, it is desirable to add
an antiseptic.
Peclosc, the mucilage-like or gelatinous constituent
of such fruits as apples and pears, and of such vege-
tables as turnips and beets, acts pharmaceutically
like mucilage, being soluble in aqueous extracts, but
precipitated upon the addition of alcohol.
The gelatinous principle of sea weeds shares the
properties of gum and pectose, and exists in very large
percentage.
Fixed oils, or fats, as those oils are called which are
solid at ordinary temperatures, are compounds of
special acids, known as fatty acids, with glycerin.
From the names of these compounds those of the
acids are derived, as oleic acid from "olein," stearic
acid from "stearin," palmitic acid from "palmilin."
Many fats are mixtures of such compounds. In the
plant, fats are stored in parenchymatic tissue in the
cell cavity. As they are reserve foods, of special use
in the developing embryo, we find them specially
characteristic of seeds, stored in both endosperm and
embryo. They have a characteristically smooth
feeling to the touch, are not volatile or inflammable,
but combustible, insoluble in water, rarely soluble in
alcohol, and then but partly so (see Castor and Croton
Oils), but are soluble in volatile oils, ether, and chloro-
form. Heated with or kept mixed with alkalies, they
are decomposed into their glycerin, which is left free,
and their acid, which unites with the alkali to form
soap, the process being known as "saponification."
On exposure to the atmosphere, they undergo a
peculiar decomposition known as rancidity, giving
them a very disagreeable odor and taste. Physiolog-
ically, they are important nutrients, of exceptional
value because of their ready absorbability through
the skin, especially when rubbed upon it. They are
not dialyzable, but by the aid of an albuminous
substance and of gum they are resolved into an
extremely finely divided state of suspension known as
an "emulsion," and, more or less of this change taking
place in the intestine, they can then become absorbed.
They act as protectives, and, by their lubricating and
softening power, as laxatives, whether taken internally
or per rectum. It has been suggested that if taken
in large quantities, the glycerin set free by their
saponification in the duodenum acts as a laxative
also.
They readily dissolve a great number of substances,
and become thus of the greatest use pharmaceutically,
as vehicles. This use is the more important because
of their great absorbability, which favors the absorp-
tion of many dissolved medicinal substances used
externally and internally. This property has to be
considered in poisoning, as some poisonous substances
not naturally absorbable from the intestine may be
so under their influence. Fats are naturally destruc-
tive to insect life, apparently by clogging up their
breathing apparatus. They therefore exert an
important action as parasiticides and increase the
activity of other agents of this class. For similar
reasons, they are efficacious in destroying ascarides.
The medicinal effect proper of fixed oils is very
slight, if we except a few like castor and croton oils,
which are apparently complex substances and contain
108
an irritating element. The same is probably true of
toxicodendrol, the poisonous fat of poison ivy and
its relatives.
Resins. — These are in some respects like the fats,
in others like the volatile oils. They are solid, non-
volatile and non-inflammable, but fusible and com-
bustible. They are insoluble in water, but most
readily soluble in volatile oils; frequently also in
alcohol, fixed oils, ether, and chloroform. They are
acid in nature and are saponified by alkalies, giving
us a series of resin soaps. Nitric acid converts them
into a peculiar substance resembling tannin. They
are apparently, at least for the most part, waste
substances in the plant, which transports them
through its tissues dissolved in volatile oils, as liquid
oleoresins, in which form they are stored in special
lacuna 1 , ducts, or tubes. They are of use to the plant
by rendering its food storage parts antiseptic and
disagreeable, or even dangerous, to animals eating
them. Pharmaceutically, the resins are very trouble-
some, as they are dissolved in the alcohol in the
extraction of many drugs, and are then most easily
precipitated upon the addition of water, and often of
acid substances. As to their medicinal properties
and uses, the resins, by warming, become adhesive
and have numerous and important uses depending
upon this property. Those which are little irritating
can be used as protectives, upon the evaporation of
their solutions painted upon the surface. They are
more or less antiseptic; less so than volatile oils.
They are usually more or less irritant, many being
thus available as counter-irritants. One class of
them exhibit this irritating property especially in the
intestine, and become purgative, some very power-
fully so. Among these may be mentioned those of
jalap, scammony, podophyllum, leptandra, iris, and
euonymus. Preparations of such drugs should be
thoroughly subdivided through an excipient, so that
no large particle shall lodge in a pocket of intestine
and produce undue irritation.
Gum-resins are merely mixtures of gum with resin,
which adapts them very well to being used in the form
of emulsions. Not only do the relative percentages
of gum and resin vary widely in different gum-resin-,
but the percentage is quite variable in different lots
of the same. The activity is, of course, proportional
to the percentage of resin. Important gum-resins
are myrrh, asafetida, ammoniac, elemi, galbanura,
and gamboge. They occur also in many drugs, such
as sumbul, angelica, parsley, and lovage. Volatile
oil is a very common constituent of gum-resins.
Volatile Oils. — For the sake of long custom and
convenience, these are treated as a class of active
constituents, although the idea is not a scientific one.
They are in reality mixtures which are very indefinite
in kind, as well as in degree. The name may without
impropriety be extended to all volatile and aromatic
constituents of plants. They consist mostly of one
or more oxygenated compounds mixed with one or
more hydrocarbons, usually terpenes. Of these, the
former is commonly the active one. Since volatile
oils are rather irregular in the relative amounts of the
active and the inactive portions, and also highly
subject to adulteration, which is very difficult of
detection, the use of {he active constituents, the
purity of which is readily ascertained, is much prefer-
able to that of the oil. Doubtless such use will
extend as these facts become more generally appre-
ciated, and this result will be hastened by a more
common custom of regarding and speaking of these
oils as indefinite and irregular mixtures, a custom
which is carefully followed in this work. Their
chief use to the plant is perhaps as solvents of other
constituents. Their nutritive relations are not well
known, and if they were, they could not be easily
defined, owing to their variable chemical nature.
Their fragrant properties are undoubtedly of value in
indirect ways, such as attracting insects. Their
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Active Constituents of Plants
antiseptic properties and the obnoxious character of
many of them to some animals undoubtedly serve a
protective purpose. They may be found in any part
of the plant, perhaps most frequently in the seed.
They may often be seen in the leaf, in the form of
pellucid dots, when viewed against the light. Owing
to their volatile nature, drugs which depend upon
their presence are very liable to deteriorate on being
kept, and unusual care has to be exercised in their
preparation and preservation. On this account they
are usually dried in the shade.
These substances leave no greasy stain on paper.
They are light, volatile, aromatic, and inflammable.
They dissolve in water sufficiently to render the latter
aromatic and somewhat medicinal. They are readily
soluble in alcohol, fixed oils, and glycerin, and act as
solvents of resins, fats, and many medicinal sub-
stances. Aside from their medicinal properties, they
have a wide use within as well as outside the bounda-
ries of pharmacy, in odorizing and flavoring. In their
physiological and medicinal properties, volatile oils
agree in some characters and vary greatly in others,
so that they fall naturally into different therapeutical
classes. Their local stimulant properties are very
general. This makes them counterirritant; some
of them, like oil of turpentine, very powerfully so,
especially when confined under an air-tight covering.
Others which are strongly counterirritant are those
of mustard, amber, erigeron, cinnamon, cloves, and
camphor. The irritating effect of some volatile oils
is followed by a local anesthesia, occasionally quite
strong, as in the case of menthol and oil of cloves. In
line with their counterirritant action may be con-
sidered their stomachic and carminative properties,
which are perhaps more general than any others.
Here again certain oils, especially those of the
families Umbelliferse (anise, fennel, caraway, etc.)
and LabiataB (mint, thyme, pennyroyal, etc.), excel
others. As to their gastric effects, it is to be noted
that their presence with the digesting food mass tends
to inhibit the process. This action also is greater in
the ease of certain oils, and is said to be quite wanting
in that of oil of peppermint, which is thus an excep-
tionally valuable carminative. Aside from their
intestinal effects in stimulating secretion and peris-
talsis, they exert a strong action in stimulating the
sympathetic nerves, thus overcoming the excessive
relaxation upon which various forms of serous
diarrhea depend in whole or in part. This action
effects a final result similar to that of the true astrin-
gents, and makes a combination of volatile oils and
astringents highly effective. Their carminative prop-
erties render them of great use in combining with
griping purgatives. Their antiseptic properties are
quite general and strong, though they vary greatly
in degree in the different oils. They act not only as
direct germicides, but they stimulate the cells them-
selves in their fight against the foreign organisms.
In general, the oils of the family Jlyrtacese and many
of those of the Lauraeeae are thus antiseptic, as are
those of birch, wintergreen, sandal, copaiba, and
thyme. Oil of cinnamon is probably the most power-
fully antiseptic of any, eucalyptol, if pure, perhaps
standing next. Volatile oils agree in their strongly
diffusive properties, on account of which their
systemic effects come on quickly. If the vapor is con-
fined, they are quickly absorbed, even through the
skin, as they are by inhalation. They then become
systemic stimulants, though overdoses may act as
depressing poisons. This stimulation makes them
antispasmodic in many cases. Elimination begins as
promptly as absorption, and their local effects are
again seen at the point of excretion. They vary in
their selection of the channel of excretion. Some,
like eucalyptus, copaiba, and cubebs, have a tendency
toward the respiratory mucous membrane and become
important stimulating and antiseptic expectorants.
Others, like sandal, copaiba, cubebs, birch, winter-
green, turpentine, juniper, savin, tansy, and buchu,
have an affinity for the kidney, and become stimulat-
ing (to irritating) and antiseptic diuretics, some
important antiblennorrhagics. A few, like oil of
chenopodium, are powerfully anthelmintic. Those
especially adapted to perfuming and flavoring may
be named as orange, lemon, bergamot, rose, bay,
bitter almond, citronella, lavender, nutmeg, and
cinnamon.
Oleoresins, being resins dissolved in volatile oils,
naturally combine their properties. They very
often, however, contain a third substance in addition,
and this may give to them specific properties distinct
from those of either the oil or the resin, and in some
cases exceedingly powerful. The most important
oleoresins in use are those of the male fern, capsicum,
ginger, copaiba, black pepper, cubeb, turpentine, and
hops. Other important oleoresins contained in drugs
but not commonly isolated for use are those of
calamus, iris, inula, prickly ash, mezereum, and
stillingia.
Balsams are liquid or solid oleoresins depending in
part for their properties upon the contained benzoic
or cinnamic acid, or both. Their properties are
readily deduced from this composition. The principal
ones are benzoin, dragons'-blood, tolu, and peru.
Copaiba, though commonly so called, is in no sense
a balsam.
Amaroids (their Latin names ending in "inum,"
their English in "in"). — This term has been proposed
for those bitter extractives of plants which, having a
definite chemical composition, do not belong to any
of the recognized classes of proximate principles.
While not highly scientific, the term is often very
convenient.
Glucosides (their Latin names ending in "inum,"
their English in "in"). — These are compounds of
glucose with some other substance, the latter class
covering a wide range and occasionally containing
nitrogen. They are especially numerous in the
Liliaeeae, the Apocynaceae, and some other families,
but are very widely distributed elsewhere. They
act as reserve foods to the plant, and are therefore
more abundant in those parts which act as storage
reservoirs, and at the close of the growing period.
The bodies associated with the glucose are very fre-
quently poisonous or obnoxious, subserving thus a
protective function, while the glucoside in this way
also acts as a protective of other parts or constituents.
Owing to the readiness with which they are decom-
posed (in the plant by special enzymes), their nutri-
tious portion is readily available and at once assim-
ilable. For the same reason they constitute very
unstable medicinal agents and, like drugs contain
ing them, require to be treated with great care in
pharmaceutical operations. They are mostly soluble
in both water and alcohol. Some, like amygdalin,
are inactive until such decomposition occurs, while
others may be thus rendered inactive. Such decom-
position is effected by the action of dilute acids,
especially if heated, by hot water, and by the pro-
longed action of alkalies. They are mostly precipi-
tated by tannin and lead acetate, and very frequently
by mercuric chloride. They are usually very ener-
getic physiological agents, but their actions are too
diverse for generalization. It may be said, however,
that they are as a class more disposed to act upon the
circulation than in any other one direction. Several
of the glucosides are widely distributed among differ-
ent plants, and, exhibiting variations among them-
selves, may be regarded as forming sub-classes. Tannin
or tannic acid (elsewhere considered) is technically a,
glucoside, but differs so much from the others that it
is difficult to regard it as such. The saponin group (see
Saponin) have also distinct and important properties.
The chief interest in glucosides as a group centers
in their incompatibilities, as indicated above. The
principal glucosidal drugs are as follows:
109
Active Constituents of Plants
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Amygdalin.
Emodin
or relatives.
Saponin or a similar
body.
Bitter almonds,
Peach seeds,
Wild cherry.
Cherry laurel,
Peach, plum, and cherry leaves, etc.,
Buckthorn, cascara sagrada, and other
species of Rhamnus,
Aloes,
Rhubarb,
Srnna,
Apocynum — apocynin and apocynein.
Convallaria — convallamarin and couvalhirin
Digitalis — digitalis and others.
Dulcamara — dulcamarin.
Phytolacca — phytolaccin.
Piper — piperin.
Soap bark, ^
Soap root,
Euonymus,
Senega,
Caulophyllum and others, J
Squill — scillin and others.
Black mustard — sinigrin.
White mustard — sinalbin.
Strophanthus — strophanthiu and strophanthidin.
Alkaloids (their English names ending in i/ic, their
Latin in ina, although it is now proposed to abolish
this most convenient distinction and to spell them
with a final in, a practice actually now in use to a
great extent in Germany). — These are nitrogenized
organic bases, occurring in plants (also in animals)
usually, if not always, as waste products, and in
combination with acids. Although commonly waste
products from a nutritive standpoint, they perform
the most useful purposes in the plant economy.
Usually poisonous and intensely bitter, they often
serve to protect those parts of the plant which are
used for food storage from consumption by animals.
They may occur in any part of the plant, but are most
often found in the seeds, leaves, and bark of both
stem and root. They are characteristically common
in some families, like the Rubiacea?, while from others,
like the Compositae, the largest of all families, they
are nearly or quite absent. Alkaloids are usually
crystallizable. Many were formerly known only in
a liquid or amorphous state, but many of these, when
thoroughly purified, have since been found crystalliza-
ble. Those which are not so, yet usually yield salts
which are. Some alkaloids are volatile. Many
alkaloids, while acting as proximate principles them-
selves, readily separate, either in the plant by natural
processes or under laboratory treatment, into other
alkaloids and some associated substance, so that
series of them are formed. These are necessarily of
unstable chemical composition. In some cases, an
alkaloid will result from the decomposition of a
glucoside, as solanidine from solanin. Alkaloids
differ greatly in solubility, but the strong tendency is
toward solubility in alcohol and insolubility in water,
while of their salts the reverse is true. A few which
vary markedly from this rule are enumerated below.
These bodies show their basic nature by turning red
litmus paper blue, but more especially by uniting
with acids to form salts. They do this without dis-
placing the hydrogen of the acid, as metals do. They
vary greatly in the intensity of this affinity for acids,
some, like caffeine, being very feebly basic. In some
cases we are even uncertain whether they can properly
be classed as alkaloids. Alkaloids are as a class prob-
ably the most active physiological constituents of
plants. Their actions are so dissimilar that they can-
not be at all generalized, except to say that by their
almost invariably bitter taste they act, in the absence
of other antagonistic properties, as bitter stomachics
and tonics. In many cases two alkaloids, the one a
derivative of the other, occur in the same plant, with
antagonistic properties. Alkaloids converted into
methyl compounds are thus usually antagonistic to
those so yielding them.
It is of the utmost importance that the prescriber
should keep in mind the incompatibilities of alkaloids.
Some of these incompatibilities are innocent, or can
even be utilized in important ways. Thus the addi-
tion of acids converts alkaloids into salts, which may
then be dissolved in water, the physiological prop-
erties being usually unaltered. These salts differ
greatly in solubility. In most cases acetates are the
most soluble, hydrochlorides next, and sulphates the
least. In other eases, a physical incompatibility
exists, so that the alkaloid is precipitated. Owing
to their energetic action such a result is exceedingly
dangerous, the first portions of the medicine being
ineffective, the last portions poisonous. In this
connection it may be stated that all salts which will
turn red litmus paper blue will precipitate aqueous
or weak alcoholic solutions of alkaloidal salts. Svich
solutions are almost always precipitated by alkali
hydrates, soluble salicylates, benzoates, iodides, and
bromides, tannic acid, chlorides of mercury and of
gold. The presence of. mucilage or hydrated starch
will sometimes prevent this precipitation, especially
th.it by tannic acid. In other cases incompatibility
involves the destruction of the alkaloid. Oxidizing
agents will usually accomplish this result, except when
they enter into a saline combination. This fact is
utilized in some cases of antidotal treatment, as of
morphine by potassium permanganate. Chloral
hydrate is incompatible with many alkaloids, forming
a soft or liquid mass. The solanaceous alkaloids,
of which atropine is the type, as well as aconitine and
confine, are decomposed by alkalies. The strength
of many drugs can be readily standardized by de-
termining the average percentage of alkaloid con-
tained.
The principal drugs which depend upon alkaloids
for their activity are the following:
Aconite (aconitine).
Aspidosperma (aspidospermine, a mixture of six).
Belladonna (atropine).
Berberis (berberine).
Coffee (caffeine).
Cannabis indica (?).
Chelidonium (chelerythrine and chelidonine).
Cinchona (quinine, cinchonine, and cinchonidine,
chiefly).
Coca (cocaine).
Colchicum (colchicine).
Conium (confine).
Ergot (?).
Gelsemium (gelsemine and gelseminine).
Granatum (pelletierine).
Guarana (caffeine).
Humulus (trimethylamine, partly).
Hydrastis (berberine, hydrastine, and [artificial]
hydras tinine).
Hyoscyamus (hyoscyamine and hyoscine).
Ipecac (emetine and cephaeline).
Lobelia (lobeline).
Menispermum (berberine and menispine).
Nux vomica (strychnine and brucine).
Opium (many, the principal being morphine,
codeine, narcotine, narceine, and the artificial deriva-
tives apomorphine, apocodcine, and heroine).
Physostigma (physostigmine or eserine).
Pilocarpus (pilocarpine and pilocarpidine).
Piper (piperidine, partly).
Sanguinaria (sanguinarine, chiefly).
Seoparius (sparteine, partly).
Spigelia (spigeline).
Staphisagria (four alkaloids, the properties not
w r ell differentiated).
Stramonium (daturine, a mixture).
Tobacco (nicotine).
Veratrum (veratrine, a mixture).
Important alkaloids which are soluble in water
are confine, codeine, caffeine, nicotine, atropine
(nearly four grains to the ounce), pelletierine, lobeline
(considerably).
110
REFERENCE HANDBOOK OF TFIE MEDICAL SCIENCES
Acupuncture
Alkaloids which, with their salts, are little solu-
ble in ordinary alkaloklal solvents arc morphine,
trigonelline, etc.
Enzymes, 'rinse are vegetable ferments, acting
like the animal ferments, pepsin, trypsin, etc., in de-
composing or digesting nutrients for the use of the
plant. There are different classes of them, each act-
ing upon a certain class of nutrients. The diastases
acting on starch have become extensively utilized in
medicine, but most enzymes have not. One class has
for its function the decomposition of glucosides,
another the digestion of amaroids, another acts
upon certain gums. Like pepsin and others of its
Class, the vegetable enzymes cannot be extracted
in a pure condition nor can their composition be
determined. II. II. Rusby.
Actuarius, John. — Very little is known about the
life of Actuarius beyond the following few facts:
He practised medicine during the thirteenth or
fourteenth century, and was attached to the Court
at Constantinople. He wrote treatises on the princi-
ples of therapeutics, on the composition of various
remedial agents, and on the urine as an aid to diagno-
sis. He is systematic in his manner of treating these
subjects and his style of writing is clear. Among
Greek medical authors he is the first to mention the
milder purgatives like cassia, manna, senna, etc.
Editions of his treatise on urine were published in
Venice (1519), Basle (1520), Paris (1522), and
Utrecht (1(170); and a collection of his entire works,
in two volumes, was issued in Paris in 1556.
A. H. B.
Acupressure. — A procedure devised by Sir J. Y.
Simpson, of Edinburgh, in 1859, for arresting hemor-
rhage from a vessel by means of pressure made bj r a
needle transfixed through the neighboring tissues.
The flow of blood through an artery may be arrested
in any one of three ways. The vessel may be simply
compressed between the needle and some firm tissue,
as a bone or the in-
tegument, as repre-
sented in Figs. 37 and
38. When the artery
lies embedded in a
soft tissue, as in a
divided muscle, its
occlusion may be ac-
complished by tor-
sion. This is done by-
introducing the nee-
dle on one side of the
vessel, and, when it
has passed through a portion of the tissue, twisting
it around the artery, and fixing its point in the tissue
in a direction opposite to that in which it was first
entered; or the artery need not be included in the
bight of the needle, but the latter may be turned
before reaching the vessel, the latter then being com-
pressed by the elastic force of the twisted tissues
acting upon the needle.
A third method, applica-
ble also in cases in which
the vessel lies in a yield-
ing tissue, consists in
pressure between the
needle and a slip-knot.
The needle is passed
beneath the artery, and
a loop of fine wire is slipped over its point, the
ends of the loop passing over the artery, and being
fastened by two or three turns over the shaft of the
needle (see Fig. 39). In the case of small vessels, the
needles may be withdrawn at the expiration of
twenty-four hours; but when large arterial trunks
are occluded, the pressure should be maintained for
forty-eight hours at least.
The advantages claimed for this method are: the
ease and rapidity with which the needles may be
applied, no delay being caused in the operation; the
absence of danger from Suppuration of the ends of the
divided vessels; and non-interlerenee with rapid clo-
sure of the wound, no inflammation being excited by
the presence of the needles in the tissues for so short
Fiq. 39.
a period of time. These advantages, however, are
less manifest at the present time, since the intro-
duction and general employment of antiseptic liga-
tures, and it is not likely that the procedure will ever
again enjoy the popularity which it at one time
possessed. T. L. S.
Acupuncture. — An operation which consists in the
introduction of needles into the body, either as a
means of giving exit to the fluid in edematous tissues
or for the relief of pain in neuralgia and muscular
rheumatism. It is a method in great vogue in China,
and is used by the physicians of that country not only
to assuage pain, but to promote reparative action in
ulcers and in the treatment of various other affections.
It is said to have been introduced into Europe from
China by the missionaries in the seventeenth century.
The instrument employed is a round polished needle,
having a cylindrical handle of sufficient size to permit
of its being readily manipulated by the fingers. It is
introduced into the tissues by a quick rotatory
movement, and is then left in situ for a number of
minutes, or even for an hour. Sometimes the inser-
tion of a single needle is sufficient to relieve the pain,
but ordinarily half a dozen or more are employed.
This little procedure may be practised almost pain-
lessly, and is sometimes wonderfully effective in con-
trolling neuralgic and rheumatic muscular pains. It
often fails, indeed, and it seems impossible to deter-
mine beforehand in what cases it will prove service-
able, but certainly no case of lumbago or sciatica
should be abandoned until acupuncture, as well as
the more ordinary remedies, has been tried. In
anasarca, when the scrotum and lower extremities
are distended with fluid, the patient may experience
comfort from a few punctures with a three-cornered
surgical needle. The operation should be practised
with caution, however, as it is apt to excite an ery-
sipelatous inflammation of the integument. In the
treatment of paralysis insulated needles are some-
times used as a means of introducing the electric
current into the deeper tissues. This procedure has
received the name of electropuncture.
There is another form of acupuncture, called Baun-
scheidtismus, which at one time enjoyed a great
popular reputation, and which even now is not very
infrequently employed. It was devised by Carl Baun-
scheidt, a German mechanic, who is said to have con-
ceived the idea from observing that the irritation
caused by the bites of insects afforded him consider-
able relief from the pain of an articular affection from
which he was suffering. The instrument employed
consists of a cylinder enclosing a button into which
are inserted from twenty to thirty short needles.
The open end of the cylinder is placed on the integu-
ment, and then by means of a handle the button with
needles attached is drawn up into the cylinder com- .
pressing a spiral spring: when the handle is released
the force of the spring impels the needles suddenly
111
Acupuncture
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
and sharply into the skin. The operation may rest
here or an irritating fluid, such as mustard water or
cajeput oil, may be applied to the punctures. This
is employed for the relief of neuralgia and musculai
pains, and often proves of very great service.
There is still another form of acupuncture, if such
There is <»
it can be called, though it is more nearly related to
hypodermic medication. It consists in the hypo-
dermic injection of pure water, and has received the
name of aquapuncture. Many superficial pains, even
though quite severe, may be relieved by this simple
procedure. That the relief thus obtained is not
merely the effect of imagination, is evidenced by the
fact that neuralgias of distant parts are not benefited
by aqueous injections, but in order to be effectual the
operation must be practised at a point as near as
possible to the seat of pain. The Schlerich method of
local anesthesia is a form of aquapuncture, the strength
of the cocaine solution commonly employed being in-
sufficient to account for the complete anesthesia pro-
duced. Aquapuncture has been employed in various
forms of neuralgia, in lumbago, and in painful func-
tional affections of the abdominal viscera. Bartholow
claimed to have obtained excellent results from the
injection of water into the substance of paralyzed and
atrophied muscles. From 2 to 4 c.c. (4 to 1 dram)
of fluid may be used for each injection, and the opera-
tion may be repeated if no relief is experienced at
the expiration of two or three minutes. (See also
Anesthesia, local.)
T. L. S.
Acystina. — A group established by Sambon to
include those protozoans in Hartmann's tribe Bmu-
cleata in which "the ookinete remains free and
does not become encysted." It includes two families:
HcemoproteidcB and Leucocytozoidce. See Protozoa.
A. to. x.
Adamantinoma.— This is a variety of neoplasm
rather frequently found in the lower jaw, and more
rarely in the upper. It develops from the remains
of the enamel-organs, hence its name, adaman-
tinoma, or adenoma adamaiitiiuim as it is sometimes
wrongly called, since it has nothing to do with glands.
It consists of cords and masses of epithelial cells
resembling in structure the fetal epithelial buds that
form the teeth. The stellate cells in the central
portion of these epithelial masses may form true
enamel, but they often degenerate and undergo
liquefaction, thus giving rise to the formation of
multiple cysts. When the cysts are large and
numerous the growth often assumes the character of
a multilocular cystoma. The tumor is essentially
benign and closely related to the odontoma with which
it may be associated. The most common site for
both of these neoplasms is at the angle of the lower
jaw in the neighborhood of the molar teeth. It is
probable that these neoplasms are both the result of
disturbance of development of the teeth. The writer
has seen a similar tumor replacing the hypophysis in
a case of dystrophia adiposogenitalis. In this loca-
tion the adamantinoma must be regarded as a teratoid
tumor arising from remains of the craniopharyngeal
duct. Aldred Scott Warthix.
Adams County Mineral Springs. — Adams County,
Ohio.
Post-office. — Mineral Springs, Ohio.
Access. — Via Cincinnati, Portsmouth and Vir-
ginia Railroad to Mineral Springs station, thence four
miles by carriage to Spring hotel and cottages. Con-
veyances can also be had at Rome (on the Ohio River)
for the Springs.
These springs, the medicinal properties of which
were recognized by the Indians, are two in number
and flow about sixty gallons of water hourly, having
a temperature of 56° F. They issue from the base
of a high hill and are surrounded by picturesque and
charming scenery. According to a partial analysis
by Prof. E. S. Wayne, the water of Spring No. 1 is
highly charged with gas and contains 205.35 grains
of sol'id matter per United States gallon, composed as
follows: Magnesium chloride, calcium chloride, cal-
cium sulphate, calcium carbonate, sodium chloride,
iron oxide, and iodine. The water may be classified
as a saline calcic with ferruginous properties.
Spring No.2. In- 1.000,000 Parts there are:
Magnesium sulphate 10S ■ U
Sodium sulphate 65.41
Calcium sulphate 56.00
Sodium chloride 16. *9
Potassium chloride 3 . 69
Ferrous carbonate trace.
Total mineral matter 250.00
Free acid as sulphuric 19.60
The accommodations for visitors are now very sat-
isfactory, the hotel having been enlarged and a num-
ber of cottages added. The location affords a pleasant
retreat for those who seek respite from the cares of
business or need the refreshing influences of rural
scenery and air. The water has long been used
by persons suffering from affections involving the
stomach, bowels, kidneys, and liver.
Emma. E. TA alker.
Adams, William. — Born in London, England, on
February, 1, 1820. He studied at Kings College, and
afterward held successively the following positions:
Pathological Prosector in St. Thomas' Hospital, in
1S42- Assistant Surgeon (in 1851) and, later (in 1857),
Surgeon in the Royal Orthopedic Hospital; Instruc-
tor in Surgery in tlie Grosvenor Place Medical School,
in 1854; Surgeon in the Great Northern Hospital, in
1S55- and Surgeon in the National Hospital for
Paralytics and Epileptics, in 1874. His death
occurred February 3, 1900.
Adams was a prolific contributor to medical liter-
ature The following are the titles of some of the more
important of his writings: " A Course of Lectures on
Orthopedic Surgery," 1S.55— 1858; "On the Repara-
tive Process in Human Tendons after Division, 1.S60;
"On the Pathology and Treatment of Club-foot
(awarded the Jackson Prize by the Royal College
of Surgeons in 1866); and "On the Treatment of
Dupuytren's Contraction of the Fingers, and on the
Obliteration of Depressed Cicatrices by Subcutaneous
Operations," 1879. A - H - B -
Adams, Sir William.— Born in Cornwall, England,
in 1700 He began the study of medicine under a
practitioner in Barnstaple and at the age of seventeen
went to London where he became a pupil of Sam
at the Moorfields Eye Hospital. After practising for
a time as an oculist he suddenly acquired fame by
the publication of a work on Egyptian ophthalmia,
which was then endemic in the British army in which
he advised treatment contrary to that followed by
Saunders and others connected with the London i.ye
Infirmary. This led to a polemic in which he accused
his opponents of attempting to prevent the rational
treatment of that disease. The quarrel made con-
siderable noise, but he triumphed and won the favor
of the Court, being appointed oculist to the prince
Regent, afterward George IV and to the latter a
brother the Duke of Sussex. He was later knighted
and the position of ophthalmologist to the Greenwi 1
Hospital for invalided soldiers and sailors was created
for him The members of the regular medical stan
112
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Adaptation
were however, incensed at this appointment and
.soon procured the abolition of the office. Adams
receiving a grant of £4,000 as compensation for his
discharge. Thereafter his life was uneventful and
was passed in the enjoyment of a large and lucrative
practice. A few years before his death, in order to
,,,,.,. i the conditions of a large legacy, he took the
name of his wife, Rawson. He died at Albemarle
In I ebruary, 1829. , . , . . _ t .
In addition to his polemical writings on Egyptian
ophthalmia, the most important of Adams' contri-
butions to medical literature are: "Practical Obser-
vations on Ectropion or Eversion of the Eyelids,
with the Description of a New Operation for the
(in,, of that Disease" (since known as Adams'
operation), 1*1-'; "A Practical Inquiry into the
Cause of the Frequent Failure of the Operation for
Depression," etc., 1817; "A Treatise on Artificial
Pupil," etc., 1819. T. L. S.
Adaptation. — If we think of life, as most of us do,
herently a process of adjustment of relations to
r relations, clearly adaptation is the most univer-
sal of vital events. A complete denotation of the
term for Medicine would comprise much of the chem-
istry, anatomy, and physiology underlying the whole
profession. Still, one thinks of adaptation more nat-
urally as an adjustment of structure to function or
to other structure than in the opposite phase of adap-
tation of function to structure. In other words, pur-
pose is the ultimate meaning of organism, the ever-
changing purpose expressed only in properly adapted
structure and for which indeed the structure exists.
Any other view seems to involve the thinker at once
or else ultimately, sooner or later, in a dilemma which
convicts the human mind, inherently and character-
istically rational, of irrationality. Function, then,
purposiveness, is properly considered primary to
structure, and adaptation becomes a series of changes
in protoplasm; and it is thus that the term is com-
monly understood.
The ulterior causes of organic adaptations we may
find set forth at any length almost in the discussions
of the determinants of evolution by the old-time Dar-
winians (selectionists) on the one hand and by the
mutationists (disciples of DeVries and Mendel) on
the other. Adaptations are at once the causes and
the results of this principle of unrollment or progress
which we designate as evolution. Many other re-
searchers than these of course have elaborated our
knowledge of the influences exerted on an organism
by environment, notably Buffon, Lamarck, Geoffrey,
while DeVarigny in his book called "Experimental
Evolution" has collected a large number of examples
of variation or adaptation. C. B. Davenport's " Ex-
perimental Morphology" discusses many of the char-
acteristic adaptative reactions of animals and plants,
while T. H. Morgan's "Evolution and Adaptation"
has an illuminating account of the most broadly bio-
logical relations of the theory of the subject we are
discussing. From the last-mentioned book we may
quote two of many useful paragraphs:
"In regard to the perpetuation of the advantages
gained by means of this power of adaptation" (for
medical science, one of the most salient aspects of the
subject), "it is clear in those cases in which the young
arc nourished during the embryonic life by the mother,
that, in this way, the young may be rendered im-
mune to a certain extent, and there are instances of
this sort recorded, especially in the case of some bac-
terial diseases. Whether this power can also be
transmitted through the egg, in those instances in
which the egg itself is set free and development takes
place outside the body, has not been shown. In any
case, the effect appears not to be a permanent one
and will wear off when the particular poison no longer
acts. It is improbable, therefore, that any permanent
contribution to the race could be gained in this way.
Vol. I.— S
Adaptations of this sort, while of the highest im-
portance to the individual, can have produced little
direct effect on the evolution of new forms, all hough
il may have been often of paramount importance to
the individuals to be able to adapt themselves, or
rather to become able to resist the effect of injurious
substances. The important fact in this connection
i- the wonderful latent power possessed by all animals.
So many, and of Mich different kind-, are the sub-
stances to which they may become immune, that it
is inconceivable that this property of the organism
could ever have been acquired through experience,
no matter how probable it may be made to appear
that this might have occurred in certain cases of fatal
bacterial diseases. And, if not. in so many other cases,
why prevent a special explanation for the lew case
How far-reaching and complex at once the relations
of adaptation appear to be, as we have already said,
far beyond all present explanation, is suggested in
the following sentences also from Morgans treatise,
it being noteworthy that they seem to express this
authority's opinion on this matter as well as that of
the writer whom he quotes: "Niigeli's wide experi-
ence with living plants" (protoplasm is one appar-
ently in alga and in man) "convinced him that there
is something in the organism over and beyond the
influence of the external world that causes organisms
to change; and we cannot afford, I think, to despise
his judgment on this point, although we need not
follow- him to the length of supposing that this inter-
nal influence is a 'force' driving the organism forward
in the direction of ever greater complexity. A more
moderate estimate would be that the organism often
changes through influences that appear to us to be
internal, and while some of the changes are merely
fluctuating or chance variations, there are others
that appear to be more limited in number, but perfectly
definite and permanent in character. It is the latter,
which, I believe, we can safely accredit to internal
factors, and which may be compared to Nageli's 'in-
ternal causes,' but this is far from assuming that these
changes are in the direction of greater completeness
or perfection, or that evolution would take place in-
dependently of the action of external agencies."
From this point of view adaptations with which the
medical man is most apt to be concerned (and when
is he not concerned with some or other adaptations!)
must be deemed as much determined from within,
perhaps in the inherent metabolism of the organism,
as from without in the immensely complicated physio-
chemimental environment. In other words, the
changes of an adaptive kind that occur in human
beings appear to be alan gebraic balance of energies
or at least tendencies without and within the person-
ality — forces acting upon but never wholly controlling
the bodily nature of man, in a broad sense.
Among the varieties of adaptation discussed by
Morgan (loc. cit.) are sex, instincts, form, symmetry,
degeneration, protective coloring, length of life,
secondary sexual organs, individual adjustments,
growth, atrophy, reactions to poisons, and regenera-
tion. In the broad range of practical medicine many
other phases of adaptation will doubtless occur to the
reader, most of them, but by no means all, useful to
the individual. Many of these adjustments to con-
ditions outside of the organism w : ould more naturally
be thought of perhaps as the "effects" of certain
"causes," yet at the same time obviously they are
steps taken by the self-protective living protoplasm
toward meeting new conditions. Thus, for example,
the undersize of underfed children, while properly a
result of too little food (and especially, perhaps, of too
little protein) results in fact in an adaptation to the
lack of sufficient food, a small, thin, weak inactive
individual requiring somewhat less nutriment than
one of the opposite characters of structure and habits.
This illustration has its chief interest, however, in
calling attention to the fact that adaptations are in
113
Adaptation
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
reality effects whose causes in the total coordination
of the living world often are far too complex to be
detailed or in any degree described in this present
early stage of human knowledge.
One conspicuous aspect of adaptation for our
immediate purpose, as elsewhere, is the advantagous-
ness to the individual of wide and ample powers of
adaptation to new conditions both useful and the
reverse. By having this efficiency in a high degree
the individual on the one hand can profit by favorable
conditions in the physio-chemi-mental environment
and, on the other hand, fail to suffer from or to
succumb to those effects that are unfavorable. Peo-
ple differ not a little in this respect, as is readily seen
in the various and varying immunity of some persons
and the susceptibility of others to infections. About
the precise adaptations of the organism to these
multivarious conditions we are of course just begin-
ning to learn a little something — but so far that little
certainly is not much. George V. N. Dearborn.
Addison, Thomas. — Born at Newcastle-on-Tyne,
England, in April, 1793. He received the degree of
Doctor of Medicine from the University of Edinburgh
in 1S15. Shortly afterward he was given the appoint-
ment of House Physician at Lock Hospital. About
1820 he was received as a pupil at Guy's Hospital,
London, and for thirty-seven years he retained a con-
nection with this institution in one capacity or an-
other, first (1824) as Assistant Physician; then next
(1827) as Instructor in Materia Medica; and finallv
(1S37) as full Physi-
cian and as a co-
lecturer with Bright
on the Practice of
Medicine. His dis-
covery of the disease
which bears his
name (" Addison's
disease") brought
him a world-wide ce-
lebrity. A master-
ful description of
this disease was pub-
lishcd by him in
1855, under the
title: "On the Con-
stitutional and
Local Effects of Dis-
ease of the Suprare-
nal Capsules," with
plates. Almost
equally meritorious are the papers on pneumonia, on
pneumonic phthisis and on phthisis, which he pub-
lished from time to time, in the Guy's Hospital Re-
ports. His death occurred at Brighton on June 29,
I860. A. H. B.
Addison Mineral Springs. — Washington County,
Maine.
Post-office. — Addison, Maine.
Access. — Via steamer from Portland. The spring
is two and a half miles distant from the railroad
station, Columbia Falls or Columbia Station on the
Washington County Railroad. There is a good road
to the spring. Hotel and private families accommo-
date visitors.
This spring is located in a charming hilly section
within one-quarter of a mile from an inlet of the
Atlantic and about one hundred feet above the ocean
level. The ocean is nine miles distant. The beauti-
ful Pleasant River is near by. The scenery in the
neighborhood is charming. The spring which is
boiling, is about five feet in diameter and four feet in
depth, and has a steady, voluminous, and rapid flow.
Tin' following analysis was made by Professor Hayes,
State Assayer and Chemist, Boston, Massachusetts.
v wi»W -•
Fig. 40. — Thomas Addison.
One United States Gallon Contains:
Potassium sulphate . 60 grain.
Sodium sulphate . 27 grain.
Calcium sulphate . 52 grain.
Sodium chloride 0.S9 grain.
Sodium bicarbonate . 44 grain.
Calcium bicarbonate 2.65 grains.
Magnesium bicarbonate 1.12 grains.
Iron bicarbonate 1 .65 grains.
Silica and alumina traces.
Total 8. 14 grains.
The gases present are principally nitrogen, oxygen,
and carbonic, acid with a little sulphureted hydrogen.
According to the classification adopted by Dr. James
K. Crook, this water is properly termed a light alkaline
chalybeate. It has been used with apparent benefit
in acid dyspepsia, renal congestion, skin affections,
and other conditions in which a mild antacid diuretic
is required. Emma E. Walker.
Addison's Anemia. — See Anemia, Pernicious.
Addison's Disease. — Synonyms. Bronzed Skin
Disease; Melasma Suprarenale. Of the above terms
the one adopted as the title is to be preferred, for
while the peculiar discoloration of the skin is not an
invariable characteristic of the affection, the credit
of Addison to the discovery of the disease called
by his name has never been called in question.
Definition. — A disease characterized by progres-
sive asthenia, digestive disorders, pain and tenderness
chiefly seated in the epigastric, hypochondriac, and
lumbar regions; and an abnormal pigmentation of the
skin and mucous membranes.
Historical Notice. — The first case of Addison's
disease on record is to be found in Lobstein's treatise,
" De nervi sympathici humani fabrica et morbis,"
Paris, 1823, from the English translation of which, by
the late Prof. Joseph Pancoast, I take the following
extract: "I have myself observed the nerves forming
the suprarenal plexus much thicker in disease, where
the capsular renales, which were more than twice aa
large as usual, had degenerated into tuberculous sub-
stance." The patient was an unmarried woman,
twenty-five years of age, who died in " convulsive
spasms analogous to the epileptic. ***** Noth-
ing unusual was discovered in the body of this woman
but the aforesaid change in the suprarenal glands, and
the enlargement of the nerves."
Notwithstanding the fact that there is no record of
any darkening of the complexion, the above was
undoubtedly a typical case of Addison's disease, in
which, moreover, death by convulsions is not uncom-
mon. The observation regarding the thickening of
the nerves in this, the first recorded instance of the
disease, is of remarkable interest. The second case
was recorded in the "Halle Hospital Reports" by
Schotte, in October, 1823, and republished in vol. vii.
of the Deutsches Archiv fur klin. Med., by Risel, in the
course of his article "Zur Pathologie des Morbus
Addisonii." The third case came under the observa-
tion of Richard Bright, at Guy's Hospital, in July,
1829. It is contained in Bright's classical "Reports
of Medical Cases," and also figures as Case V. in Addi-
son's original memoir. The lesions of the capsules
were characteristic; there was no other affection of
any consequence, and for the first time in the history
of this disease it was noted that the "complexion w:is
very dark." A few other cases were reported before
the year 1S55, when Addison published his work " ( )n
the Constitutional and Local Effects of Disease of the
Suprarenal Capsules," but it was reserved for his
sagacity to detect the relation between the well-
marked constitutional symptoms of the affection, the
peculiar pigmentation of the skin, and the structural
changes in the suprarenal capsules.
114
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Addison's Disease
It is no disparagement to the memory of Addison to
say that the general acknowledgment of his discovery
was retarded by his including in his treatise cases
which, at the present day, would be rejected from the
, egory of Addison's disease. Of his eleven eases
there are but lour uncomplicated with other affec-
tions, two complicated; while of the remaining five,
one was a case of softening of the lira in with advanced
kidney disease ami tuberculous deposits in various
organs, among others in one suprarenal capsule, and
tin' oilier four were eases of widespread carcinomat-
deposit, the suprarenal capsules being more or
less involved in each. Addison was evidently under
impression that the symptoms of the disease were
I ,. t he suppression of the unknown function of the
adrenals, ami ih.it, therefore, any destructive lesion
of the-.- bodies was capable of causing them. This
view of the pathogenesis of the affection has been
called in question by distinguished pathologists, who
insisted on restricting the term Addison's disease
to a tuberculous inflammation of the adrenals. The
inal view of Addison, however, is resuming its
sway and bids fair ere long to be generally adopted.
A n ill be seen later on, the most reasonable theory of
the pathogenesis of the disease is that of adrenal
inadequacy.
Etiology. — Age, sex, and occupation are promi-
nent factors in the etiology of this disease. The lesion
of the adrenals being, in the great majority of cases,
tuberculous, it follows that the affection is most com-
mon during those decades in which tuberculous proc-
es prevail — i.e. between twenty and forty years < f
age. Exceptionally, the disease may manifest itself
both in adolescence and in old age, and it may even be
Congenital. For example, Belyayeff has reported the
of an infant born with a dingy yellowish-gray
skin who died at the age of eight weeks. At the
autopsy both adrenals were found in a state of cystic
degeneration. The disease is much more prevalent
in males than in females, and especially so among the
laboring classes. Of 1S3 undoubted cases tabulated
by < ireenhow, 119 were males and sixty-four females,
and more than nine-tenths of the whole number were
engaged in laborious manual work. Several cases
have been associated with psoas or lumbar abscess,
t'n.' adrenals becoming involved by extension of the
inflammatory process. In others devoid of such
spinal complication, the origin of the disease has been
attributed by the patient to overexertion of the spinal
muscles. Such was the fact in one of my own cases,
the patient's first symptoms having been weakness and
pain in the back immediately following the occupation
of weeding her garden. In cases like those last
referred to, it is probable that the lesion was well
advanced at the time of the overexertion or trauma-
tism, the latter merely serving to awaken dormant
symptoms.
Symptomatology. — To quote the words of Addison:
" The leading and characteristic features of the morbid
state to which I would direct attention are — anemia,
general languor and debility, remarkable feebleness of
the heart's action, irritability of the stomach, and a
peculiar change of color in the skin, occurring in con-
nection with a diseased condition of the suprarenal
capsules."
Taking these in order, the anemia first claims atten-
tion. As is well known, it was while studying the
disease which he termed idiopathic anemia, now more
generally known as pernicious anemia, that Addison,
as he expressed it, "stumbled upon" the discovery
of the disease which bears his name. With his mind
intent upon the disease which presents the profound-
est grade of anemia, it was natural that Addison should
attribute the languor and debility of the bronzed skin
disease to a similar state of the blood. The anemia
of that affection is, however, more apparent than real.
In one of the most typical cases on record, described
and pictured by Byrom Bramwell in his atlas of clin-
ical medicine, theredcorpu cles numbered 3,250,000,
while the hemoglobin was present "in at least the
norma] amount." In another case of dis-
tinguished clinician the red corpuscles numbered
3,500,000 per cubic millimeter, i.e. seventy Jier cent, of
the normal. These figures certainly do Dot repn
a high gi ideoi anemia. As to the leucocytes, the only
change worthy of remark is a relative lymphocytosis.
According to Dr. Wilkes, to whose vigorous and loyal
efforts tin- general recognition of Addison's disease is
perhaps chiefly due | Etolle ton), anemia is not a fea-
ture of the disease. Under the microscope the red
corpuscles are seen to be of normal size and shape, and
to form rouleaux as in health, while the white cells
may or may not be slightly in excess. In one or two
cases free pigment granules are -aid tn have been
present, but the observation stand- in urgent need of
confirmation. Anemia not being present in sufficient
degree to account for the profound asthenia of Addi-
son's disease, to what then is it due? As will be seen
under the head of pathogenesis, it is most reasonably
to be attributed to an irregular distribution of the
blood, to its accumulation in the enormous district
of the abdominal vessels.
The languor and debility or, in one word, the
asthenia which, according to Addison ami all subse-
quent observers, is a cardinal symptom of the disease,
is also one of the earliest. In all histories of the
disease the patient has been compelled to abandon
his usual occupation by reason of muscular weakness,
and when there is no complication with other wasting
disease this prostration is unattended, at least in the
early stage, with any marked diminution in the vol-
ume of the muscular and adipose tissues. The
power of resistance to depressing agents is greatly
reduced. Mental and bodily exertion which would
be regarded by the healthy as trivial, is followed by
exhaustion, and the use of purgatives is positively
dangerous. As remarked by Bramwell, in more
than one of the recorded eases death has resulted
from an ordinary dose of a purgative drug.
With this asthenia there is enfeebled action of the
heart, of which the apex beat is faint or imperceptible
and the sounds weak and distant. Anemic murmurs
are rare and the same is true of valvular defects,
dilatation and hypertrophy. Edema is seldom
observed. The pulse presents varying features, but
is always weak and compressible. It may be frequent
or infrequent, full or small. Patients are liable to
attacks of collapse induced by vomiting, purgation,
or other depressing cause, or without apparent cause,
which may be so severe as to resemble the collapse of
cholera. Contrary to the usual frequency of the
pulse in collapse, a remarkable diminution in the
number of the heart beats has been observed in several
cases (Risel mentions seven), and this without any
disease of the brain or important cardiac disease. In
a ease reported by Cholmeley (Medical Times and
Gazette, 1S09, vol. ii., p. 219) in which death was
preceded by profound collapse, dyspnea, and con-
vulsions, the pulse fell to thirty-six per minute. In
advanced cases, the blood pressure is almost invaria-
bly low and is not raised by coincident nephritis or
arteriosclerosis. Pressures as low as seventy-five are
recorded.
Symptoms referable to disordered digestion are
always more or less prominent and are of early
appearance. Among them are marked anorexia,
nausea and vomiting, constipation alternating with
diarrhea, and epigastric tenderness. Sometimes the
nausea and vomiting occur in paroxysms without any
apparent exciting cause, and on this account, as well
as because of their severity, they have been compared
to the gastric crises of locomotor ataxia. Epigastric
tenderness was a prominent feature of two cases that
came under my care at the Episcopal Hospital of
Philadelphia. In the report of the first I noted that
"at times there was great tenderness about the
115
Addison's Disease
REFERENXE HANDBOOK OF THE MEDICAL SCIENCES
umbilical region, and on one occasion, after palpating
the abdomen, the patient uttered loud cries for ten
or fifteen minutes and seemed in great agony"
(Trans. Path. Sue. Phila., vol. v.). In the other case,
"the pain was latterly most severely felt in the left
lumbar region, in which situation there was also a
great degree of tenderness on pressure" (Trans.
Path. Soc. Phila., vol. x.). In the first of these cases
nothing was found at the necropsy to account for
this remarkable tenderness; in the second, it might
have been due to the great tumefaction of the lumbar
glands.
The date of the appearance of the pathognomonic
discoloration of the skin, from which the disease derives
one of its names, is very variable. It may either
precede or follow the constitutional symptoms, or the
disease may terminate fatally without its manifesta-
tion. Greenhow has collected a number of cases
illustrating the erratic appearance of this, the only
pathognomonic feature of Addison's disease. In one
of his cases the pigmentation of the skin is said to
have been the sole symptom for eight years, at the
end of which period the pigmentation deepened and
the other well-known symptoms of Addison's disease
were superadded. This case is the most remarkable
on record in so far as the early appearance of bronzing
is concerned, but it has been criticised by Brain well,
who has shown that the original pigmentation,
limited to the forehead and parts adjacent, was
probably due to n
the other hand, when the constitutional symptoms
are well pronounced in a primary case, and the bronz-
ing of skin is not yet developed, the diagnosis is to be
made only, if at all, by the exclusion of other wasting
diseases, especially cancer of abdominal organs and
progressive pernicious anemia. Many years ago there
came under my care at the Episcopal Hospital of
Philadelphia a case of lumbar abscess with several
open sinuses leading to carious vertebrae. The gen-
eral surface of the body was of a dark dingy hue, and
the orifice of each sinus was surrounded by a broad,
deeply pigmented ring. The patient had been pre-
viously at another institution, where secondary dis-
ease of the adrenals had been suspected. The autopsy
showed these bodies to be perfectly healthy and the
kidneys to be involved in extensive amyloid degenera-
tion. A dingy discoloration of the skin is not uncom-
mon in amyloid disease of the kidney, as first pointed
out by Grainger Stewart.
The discoloration of skin, although not the most
essential characteristic of the disease, is justly re-
garded as its most important diagnostic feature. It
is to be distinguished from melasma gravidarum, pity-
riasis versicolor, lichen, and pigmentary syphilides,
and this is readily done by any one familiar with
these affections. The melanoderma of phthisical pa-
tients presents more serious difficulty. Although the
latter is often confined to the face and does not invade
the mucous membrane of the buccal cavity, the ditfi-
culty is a real one, and is augmented by the fact that
pulmonary tuberculosis is the most frequent compli-
cation of Addison's disease. The seat of the melasma
suprarenale, or its greater intensity, upon the face and
neck, the dorsum of the hands, areola of the nipple
and about the umbilicus, in the axilla, groin, and upon
the genitals, is characteristic. Other diagnostic fea-
tures of the pigmentation have been described above
under the head of Symptoms. A discoloration of the
skin liable to be confounded by the inexperienced with
that of Addison's disease is sometimes seen in badly
nourished paupers of dirty habits, whose skin is the
abode of vermin (vagabonds' disease). This pigmen-
tation shows itself in the form of patches separated
by healthy skin; the epidermis is often roughened,
and the discoloration more marked upon the trunk
than on the face and hands. The skin is also often
marked with scratches, the result of the intense itch-
ing. Under the microscope, the particles of pigment
in this affection are found in all the layers of the
epidermis, instead of being limited, as in Addison's
disease, to the deeper layers of the rete Malpighii.
The pigmentation of chronic malarial poisoning i-
distinguished from that of Addison's disease not
only by its distribution, but by the history of the
case and the frequent presence of splenic enlarge-
ment; chronic icterus, with which Addison's disease
was formerly confounded, is distinguished by the
presence of pigment in the ocular conjunctiva and in
the urine.
Other discolorations of the skin simulating closely
the pigmentation of Addison's disease are mentioned
by systematic writers, but are so rare as to be in them-
selves pathological curiosities. Among them may be
mentioned a diffuse pigmentation associated with
chronic scurvy (Bramwell), and a few other cases of
melasma occurring without obvious cause. Accord-
ing to the author just cited, there are certain forms of
pigmentation of the skin associated with chronic peri-
tonitis, or malignant disease of the abdomen or pel-
118
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Adenoma
vis which it is impossible to distinguish from Addi-
son's disease. This fact, though discomfiting to the
clinician, is of great interest to the pathologist, as
tending to prove that the most characteristic symptom
of the affection, the melasma suprarenale, is to be
attributed rather to the implication of the abdominal
sympathetic than to that of the adrenals.
Prognosis. — The prognosis is in the highest degree
unfavorable, although recoveries of cases presenting
every sign and symptom of the affection have been
reported by the most competent observers. Among
these may be mentioned Sir William Gull and Dr
Finney. In making predictions as to the duration of
life, the remittent character of the disease should be
liiune in mind. A case seen during a period of exacer-
I, 1 1 em may lead to the prognosis of a speedily fatal
result, but the worst symptoms may disappear and be
followed by a prolonged period of remission. The
average duration of the life of hospital patients who,
i rule, do not apply for treatment until forced to
;ekiio\vledge the fact of their illness, has been es-
timated at two years. Sudden death without pre-
ceding exacerbation is sometimes observed, the fatal
result being apparently due to syncope.
Treatment. — At the present time, there may be
said to be a specific treatment of Addison's disease —
that with adrenal extract. This fact, however, in no
way diminishes the importance of general therapeutic
measures, of which the most important are the fol-
lowing: Cessation of work is the first thing to be
insisted upon in the way of treatment, and during the
exacerbations strict confinement to bed. An im-
mediate mitigation of the symptoms has often fol-
lowed the admission to hospital of a patient who, up
to that time, had been endeavoring to resist the
gradually increasing asthenia. A moderate amount
of stimulants is generally well borne, but. cod-liver oil,
which might seem appropriate on account of the
tuberculous nature of most cases of the disease, is, as
a rule, not tolerated. Remedies to allay irritability of
the stomach are frequently indicated, such as ice,
lime water, carbonic acid water with brandy, bismuth,
creosote, hydrocyanic acid, and small doses of opium.
Massage and faradization are well worthy of a trial
in order to drive the blood from the abdominal
vessels. Iron and arsenic should be employed ten-
tatively and will be generally found useful, and
the same is true of mix vomica and its derivatives.
Cathartics are to be avoided, as profound depression
has often followed their employment in this disease.
When constipation is troublesome it should be relieved
by enemata and suppositories. The diet should be
simple but nourishing, consisting of soups, milk, eggs,
meat jellies, koumyss, and the like.
Treatment with Adrenal Extract. — The success that
has attended the use of adrenal extract is such as to
make it imperative in all cases of Addison's disease.
This is not a mere obiter dictum, but is the result of a
careful study of many of the reports upon the subject.
A few examples will suffice to show the kind of evi-
dence on which the administration of the adrenal
extract is based.
< isler (International Medical Magazine, February,
1890) reports a case in which there was marked im-
provement under the use of the extract, attended
with considerable gain in weight and restoration of
general vigor. The pigmentation, however, which
was of advanced grade, had not diminished except
on the palate. A case is reported by Suckling
(British Medical Journal, May 28, 1S9S) in which the
symptoms and signs were well pronounced except
pigmentation of mucous membranes, of which there
is no mention. Tablets of suprarenal extract (aa gr. v.)
were given to the extent of from twenty to thirty-
five daily. In the course of a year recovery was
complete with disappearance of melanodermic and
leucodermic patches. Kinnicutt tabulated forty-
«ight cases (American J ournal of the Medical Sciences,
July, 1897) treated with adrenal preparations. "Six
patients are reported as cured or practically well,
twenty-two improved, eighteen unimproved, and in
two instances an aggravation of the symptoms is
tiled to have occurred during treatment. In the
second class of eases, those in which improvement
took place, the improvement was but temporary;
but this was as much as could be expected, since in
many the disease of the adrenals was associated
with grave tuberculous lesions in other parts of the
body.
A scries of 120 cases, including ninety-seven
previously collected by E. \V. Adams ( J'ractitioner,
lxxii., 473, 1903) was analyzed by Sajous with ref-
ference to the effect of adrenal preparations. In
fifty-one the benefit was slight or nil, in thirty-six
there was marked improvement and in twenty-five
there was permanent benefit. The adrenal extrac-
tives should not be administered in a haphazard
manner. In one of the cases in which permanent
benefit was the result of their administration, the dose
was one-twelfth of a grain; in another, the initial dose
of the extract was ten grains thrice daily and was
gradually increased until 175 grains were administered
per diem. The adrenal preparations should be given
to meet certain indications of wdiich the most promi-
nent are diminished blood pressure and hypothermia.
When the temperature and the blood pressure are
raised to the normal standard, the full effect of the
remedy has been secured and is only to be maintained
by a careful observation of the case and, perhaps, by
occasional suspension or increase of the dose employed.
As Sajous remarks with reference to the cases in which
there was permanent benefit: "Although the remedy
was used empirically it so happened, in all prob-
ability, that the doses employed coincided with the needs
of the organism." The most satisfactory preparation
has been found to be the desiccated gland — glandulae
suprarenales sicca?, U. S. P., the dose of which must
be ascertained by tentative use with the aid of the
thermometer and the blood pressure tests. The
subcutaneous injection of adrenal fluid extracts is
exceedingly painful and the active principles which
they contain are rapidly oxidized and, it is believed,
rendered inert during their absorption.
On the theory that Addison's disease is chiefly due
to suppressed function of the adrenals, the use of
adrenal extract would find its most successful employ-
ment in those cases in which the lesion consists of
simple atrophy or fibroid degeneration.
Frederick P. Henry.
Adenitis. — See Lymphatic Glands, Diseases of.
Adenoid Vegetation. — See Tonsils, Pharyngeal.
Adenoma. — Adenoma (from aS-n", gland, and -oiua
noting in pathology a swelling or tumor) is the term
applied to a new growth originating in glandular
epithelium and corresponding in histological structure
with the general type of gland tissue.
Every new formation of glandular tissue, every
glandular hyperplasia, cannot be regarded as an
adenoma, and sometimes it is impossible to say
whether an apparent growth is a simple hyperplasia
or a tumor. A gland which is increased in size in
consequence of excessive nutrition and function can-
not be called an adenoma, but must be considered a
hyperplasia.
In the same way must be considered those forma-
tions in mucous membranes which frequently develop
in consequence of chronic inflammation and take the
form of tumors. These are local new formations which
project above the surface in the form of polypi or
papillary masses. The new growth commences in the
119
Adenoma
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
connective tissue, and the epithelium also takes part,
in that, by the increase of the surface, the covering
epithelium also must increase. If there are glands
present their ducts are usually obstructed, and cysts
are formed with papillary projections within them.
This must be considered simply as a growth due to
chronic irritation, and as entirely distinct from the
true glandular polyp of the mucous membranes in
which a formation of new glands actually occurs.
Clinically, these can usually be distinguished for the
simple polyp disappears when its cause, chronic
irritation, disappears.
Etiology. — The causation of adenomata is ob-
scure though probably no more so than that of new
growths in general.
In some forms congenital misplacement of tissue ele-
ments appears to play an important part. Thus in the
kidney, adenomata sometimes are found which cor-
respond in structure to the adrenal. These, as
pointed out by Grawitz, develop from aberrant
remnants of the adrenal embedded in the kidney
substance. This is also true of adenomata correspond-
ing to the structure of the mamma occasionally seen
in the axilla, and of the rather unusual substernal
tumors in which a tissue similar to that of the thyroid
body is found. Here it is probable that the theory
of embryonic remains of Cohnheim gives the true
explanation: the tumor in each of these instances
develops from embryonic fragments which become
separated from the gland in its development. Although
in certain locations, as the stomach and rectum, the
adenomata appear to bear out Virchow's irritation
theory, in other locations they offer it no support
at all.
The parasitic theory receives absolutely no support
from the adenomata, for it is impossible to conceive
of a vegetable or an animal parasite causing the re-
production of definite gland tubules.
Varieties and Structure. — The appearance of
adenomata varies greatly with their location. Natu-
rally any particular cell or arrangement of cells cannot
be described as peculiar to this tumor, any more than
any type of cell can be regarded as characteristic of all
physiological glandular structures. The adenomata
differ from one another in structure as much as the
structure of the liver differs from that of the lacry-
mal gland.
In the stomach, intestine, and uterus, in a general
way, the epithelial cells are arranged as tubular acini
with a central lumen, the cells generally occurring in
one layer, though there may be more. The acini are
separated from one another by connective tissue in
which the blood-vessels and lymphatics are borne.
Why the cells in their growth should grow as tubules
instead of breaking through the basement membrane
and forming atypical groups of epithelial cells, as is
seen in the form known as adenocarcinoma, is diffi-
cult of explanation. It is probable that the inherent
tendency thus to develop is not early influenced by
their altered environment. That they do not break
through and grow as carcinoma is frequently seen
in some large and rapidly growing adenomata.
The cells lining the tubules may be columnar or
cuboidal, according to the gland from which the
tumor develops.
In addition to the tubular form there is an un-
common variety, the racemose adenomata, in which
the appearance is that of a complicated gland struc-
ture with closely aggregated acini of circular out-
line containing columnar, cuboidal, or polyhedral
cells.
Then, again, in the liver, kidney, and adrenal occur
adenomata resembling more or less closely the normal
structure of those organs.
As in any other epithelial tumor, the relation be-
tween the epithelial cells and the connective tissue
varies. When the development of the connective
tissue is excessive, far beyond that of the normal
gland, it must receive some recognition in naming the
tumor, for it is as truly new formed as is the epithelial
portion: in such cases it is called an adenofibroma.
When this connective tissue is especially abundant in
cells and represents an embryonic tissue, the term
adenosarcoma is used. In the ovary occurs an
adenoma in which the acini line cyst cavities. This is
termed an adenocystoma.
Adenomata, as far as known, do not contribute to
the body metabolism. That there is a partial preser-
vation of function is occasionally seen. In the
adenoma of the liver sometimes a biliary pigmentation
occurs; in the adenoma of the breast there may be a
secretion of milk-like fluid; in the adenoma of the
intestine the tubules may contain mucus; in the ade-
noma of the thyroid colloid material may collect.
But these substances remain in the tubules in
which they are formed, and take no part in the general
metabolism.
Secondary Changes. — All forms of degeneration
are common in adenomata. Hyaline transformation
may give the tumor an appearance justifying the term
"cylindroma." This, however, is rare. Myxomatous
and calcareous degenerations occasionally occur.
Cystic change may result from gradual dilatation of
the glandular acini. Hemorrhages are common, and
on free surfaces ulceration is frequent.
The most important change, however, is a carcino-
matous transformation. This is especially common in
the stomach, intestine, and uterus. The proliferation
of the epithelial cells becomes excessive; the acini be-
come more abundant and irregular; the cells depart
from their tubular arrangement and grow as solid
epithelial masses outside the acini, forming an adeno-
carcinoma, or, as Ziegler named it, adenoma destruens.
The growth may eventually become purely carcino-
matous, but it usually retains more or less its adeno-
matous type.
General Character. — The rapidity of growth
of an adenoma differs in various parts of the body in
which it has its seat, and the same holds true for its
malignancy. There are few which can be considered
as strictly benign tumors. The pure adenoma seen
in the liver may form metastases in the spleen and
less frequently elsewhere. Fatal metastases from
adenomata of the thyroid have been reported. In the
sweat, sebaceous, and lacrymal glands the tumor
usually grows slowly, remains local, and may be con-
sidered benign. In some locations, although adeno-
mata never produce metastases, they may endanger
life by their size, as in the ovary; or may obstruct im-
portant canals, as in the intestine; or may cause great
disfigurement, as displacement of the eye in adenoma
of the lacrymal gland. The general health may also
be influenced by interference with the normal function
of the organ in which they are located, or in conse-
quence of ulceration and hemorrhage. There are
few tumors more malignant than the adenomata of
the intestinal tract. They extend rapidly, infiltrating
all coats of the intestine, and frequently produce
metastases in the liver. Their malignancy does not
always depend on carcinomatous transformation, for
some of the most destructive tumors of this canal are
pure adenomata.
As regards the terms Malignant Adenoma and
Adenocarcinoma, it seems best to use the former in
designating those growths in which, although there is
extensive infiltration of surrounding tissue and eyen
the formation of metastases, the tumor still retains
its glandular type; and to use the term Adenocarci-
noma for those forms in which the cells depart from the
tubular arrangement with the formation of distinct
cancerous areas.
The principal locations in which adenomata may
occur and brief descriptions of their characteristics
dependent on location and origin are given below:
Skin. — Adenomata of the skin are rare. They may
develop from the sebaceous or from the coil glands.
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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Adenoma
They crow slowly and are practically always benign.
Adenomata of sweat glands are found in various parts
of the body, bu1 principally on the face, where they are
of a dirty grayish-white color with nodular surface.
Histologically, coils of dilated duels arc seen, from
which degenerated epithelium can be squeezed. Cam-
piniri (1895) describes cystic and carcinomatous
changes in such tumors. Adenomata of sebaceous
Fig. 41. — Benign Adenoma of the Small Intestine.
X 10 diameters.
glands appear principally on the face and are usually
of congenital origin. They appear as small, roundish,
convex papules, of bright color, and in old people are
often associated with fibromata.
Whitnej' has described an adenoma of sebaceous-
gland origin which was the size of an orange and con-
led large cavities filled with a material resembling
butter in "its color, consistence, and general appear-
ance. (Consult also the special article on Adenoma
of the Skin.)
Mucous Membranes. — Mouth. — Adenoma of the
mucous glands of the mouth is very rare. It occurs
a- isolated nodes and in some cases gives rise to macro-
cheilia. Adenomata of the salivary glands have been
reported.
Larynx and Bronchi. — A few cases have been
reported of benign adenomata arising from the mucous
glands of these organs. Eber (1.S96) has reported
several cases in the bronchi of sheep. They occur
as irregular nodular growths.
Stomach and Intestine. — Small, apparently benign
adenomata are sometimes seen. The malignant
adenomata and the adenocarcinomata are the most
important forms. They start as soft nodular growths
which break down readily and ulcerate. They infil-
trate all coats and may cause perforation. Metas-
tases in the liver may occur, and there is sometimes
a direct extension to adjacent organs, as from stomach
to pancreas. In the large intestine, of all forms of
new growth, this tumor is the most common cause of
chronic intestinal obstruction. Histologically, they
may be made up of dilated, irregularly branching
tubules presenting a single layer of cylindrical epithe-
lium — in the stomach originating from the gastric
tubules, in the intestine from the glands of Licberkuhn;
or in addition to this structure there may I"- irregular
solid masses of epithelium, the result of great pro-
liferation of epithelial cells and destruction of the
basement membrane.
In the large intestine the locations, in order of
frequency, are the rectum, the sigmoid, splenic and
hepatic liexures of tl Ion, and the cecum.
In the small intestine adenoma i- occasionally
found in the duodenum at the papilla marking the
orifice of the bile duct.
Vulva. — Benign adenomata arising from the
glands of Bartholin] have been reported. Kelly
describes an adenocarcinoma, as large as an oral
of the vulvovaginal glands.
/ rinary Bladder. — Adenomata of this organ are
rare. They may be sessile or pedunculated, smooth
or lobular, benign or malignant. It is not easy to
explain their origin.
tJterus. — Adenoma originates generally in the body
of the uterus, but occasionally in the cervix. It may
rapidly infiltrate the myometrium and may produce
nodules on the peritonea] surface. It has the usual
glandular structure and a small amount of fibrous
stroma. Carcinomatous areas may develop.
Occasionally a benign polypoid adenoma may be
seen, but it is often difficult to distinguish this from a
hyperplastic glandular endometritis.
Fig. 42.— M
X le- diameters.
Diffuse benign adenomyomata of the uterus have
been carefully described by von Recklinghausen and
Cullen.
Adenoma in Solid Viscera. — Liver. — Adenomata
of this organ are rare. They may occur in the normal
or in the cirrhotic liver, and appear as small, grayish-
white, reddish, or brown miliary solitary or multiple
areas. They are made up of tortuous, branching,
gland-like tubules of newly formed trabecular of liver
cells, not arranged as typical liver lobules. The cells
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Adenoma
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
are large, pale, and finely granular. They arise from
proliferation either of liver cells or of the cells of
the bile capillaries. The larger ones have a distinct
capsule. Some writers believe that they may become
carcinomatous.
Another and rare form is the adenocystoma, which
is made up of cysts containing a colorless fluid, the
walls of the cysts being covered by glandular epi-
thelium. This form probably originates from the
bile ducts.
Fig. 42, a. — Malignant Adenoma of the Rectum. Greatly magni-
fied in order to show character and arrangement of the newly
formed glands.
Kidney. — Congenital adenoma, struma aberrata
suprarenalis. — As shown by Grawitz, this tumor
develops from fragments of the adrenal body which
in the development of the kidney become incorporated
in its substance. The tumor is small, grayish, and
generally just beneath the capsule. Histologically,
it consists of large pale epithelial cells arranged in
tubules similar to those of the cortical portion of the
adrenal. The cells are filled with fat granules.
Active proliferation may occur with tendency to
malignancy. The observations of Askanazy and
Lubarsh indicate that malignant tumors resembling
carcinomata may develop from these growths.
Adenomata arising from renal tubules are rare.
They originate in the convoluted tubules, and appear
as very small nodular masses, though they sometimes
may reach a diameter of three to four centimeters.
They are distinctly encapsulated. The cells may be
cuboidal or may become cylindrical, and are arranged
in the form of single tubules; the glomeruli and different
types of tubules are never reproduced.
A papuliferous cystic adenoma, a small tumor
with fibrous capsule in which the lining epithelium is
elevated in a papillomatous manner, is occasionally
seen.
Adrenal. — Adenoma of adrenal, or struma lipomatosa
suprarenalis of Virchow, generally develops from the
cortex as an irregular nodular growth, yellowish or
pale brown in color. It may remain small or may
completely destroy the organ, sometimes attaining a
very large size. The cells resemble those of the
normal gland in structure, but are large, pale, and
granular, as though filled with fine fat granules.
Breast. — Many tumors of the breast combined with
the formation of cysts have been described under the
name of adenoma. In such cases the tumor is gen-
erally a fibroma or a sarcoma, and has grown into
the ducts of the gland as papillary projections. These
are covered by the lining epithelium, which they
push ahead of them in their growth, and which in-
creases in consequence; but this is only secondary, and
these tumors should be considered as connective-
tissue formations.
A diffuse enlargement of the breast due to uniform
increase in the glandular elements has occasionally
been described under the name of diffuse adenoma.
This condition is bilateral, usually occurs about the
time of puberty, and, strictly speaking, is a hyper-
plasia and not a new growth.
The true adeno?na is unilateral, definitely circum-
scribed, and encapsulated. It usually occurs in young
women, starting as small nodes in the upper or outer
quadrant of the gland. It becomes round or oval in
shape and sometimes grows to considerable size,
though usually small. On section it is uniformly
smooth, grayish-white, and quite firm, though occa-
sionally it is soft and slightly nodular.
Histologically, it may be composed of acini or of
ducts lined by cylindrical epithelium. The stroma
is fibrous and varies greatly in character and amount,
but is looser and more cellular than that of the normal
gland. According to the character of the inter-
glandular tissue, it may be an adenofibroma, adeno-
myxoma, adenosarcoma, etc.
Adenocarcinoma is generally considered to be an
unusual form of breast tumor. Halsted (1898), how-
ever, reports five occurring in a series of 150 breast
cancers. According to Halsted's observations, these
growths differ from ordinary cancer of the breast in that
they are softer, more pedunculated, and discharge a
peculiar serous fluid when ulcerated. Histologically,
they are composed of very large tubes lined by epithe-
lium many layers deep. In three of Halsted's cases the
growth was pure adenoma (malignant adenoma) ; in
Fig. 43. — Fibroadenoma of the Mammary Glands.
the others carcinomatous areas were present. Metas-
tases in the axillary lymph nodes were found in none.
Ovary. — The multilocular cystadenoma is the com-
monest tumor of the ovary, and the one usually
attaining the greatest size. It may be small or it may
weigh a hundred pounds or more. It is a benign
tumor and never produces metastases. The surface
may have no epithelium, or it may have a single layer
of flat epithelial cells. The numerous cysts of vary-
ing size which make up the mass are lined on their
inner surface by a single layer of cylindrical cells,
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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Adenoma
often ciliated. The nuclei are oval and placed aeai
the basement membrane. Some of the cells may be
swollen and filled with clear contents, giving them the
appearance of goblet cells. The contained fluid is
thick, viscid, sometimes jelly-like, and may be color-
less or, if there has been hemorrhage, yellowish or red-
dish-brown. This fluid is formed by secretion from
tli,. epithelial cells, by the transudation of serum from
the blood-vessels, and by the degeneration of the
epithelial cells. The most important chemical sub-
Fig. 44.
-Papillary Adenocystoma of the Ovary.
X 10 diameters.
stance in the fluid is pseudomucin, a true secretion of
the newly formed epithelial cells. It does not occur
in the normal ovary, in dropsical Graafian follicles,
or in the parovarium.
Calcification or necrosis of the cyst wall may occur as
secondary changes. Both are unusual.
The papuliferous adenocystoma is characterized by
an ingrowth into the cyst of a papuliferous connective
tissue covered with epithelium. On cross-section the
appearance is that of gland tubules. The papillary
growths may be prominent, or they may appear
simply as fiat excrescences on the surface of the cysts.
The epithelium is similar in character to that in the
multilocular adenocystomata. This tumor is not
malignant in the ordinary sense; but after rupture of
the cysts a local growth on the neighboring perito-
neum may occur.
These growths are supposed to originate from the
epithelium of mature or residual embryonic follicles or
from the germinal epithelium of the ovary. Pfliiger
has pointed out the glandular structure of the ovary,
and Spiegelberg and Langhans have shown in the
ovary, even after birth, residues of its embryonic
glandular structure. Doran, as a result of his inves-
tigations, believed that the tumor might originate in
childhood or even in the intrauterine period. Williams
states that the papillary adenocystomata originate
from the epithelium on the surface of the ovary or
from that of the Graafian follicles, or from both.
Adenocarcinoma of the ovary may originate in the
ovary, may develop in a papuliferous adenocystoma,
or may be secondary to a similar growth in the uterus.
Thyroid. — Aside from the hyperplastic changes
associated with the condition known as goiter, circum-
scribed adenomatous tumors of the thyroid occur.
These appear as soft nodular growths composed of
glandular tubules lined by tall cylindrical epithelium.
Within these tubules papillary growths sometimes
appear (adenoma papilliferum). Within the tubules
is seen the colloid material characteristic of the normal
thyroid. Although this tumor is one of the purest
types of adenoma, it may produce metastases. It
may also by direct extension invade the structure of
the larynx.
Testicle. — The form of tumor as it occurs in the
testicle is generally known as cystadenoma. It may
occur in the child or in the adult. It is attributed by
some writers to error in development. Two forms are
recognized. In one the tubules are lined by cylin-
drical cells which sometimes have cilia, their contents
being a clear or blood- tinged slimy fluid; in the other
the epithelium is stratified and the contents a greasy
substance with many fatty epithelial cells. The
Fig. 45. — Papillary Adenocystoma of the Ovary; more strongly
magnified than Fig. 44, in order to show the cyst wall, the papil-
lary ingrowths of connective tissue, and the epithelium lining the
papillary projections. As seen in cross section this epithelial
structure gives the appearance of a glandular growth.
growth usually starts in the testicle and may attain a
large size. Instances of carcinomatous changes have
been reported.
Prostate. — The tumor usually occurs in this organ as
an adenocarcinoma and is rare. It appears as soft,
nodular masses which project into the urethra or neck
of the bladder and invade surrounding tissues. Ulcera-
tion is frequent, and when it occurs is accompanied
by copious hemorrhage.
Pituitary Body. — Adenomata of this structure are
rare, but are occasionally reported in connection with
cases of acromegaly. They may be as large as a
123
Adenoma
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
pigeon's or hen's egg; may protrude from the sella
turcica, press on the brain, and extend even into
the ventricles. Histologically, they are made up of
large, tortuous, sometimes branching tubes lined by
epithelial cells.
Pancreas. — Adenomata of this gland are not com-
mon. They are generally of the racemose type.
Cesaris-Demel (1895) reports a distinctly encapsulated
adenoma the size of a dove's egg in an atrophied pan-
creas. The cells were irregular and primitive,
occurring in one and sometimes in several layers,
generally arranged in alveoli.
Lacrymal Gland. — Adenomata of this gland are not
very common. They generally occur in persons of
advanced age. By pressure they may interfere
seriously with the movements of the eye. They do
not tend to become malignant and are only trouble-
some on account of their size. Adenocarcinoma has
been reported, but is very rare.
Pineal Gland. — The occurrence of adenomata of
this body is occasionally referred to in the literature.
Richard Mills Pbarce.
Adenoma of the Skin. — Adenomatous proliferation
of the cutaneous glands is an extremely rare occur-
rence, and it is only within a comparatively recent
period that the condition has been recognized.
Hypertrophy of the skin glands, on the other hand, is
a concomitant of many chronic local disturbances of
nutrition, and doubtless in some of the cases recorded
as adenoma there has been confusion between this
condition and hypertrophy. The considerations
involved in the differentiation of hypertrophy and
adenoma have been discussed in the preceding
article.
It must be noted, however, that all these growths
are probably of congenital origin, and should be
classed with the nrevi. The terms na?vus sebaceus
and nsevus sudoriparus respectively are to be pre-
ferred to the designation of adenoma.
Adenomata of the skin naturally fall into two
classes: adenoma of the sebaceous glands (adenoma
sebaceum), and adenoma of the sudoriparous glands
(adenoma sudoriparum).
Adenoma Sebaceum. — Synonyms: Na?vus seba-
ceus; Vegetation vasculaire (Rayer); Naevi vasculaires
et papillaires (Vidal); Adenoma of the sebaceous
glands; Steatadenonia; German, Talgdrusenadenom;
French, Adenome s£bac6.
The earliest recorded cases of the disease are found in
the writings of Rayer and of Addison and Gull, who,
however, failed to interpret correctly the anatomical
condition, which Balzer was the first to recognize,
though Balzer's case, curiously enough, has been
shown by later investigators to be one of acanthoma
adenoides cysticum. Cases have since been described
by Hallopcau and Vidal in France, Mackenzie,
Pringle, Jamieson, and Crocker in England, and
Caspary and Boeck in Germany. The first case
recorded in America was described by the present
writer in 1S93, and many cases have been observed
since that time
The disease manifests itself in the form of small mul-
tiple benign tumors, which may be distributed gener-
ally on the face, but occur most frequently at the sides
of the nose. Their distribution is usually fairly sym-
metrical, but in Jamieson's and one of Crocker's cases
they were limited to one side of the face, and in my
own case the lesion was in the form of a linear patch
on the forehead. The lesions in some cases were
present at birth or appeared in infancy; but a more
active growth, as to number and size of the tumors, has
been noted at the time of puberty. In Caspary's
case and in my own they did not appear until the
seventeenth and the nineteenth year respectively.
The individual growths seldom undergo any change
after they have attained their development, though
involution of a few of the nodules with resulting faint
cicatrices has been noted.
The little tumors vary in size from one to five milli-
meters, are usually round and convex in shape, and
the epidermis over them may be smooth or have a
rough and somewhat warty appearance. Their color
may be that of the normal skin, or they may have a
brownish or even bright red hue. The color depends
greatly on the presence or absence of telangiectases,
which often appear as fine lines ramifying over their
surface, and in some cases may form so striking a part
of the tumor as to give the whole the appearance of a
vascular nevus. In Vidal's case and in mine there
was cystic degeneration of a part of the tumors, giving
the appearance of small yellow nodules from which
on incision a drop of inspissated sebaceous matter
could be squeezed. Some importance has been at-
tached to the fact that in many of the cases there
were other striking abnormalities of the skin: warts,
pigmented and hairy nevi, and small pendulous fibro-
mata indicating a congenital tendency to malforma-
tions of the skin. It is probably only a coincidence
that many of the cases have occurred in persons of
deficient intelligence, some of them epileptics.
Anatomy. — Under the microscope the entire tumor
is seen to be composed of larger and smaller masses,
which bear the closest resemblance to the acini of nor-
mal sebaceous glands. It is indeed only in the great
number, extent, and complex arrangement of the lob-
ules that an abnormal condition becomes apparent.
In some cases solid epithelial buds are given off from
existing sebaceous gland acini, and the cells of these
buds later undergo the peculiar fatty changes indica-
tive of the glands from which they take their origin.
Unna, who draws a very sharp distinction between
hypertrophy and adenoma of the sebaceous glands, re-
gards most of the published cases as examples of
hypertrophy.
The treatment of the condition is indicated only
for cosmetic purposes. When the lesions are few in
number they may be removed by excision, by
scarification, or by electrolysis. When they are
very numerous, any form of operative interference
is inadvisable.
Adenoma Sudoriparum. — Synonyms: Naevus su-
doriparus; Adenoma of the sweat glands; Spirade-
noma; Syringadenoma; German, Schweissdrusen-
adenom; French, Adenome sudoripare.
The disease which has been described under the
various names of hydradenomes eruptifs, syringo-
cystadenoma, epithelioma or acanthoma adenoides
cysticum, etc., and which was formerly regarded
as an adenoma of the sweat glands, is now known
to have no connection with these structures. The
reader is referred to the article on Epithelioma of the
Skin for an account of this condition.
In view of the fact that the sweat gland is an ap-
proximately uniform cylindrical tube, the distinction
between hypertrophy and adenoma of these glanda
can readily be made. Any deviation from the typical
structure in the form of lateral budding or outgrowth
suffices to constitute adenoma, provided, of course,
that the new formation does not break through the
membrana propria of the gland. From this point of
view adenoma of the sweat glands is by no means a
rare occurrence. It is frequently found in connection
with other diseases of the skin, especially in associa-
tion with tumors and malformations of the blood-
vessels of the cutis and hypoderm, and with cancers of
the skin. Under these circumstances, however, the
adenoma constitutes merely an interesting micro-
scopical condition without giving rise to any clinical
symptoms. In these cases the adenomatous forma-
tion affects only the coiled portion of the gland, and
it is a noteworthy fact that in all the observations
hitherto recorded there has been a sharp distinction
between adenoma of the coil and adenoma of the duct.
This distinction has given rise to the terms spirade-
124
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Adladorlioklnrsla
noma and syringadenoma. Adenomata of the sweat
glands occurring independently are of extremely rare
occurrence.
(Jnna in his " Histopathology " was able to cull only
ises of spiradenoma from the literature, to which
he added a seventh. The tumors varied in size in the
different cases from a small chestnut to a hen's egg;
were found on the head, neck, or extremities in mid-
dle-aged .11 elderly people lone case in a child); and
presented no characteristic clinical features. The
diagnosis ran be made only with the microscope.
The proliferation occurs in the form of solid epithelial
buils. which usually show a tendency to grow in
curved lines as they increase in length, and to become
canal led like the structures from which they took
their origin.
Of the syringadenomata there is but a single un-
doubted ease on record, that of Petersen. It was in
the form of a papillary ncevus unius lateris on the neck,
trunk, and thigh of a girl of twenty. The adenomat-
ous proliferation was confined strictly to the ducts
of the glands, which appeared considerably widened
shortly above the coil, the cubical epithelium became
cylindrical, and outgrowths developed which were
sometimes solid and sometimes canalled. These out-
grow tin divided repeatedly like the branches of a tree,
and produced thus the semispherical or mushroom
form of the tumors. The new-formed tubes were
lined with a distinct membrane and showed no signs
of colloid degeneration. Sigmund Pollitzer.
Adeps. — Lard. "The prepared internal fat of the
abdomen of the hog (Sms scrofa, var. domestica Gray),
purified by washing with water, melting and strain-
ing" (U. S. P.).
The tissue from which lard is obtained, lying at
each side of the backbone and enclosing the kidneys,
and which goes by the name of " leaf lard," is washed,
chopped, cleaned from connective bands and tra-
becule, and then, with a little water, exposed to a
boiling temperature until the connective tissue is
softened and the fat has run out; it is then strained,
and the heat continued until the water is nearly
removed and the melted fat is clear and homogeneous,
when it is poured out and cooled. If a very fine
product is desired, it should be filtered in a hot filter-
ing apparatus.
Lard should be of a soft solid consistency, white,
unctuous, with a faint but not at all rancid odor, and a
bland taste. Its specific gravity is about 0.917 at
25° C. (77° F.) and it melts at 3S° to 40° C. (100.4° to
104° F.). It is insoluble in water and very little
soluble in alcohol.
Olein, palmitin, and stearin are the principal con-
stituents of lard, their relative proportions (upon
which its consistency depends) varying considerably.
Commercial lard is so apt to be impure, either
being mixed with water or salt, or having a portion of
its liquid oil removed, that it is in general unfit for
medicinal use, and the apothecary will do well always
to prepare his own.
Ordinary lard rather rapidly becomes rancid and
irritating, but if perfectly pure and free from water it
will keep, in a cool place, for a very long time. When
it is to be used during warm weather, five per cent, of
it, or more if necessary, should be replaced with white
wax. For pharmaceutical purposes it is scented, as
well as preserved, with benzoin, a little of the balsam
being tied in a bag and suspended in the melted lard
for two hours. Thus treated, it is almost entirely
permanent, besides having an agreeable odor.
Lard is an article of food, and is emulsified, like
other fats, when taken into the intestines, without any
particular physiological action. As an external
dressing, it is protective and bland in a high degree,
qualities which have given it its popularity as a basis
of ointments and cerates. Those of the L'nited
States Pharmacopoeia follow: A. benzoinatus, just
mentioned. ( era) uin, Ceratum cantharidis, Ceratum
extract! cantharidis, ('. resins, Unguentum, I'ng.
bydrargyri, l"ng. mezerei, Ung. iodi, etc
II H. Rusby.
Adeps Lanjc Hydrosus. — Lanolin. Hydrous Wool-
fat. "The purified fat of the wool of sheep
arks Linne) mixed with not more than thirty per
cent, of water" I I'. S. P.). Freed from water, this sub-
stance is the Adeps I. awe or WooL-fai of the Phar-
macopoeia, but it is chiefly used fn its hydrous form.
Under the title of lanolin. Oscar Liebreich propo ed,
to serve as a basis for ointments, the peculiar body
that results from the mixture of a cholesterin fat with
water. The cholesterin fats are peculiar, in com-
parison with ordinary glycerin fats, in not decompos-
ing, in •' taking up" and holding in intimate blending
an equal quantity of water, in mixing also with gly-
cerin, and in possessing a high diffusion power. By
reason of the latter power, lanolin used as an inunction
ointment is supposed rapidly to impress the system
with any absorbable active drug substance that may
be incorporated with it. This wool-fat, or lanolin,
as it is still commonly called, is a yellowish-white
material of ointment-like quality and a faint char-
acteristic odor. It is insoluble in water, but yet will
mix with twice its weight of water and still retain
its unctuous quality. It melts at about 40° C.
(104° F.), separating into an upper oily and a lower
aqueous layer. It is somewhat sticky, but this
quality can be removed by the addition of from
twenty to twenty-five per cent, of some ordinary
oil, such as castor oil, cr of vaseline.
Clinical experience with lanolin does not seem fully
to realize the expectation of unusual power on the part
of the substance to penetrate the skin, on inunction.
Nevertheless, lanolin makes a very serviceable
material for inunction purposes, either by itself or
medicated. H. H. Rusby.
Adiadochokinesia. — This term (also within adiado-
chokinesia) was proposed bj* Babinski of Paris, to
designate a peculiar difficulty observed in certain
patients suffering from cerebellar disorder. It consists
in an inability to perform rapid alternating move-
ments, such as opening and closing the hands; rapid
supination and pronation; finger play, such as piano
playing; extension and flexion of the forearm on the
arm. It has been found, further, that the symptom
ha- a slightly wider significance than that originally
attributed to it, and "is of considerable diagnostic
importance. The defect, in order to be called adia-
dochokinesia, should not be complicated by the pres-
ence of any loss of muscular power, or of disturbance
of sensibility. It is well recognized that clumsiness
in performing rapid alternating movements exists in
ordinary hemiplegia, in a number of ataxic states,
due to impaired sensibility, but the significant
feature of adiadochokinesia is that it should be found
without the presence of muscle palsies or of sensi-
bility disturbances. It is one of a series of closely
related motor disturbances due to interference in
certain of the cerebellar paths, and one which, taken
in conjunction with other disturbances of cerebellar
mechanism, is extremely useful in the differentiation
of cerebellar disorders. Essentially, according to
Babinski, it consists of a lack of proportion, a lack
of timing, as it were, between the successive move-
ments. In other words, on the affected side there
is a time loss, or a delay in the motor impulse. This
time loss, which produces the disproportion between
the series of movements on the sound and on the
affected side, is largely due to the disturbance in the
automatic tonic mechanism, the most important
paths for the maintenance of which lie in the cerebel-
125
Adiadochokinesia
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
lum, I lie superior cerebellar peduncles, and the red
nucleus.
When this symptom is present in its pure form, a
lesion of the cerebellum, or of the superior cerebellar
peduncle almost invariably has been found, yet, at
the same time, a few cases have been recorded in
which the lesion has been extra-cerebellar, but not
non-cerebellar, by which is meant that although the
cerebellum itself has proved to be involved, yet
nevertheless cerebellar tracts have always been
implicated. Thus, a few patients showing this
symptom have been known to have frontal tumor.
Here the cerebcllo-thalamoeortical paths have been
implicated. Clinically, the majority of the patients
have shown tumors of the cerebellum. Some mid-
brain tumors, or midbrain hemorrhages with impli-
cation of the superior cerebellar peduncles have also
shown this symptom. Smith Ely Jelliffe.
Adipocere. — (French, adipocere, gras des cadai'res;
German, Fettwachs.) As the name suggests, adipo-
cere, from Latin adeps, lard, and ecru, wax, is a
material resembling in its gross appearances fat and
wax. It is a semitranslucent, white, or slightly
yellowish substance of about the consistency of
cheese at ordinary temperatures; has a greasy feel,
and yields slightly when pressed between the fingers.
If a piece be rolled between the fingers for a few
minutes it becomes much softer. When rubbed with
water it forms a lather. Its composition is that of a
soap, being made up of the calcium soaps of palmitic
and stearic acids and also of acid ammonium soaps.
Examined under the microscope it shows, occasion-
ally, very numerous scales having a crystalline form;
more commonly nothing but fat globules is to be
seen. If it be melted and again allowed to cool, it
is found, often, to have crystallized in round masses
made up of needle-shaped crystals, radially arranged;
hence like stearin.
Most of the specimens of adipocere with which one
is familiar come from the macerating troughs of
anatomical departments and from museum jars
which have long contained specimens immersed
in dilute alcohol. It thus represents the results of
a metamorphosis of dead animal tissues placed under
peculiar circumstances.
The only special point of interest in connection
with adipocere lies in the fact that it is occasionally
found in dead bodies which have been buried a con-
siderable time. In fact, nearly all the structures of
the body, except the bones, have been found con-
verted into this material. For centuries its presence
had been noted in disinterred corpses, but no oppor-
tunity was afforded for studying it on a large scale
until 1876, when, upon the removal of the bodies
from one of the cemeteries in Paris, a considerable
proportion of those buried in the common grave were
found by Foucroy to have been converted, to a
greater or less degree, into this peculiar, fatty, wax-
like material, and to it he gave the name by which
it has since been known.
The conditions favoring its formation in buried
corpses are still unknown. Doubtless moisture is
always necessary; but why, of six or eight bodies
buried in close proximity, and hence presumably
under like conditions of soil and moisture, one should
undergo almost complete change into adipocere,
while the others undergo ordinary putrefaction, as has
been observed, is at present inexplicable.
At one time it was thought that adipocere might be
of medicolegal importance in helping to determine the
length of time a corpse had been buried. Foucroy be-
lieved that thirty years was required for its formation.
Later, this was reduced to one year; and Caspar
mentions finding adipocere in the body of a new-born
child which had lain for three months in a house
cesspool. It is therefore impossible to establish an
idea, from the presence of adipocere in a corpse, as
to the length of time it has been buried.
Artificially, adipocere can readily be produced,
either by soaking muscle in dilute nitric acid for two
or three days and then washing it thoroughly in
warm water, or by allowing the muscle to soak for
months in a trough supplied with running water.
Adipocere is probably closely allied to cholesterin.
W. W. Gannett.
Adiposis Dolorosa. — At a meeting of the American
Neurological Association, held in New York in June,
1892, the writer presented the histories and photo-
graphs of three cases of an affection which up to that
time had not been recognized. Four years previously
the writer had described the symptoms which con-
stitute this affection in reporting a case under the
title of a subcutaneous connective-tissue dystrophy.
Subsequently he grouped this case, a second described
by Dr. F. P. Henry and a third rase discovered in the
wards of the Philadelphia Hospital under the name of
adiposis dolorosa by which the affection has since
been generally known. The two principal features,
fat and pain, are implied by the name. German
writers in reporting cases of this disease use the terra
"adipositas which is etymologically correct, while
the word adiposis is of mixed origin, being made up
of a Latin root and a Greek termination. It has,
however, been used for generations, more especially
by English medical writers and is paralleled by other
mongrel words, long approved by custom, such as
' tierminology." Again "adipositas" is itself a
'coned word; it is not found in any Latin writing, the
real Latin word being "obesitas," which if we insist
upon being correct, we should use.
Subsequent to the descriptions published by the
writer, cases were reported by Collins, Peterson,
Ewald, Eshner, Spiller, F6re and others and in 1901,
Louis Vitaut 1 published a thesis upon the subject.
His description was full and accurate, so much so
indeed that subsequent observation necessitates but
little modification of it. Up to the present time a
large number of cases, possibly a hundred, have
been placed on record.
Among the more important recent publications
were those by Frankenheimer, 2 Price, 3 and Poirier. 4
The three cases which the writer grouped together
in his original paper are presented in brief abstract
herewith:
Case I. — M. G., age fifty-one, female, native of
Ireland, domestic, widow. Family and early history
without significance. In November, 1886, she was
admitted to the surgical wards of the Philadelphia
Hospital for the rupture of a varicose vein of the leg.
In the following February she was transferred to the
medical wards for a severe attack of bronchitis.
Later she had an attack of severe pain and swelling
in the right knee, attended by chill and fever. She
was treated for rheumatism and obtained prompt
relief. Two weeks after this she complained of a
sharp darting pain in the right arm. It began on the
outer aspect above the elbow and gradually increased
in severity and extent, spreading upward to the
shoulder and neck, and downward to the forearm
and hand. It was shooting and burning in character.
She felt at times as though hot water were being
poured upon the arm, and again as though the hands
and fingers were being torn apart. No rise in tem-
perature was noted. The pain was often paroxysmal,
but it was never absent. On June 4, 18S7, she was
transferred to the nervous wards of the hospital and
came under the care of the writer.
Her appearance at this time was striking. She
was a tall, large-framed woman who looked as though
she had at one time presented a fine physical develop-
ment, but she seemed unnaturally broad across the
back and shoulders. On removing the clothing, an
126
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Adiposis Dolorosa
enormous enlargement of these parts was disclosed.
The enlargement affected both shoulders, the arms,
the back and the sides of the chest. It was most
marked in the upper arms and bark, forming here
huge and somewhat pendulous masses. It was
■
neSS about the knees, followed by .--welling, which
gradually increased. At first she thought that the
swelling was due to her growing fat, but later she
was astoni hed to sec that then- was a localized mass
on the inner aspect of each knee. At the time there
was dull aching pain in the affected p
_^ aBK ^pa Later, the right arm became involved, a
mass making its appearance on the outer
aspect. Her body, as she then observed,
had also become larger, as her stays wen-
too small for her. During this time, while
-till in California, inability to perspire
freely, except at the Turkish bath, was
marked, and was part of her reason for
^H| coming East. Since she has been in I'liila-
I delphia the lack of perspiration has not
bi en as marked as before. Various plans
of treatment were tried, but did not influ-
ence the progress of the disease, i.e. the
growth of the swelling. Five or six years
ago, injections of chloroform were made
into the swellings on the inner sides of the
knees, but no good was accomplished.
Painful ulcerations were the result, and
scars of considerable size mark their loca-
tion.
Jrat onbaek:
elastic and yet comparatively firm to the touch, and
it was impossible to produce pitting. In some
situations it felt as though finely lobulated and in
others, especially on the insides of the arms, as though
the flesh were filled with bundles of worms. The
skin was not thickened; it did not take part in the
swelling, and it was not adherent to the subjacent
tissues. In addition the swelling was very painful to
pressure. Pronounced pressure appeared to be
absolutely unbearable. The nerve trunks also were
exquisitely sensitive, but this painful condition was
not by any means limited to them, but permeated
the swollen tissue as a whole.
ad Upper Arm. About five years ago a slight swelling
appeared in the epigastrium. This gradu-
ally increased in size until it resembled the breasts in
shape, and afterward spread so as to involve nearly
the whole abdomen. From the knees the process
extended to the thighs, and gave rise to large masses
on their outer side and about the hips. At various
times she had suffered with pains apparently situated
in the enlarged tissues, or running down the limbs.
Sometimes these attacks were fairly well localized in
one limb, in one side, or about a joint.
Case III. — M. M., age sixty, widow, a tailoress by
occupation, and a native of Germany. Family and
early personal history likewise without significance.
On examination the patient was found to be excessively
Fig. 47. — Another View of Author's First Case.
Case II. — E. W., female, age sixty-four, married,
native of England. Family and early personal
history without significance. Present malady began
about fifteen years ago, when she was forty-nine
years old. At that time she was living in California.
The first thing noticed was a constant feeling of cold-
feeble. For some two weeks she had been unable
to walk. She lay, for the most part, in a quiet,
apathetic state, though when aroused, she answered
questions slowly, but intelligently. She was also
somewhat deaf.
Examination further revealed soft, fat-like masses
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Adiposis Dolorosa
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Fig. 48. — Author's Second Case.
or swellings in various situations. Thus, a large, soft
mass was found over either biceps, and others, some-
what smaller, over the outer and posterior aspect of
either upper arm. Two large masses were found
over the belly, separated above the umbilicus by a
deep, transverse crease. Another gave excessive
prominence to the mons Veneris. From the back of
the neck, at. its lower part, sprang a big mass like a
hump, while a diffuse swelling gave a cushion-like
coating to either half of the back, and extensive
deposits gave unnatural
prominence to either hip.
In marked contrast, the
deposit was absent from
the forearms and hands,
from the face, from the
thighs and legs, and from
the buttocks. The glu-
teal regions, in fact,
seemed flattened and
sloping.
The deposit over the
bark seemed tolerably
firm and resistant; over
other portions it was
quite soft, though elastic,
and exhibited the same
nodular feel noted in the
previous cases. Further,
it was discovered at once
that these masses were
painful to the touch, the
patient complaining very
much when only moder-
ate pressure was exer-
cised] This was espe-
cially true of the deposits
over the arms and back of the neck. In addition
the patient complained of stabbing pains in the
deposits, more marked in the regions just men-
tioned. There was no tenderness over the nerve
trunks. She complained also of headache.
These cases presented in brief fatty deposits, ac-
companied by pains, shooting, burning, or stabbing
in character. Sometimes the pain occurred in
paroxysms and at such times there was present an
increase or induration of the swellings. Sometimes
new deposits were formed during such crisrs.
Since these cases were published, enough has
been learned about the affection to enable the
following systematic description of the disease to
be presented.
Etiology. — In a proportion of the cases, neuro-
pathic elements are noted in the heredity; occa-
sionally also in collateral relatives. Again, it is now
and then noted that other members of the family
are obese as was noted by Eshner, in one of whose
cases the mother of the patient was very stout and
in another of the writer's cases in which the father
was excessively stout. Occasionally it has hap-
pened that several instances of adiposis dolorosa
were noted in members of the same family. Chee-
vers has placed on record the case of a man whose
father and sister had the same disease as the
patient; Hammond reports two cases occurring
among sisters. The affection appears to predomi-
nate especially in the female sex, the proportion
being about six to one.
It is difficult to make definite statements as to
the age at which the disease appears. The young-
est case reported is that of Hale White in which
the disease began at twelve years of age, while the
oldest patient thus far recorded was seventy-eight
years of age. According to Frankenheimer, the
majority of cases in men occur between thirty and
forty years of age and in women between thirty and
fifty years of age. Now and then there is an an-
tecedent history of alcoholism or of syphilis. The
significance of these facts, however, is open to ques-
tion, but as has been pointed out by Price and has
been emphasized by Lorand, both alcoholism and
syphilis not infrequently cause degenerative changes
in the ductless glands, structures which are probably
at fault in the production of adiposis dolorosa. In a
case described by E. W. Taylor, the disease developed
while the patient was convalescing from an acute
alcoholic neuritis. In quite a number of cases ex.
cessive menstrual flow and even uterine hemorrhages
■
EHk'^ Is
m ~
\ / 1
x /
--*fWj,
Fig. 49. — Rear View of Author's Second Case.
128
REFERENCE HANDBOOK OF THE MEDICAL SCIENI I S
Adiposis Dolorosa
have been aoted. In one ease, that of Spiller; the
adiposis dolorosa followed pregnancy, while in another,
thai of Schlesinger, it followed an abortion. Quite
:i number of cases finally have developed after the
menopause.
Fig. 50. — Author's Third Case.
Among other facts, trauma has been noted in the
ory; attention has been called to this especially
by Guidiceandrea. In one case of the writer and in
One of Eshner, trauma appeared to play a role of
exciting cause. Emotional shock has also preceded
the onset as in the case of Achard and Laubry. In
Vitaut's case there appeared to be a mild infection
of the digestive tract; in other cases exposure to cold
and dampness, rheumatism, appeared to play a role.
sionally also some other neurosis exists side by
side with the affection, as in the woman reported by
Henry and in a man reported by the writer, both of
whom suffered from
epilepsy. In othercases
again, undoubted men-
tal disease has been
noted, and even com-
mitment to an asylum
for the insane has been
resorted to in such
cases.
Symptomatology . —
The symptoms as a
rule appear very gradu-
ally. Most frequently,
as stated above, the
patient is a woman.
Up to the period of the
onset of her symptoms,
she has been apparently
well and perhaps en-
gaged with the usual
household duties or
other occupation. She
has occasion at one
time to notice a slight
pain or tenderness in
some portion of her body. These early symptoms of
pain are very variable in character and in intensity.
Most often it is a sensation of smarting or stinging
more or less annoying because of its persistence.
Sometimes the pain, even in the beginning is severe,
though this is unusual. At other times the onset of
symptoms is preceded by a sensation of cold in re-
gions in which pain subsequently makes its appear-
ance. As a rule the pains at first are not very pro-
nounced and the patient is for some time able to
Vol. I.— 9
follow her ordinary occupation. Furthermore, the
pains arc not pei i tenl bul recur al intervals, the
patient being comfortable for hour i and ometimes
for days al a tunc. Little by little the pain become
mure pronounced; they increase in intensity and
t hen also accompa nied bj di
tinol local changes. The pa-
tient nal urally examine: I lie
pari which is painful and may
note these changes herself.
Sometimes there is a little
flushing of the skin and sooner
or later a swelling is noted.
At first it is hardly apprecia-
ble but gradually becomes
mi. re pronounced. The swell-
ing may give a sensation to
the linger of a, rather firm
localized edema. As a rule it
is in the beginning a small
nodule — smaller than a wal-
nut, rarely larger. Some-
times a number of such swell-
ings are noted at the same
time. The affection contin-
ues to evolve, usually slowly;
the pains become more in-
tense and more frequent and
gradually the tumefactions
change their character and
finally become veritable tumors or great tumor
masses. In rare cases the fatty deposit appears to
make its appearance without either previous or con-
comitant pain, the pain making its appearance only
after the enlargements or swellings have for some
time existed. This, as already stated, is unusual, the
most common history by far being that just outlined.
The pain is quite commonly paroxysmal, though in
long established cases it may be continuous. In the
intervals the tumefactions are usually tender or pain-
ful to pressure.
Vitaut recognized four cardinal symptoms, namely,
Fig. 51. — Rear View of Author's Third <';tsr.
swelling, pain or tenderness, asthenia, and psychic
symptoms. The swellings may present themselves
under three different aspects. Sometimes they are
small, of variable dimensions, distinct from one
another and readily isolated. Under these circum-
stances they present what Vitaut has termed the
nodular form of the disease. Sometimes they form
extensive masses invading an entire limb or the seg-
ment of a limb. To this condition Vitaut has given
the name of the localized diffuse form. Finally a
129
Adiposis Dolorosa
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
tumor properly speaking may not be present, but the
entire body may be augmented in volume in conse-
quence of a hyperplasia of the fatty subcutaneous
connective tissue. This condition Vitaut has called
the generalized diffuse form.
When the affection presents itself in the nodular
form, we notice at first pains variable in character,
for example, stinging, itching, smarting, shooting,
which is soon followed by a slight redness of the skin
and a slight induration scarcely appreciable by the
finger. If we examine the painful area, we feel a
tumefaction usually of small size, at first yielding
and later a little more resistant. The sensation is
that of a firm edema which is not well differentiated
from the surrounding tissue. The tumefaction
appears to develop slowly in keeping with successive
attacks or crises of pain. Gradually it becomes
somewhat better defined, its volume increases and
its consistence changes so that it no longer has the
appearance of a simple tumefaction, but that of an
actual tumor. Each increase of swelling is pre-
ceded or attended by characteristic pains. The
latter are sometimes so sudden in their onset and so
severe as to cause the patient to cry out. During
the height of the paroxysm, the tumor may resemble
very closely, in the sensation which it gives to the
fingers, a "caking breast." The painful crisis having
passed, it is found that the dimensions of the swelling
have distinctly increased. It has become perma-
nently larger as well as more resistant and better
defined. After repeated paroxysms, the swelling
resembles a distinct tumor more and more closely.
In certain portions the mass may appear finely
lobulated, while in other parts it gives to the fingers
the sensation of a bag of worms beneath the skin.
Each painful crisis leaves behind it very appreciable
changes. In an area where nothing existed pre-
viously, we find after a crisis a diffuse edematous
tumefaction; if the tumefaction has existed previous
to the crisis, we find it transformed into a lobulated
tumor more or less well encapsulated. Sometimes
after a crisis we discover around the tumor a well-
defined edematous zone which in subsequent crises
undergoes a transformation such as the original mass
itself had undergone. In this way the mass may
eventually attain great size. The various stages of
the evolution of these masses can be followed very
closely by palpation. One and the same patient,
besides, usually presents in various regions tumors
in various stages of development. Painful crises
supervene usually without appreciable cause; at
times they are provoked by trauma and at others
they ensue upon unusual exertion. The patient is
frequently very positive in stating that slight con-
tusions of the surface or that excessive fatigue provokes
the painful crises.
The swellings vary considerably in size. Some of
the very smallest may be no larger than a pea,
though so small a mass is the exception. More
frequently the mass is of the size of a walnut or a
small orange. .Much larger sizes are met with. The
larger masses are, of course, evident to ordinary visual
inspection, the smallest ones require to be sought
for by palpation. If we examine the patient atten-
tively in a good light, we are struck by the changes in
the skin in certain areas. In places indeed it presents
a bluish tint due to a slight superficial veining and if
we examine such a region by the feel, we frequently
discover a small subjacent tumor. Small as the tumor
may be, it may betray its existence by this bluish tint
in the skin which covers it. It happens sometimes
that these small tumors become confluent and finally
form a single large mass. Such a mass gives rise to a
sensation like that of a varicocele or of a bag of worms.
This sensation of a bag of worms is noted with especial
frequency in the fatty masses which are loose and
pendent.
Swellings may occur in almost any situation except
in the face, hands and feet. These are rarely, if ever,
involved. Sometimes the swellings are symmetrical,
especially in the beginning of the disease, but soon
they group themselves about without any apparent
order. They develop by preference over the limbs
or in the segments of a limb. In some patients they
are limited to the arms and thighs, or forearms and legs
in others. Sometimes we find them on the thorax,
abdomen, and lumbosacral region. In the stage of
edematous swelling, the tumor masses pass without
exact limitation into the surrounding tissue. As a
rule the skin is but slightly movable over them.
Later, however, distinct tumor masses, more or less
encapsulated, are formed. They are mobile in all
directions. They are slightly adherent to the skin
so that if one tries to displace the overlying skin,
motion is transmitted to the swelling. At times,
however, the skin can be gathered in a fold above
the tumor. These masses again, it must be borne in
mind, are painful not only during the crises, but are
tender to pressure; this tenderness as already stated,
may persist in the intervals between the paroxysms.
When the painful swellings are localized, though
diffuse, they may begin primarily as diffuse wide-
spread enlargements or a number of nodules may
become confluent and in this way present a diffuse
mass. However, the more frequent manner is the
gradual appearance of a diffuse mass without the
previous formation of nodules. In such a case the
pains are felt over a correspondingly extensive region.
At first the entire region presents an edematous
swelling easily observable by the eye. Subsequently
the evolution of the mass is substantially the same as
in the nodular form. Painful crises are here again
present and the swelling increases in size with each
successive attack. Finally a mass is formed which is
resistant and painful to pressure. It may be quite
smooth or it may be finely lobulated, or separate;
apparently encapsulated tumors may be found im-
bedded in the general lipomatous mass. It is difficult
to make out the limitations of the latter as clearly as
in the nodular form. These diffuse masses are found
more frequently upon the thighs, the buttocks, the
back, the abdomen, and the upper arms. The swell-
ings are usually very painful and during a "crisis"
may be much nodulated and may present the sensation
to the fingers of a breast distended by milk, i.e. a
sensation of a caked breast.
When the affection presents itself in the generalized
form, the appearance may be less distinctive but the
origin and course are the same. The swelling may
appear rapidly, even suddenly and involve the greater
part of the surface of the body and limbs, exclusive
of the face, hands, and feet. It steadily increases and
results in a general lipomatosis. Most commonly,
however, like the localized diffuse form, it begins in
a certain part, for instance the abdomen, sometimes
upon one side and then begins to diffuse itself gradu-
ally over the neighboring portions of the trunk and
limbs. In other portions of the body similar swell-
ings may make their appearance, perhaps at the
same time, perhaps a little later and these becoming
confluent with the original mass and with each other,
a diffuse lipomatosis again results. The parts
affected are ordinarily the thighs, hips, buttocks,
abdomen, chest, upper arms, and forearms. In
exceedingly advanced cases, small masses of fatty
tissues may be observed over the thenar and hypo-
thenar eminences and even on the soles of the feet;
in one case the writer observed even a slight invasion
of the face. Even in excessively diffuse forms, with
enormous increase of the body weight, the writer
has never observed an invasion of the backs of the
hands or the dorsum of the feet.
The swelling of the generalized diffuse form is
much less resistant than the nodular or localized
diffuse forms. The entire fatty mass is spontaneously
painful and tender to pressure, though the pain is not
130
KKIT.K i:\CK HANDBOOK OF THE MEDICAL SCIENCES
Adiposis Dolorosa
equally diffused but more pronounced al certain
times and in certain areas than others. Local II net na-
tions of induration also are noted. Sometimes the
Buffering, owing to the universal pain and tendernes
is exceedingly great; it may be so pri inced as to
prevent any motion on the part of the patient and to
immobilize him in bed. The nodular form is the
most common.
A word remains to be said regarding the character of
the pain. This occurs either spontaneously or is readily
elicited by pressure. Most frequently the pain
precedes the appearance of the edematous swellings.
Sometimes it comes on at the same time as the swelling;
more rarely it is not noted until after the swelling
has made its appearance. Slightly marked and
intermittent at first, the pain becomes more violent
after the disease has been established. It is described
by the patient as stinging, burning, pinching, darting,
or even lancinating. Most frequently it darts and
radiates or is diffused in and about the nodules. It
does not follow the large nerve trunks or indeed any
nerves. The patient describes the pain as though it
was situated in the thickness of the masses. One
characteristic is presented by all cases, namely the
paroxysmal exacerbations of pain already described.
Suddenly and without cause or following an effort or
trauma the patient again feels active pain. At the
same time the new formations increase in volume.
In addition to the fatty masses and the pain there
an 1 present the asthenia and the psychic symptoms.
All or almost all of the patients present the symptoms
of a general asthenia. The patient is very readily
exhausted. Even in cases in which the muscular
development is good this fact is early noted and in
cases which are advanced, the asthenia is very pro-
nounced. Indeed the patient may become bedridden
by reason of this weakness as well as because of the
pain which is usually made worse by exertion, espe-
cially in advanced cases.
Psychic symptoms are also very frequently present.
A cerebral asthenia or cerebral exhaustion is rarely
absent. There is present in addition usually great
irritability. This is at times so marked as to be at-
tended by a change in character and in disposition.
The patient frequently quarrels with his neighbors in
the wards and to such an extent that isolation may
become imperative. Sometimes the patient thinks
that the other patients or the nurses " are against
her." Systematized persecutory ideas are, however,
not present. The sleep may be broken and there
may be distressing dreams and nightmares. One of
Eshner's patients had to be committed to an asylum
because of the pronounced character of the mental
disturbance. Hale White's patient had two attacks of
mental disturbance and Guidiceandrea has noted
delusions of persecution and a true dementia. Other
symptoms are also occasionally noted. Thus there
may be present lessened sensibility, to touch, pain, and
temperature or paresthesias may be complained of,
such as velvety sensations in the finger tips and in the
soles of the feet. Patients have also complained of
sudden sensations of cold or of heat, of formication, or
of cramps in various parts of the body.
Symptoms may also be presented by the special
senses. Thus narrowing of the visual fields has been
noted. In others, subjective sensations, such as
phosphenes and muscae volitantes. In one case
amaurosis was observed; this disappeared under
thyroid treatment. In a case of the writer there was
noted a circinate retinitis — a mass of partly fibrinous
and hemorrhagic exudate in the center of the retina,
surrounded by crescents of fatty degeneration in
Mueller's fibers.
The auditory perception has been observed to be
diminished in a number of cases. Occasionally tin-
nitus aurium has been recorded and finally in one of
the writer's cases, smell and taste were distinctly
impaired.
Vasomotor phenomena are quite often present.
The skin over a nodule may present no changes what-
ever. On the oilier hand, it may be no ed that it is
somewhat injected during a crisis of pain or much
veined and slightly bluish. Sometimes the face is
much flushed, especially over the malar regions and
the forehead or it may be tin- nnk. \o induration
or swelling accompanies these changes in color. Cya-
nosis of the extremity and transitory edema have
also been observed. A very common symptom
noticed is that the flesh bruises very readily and quite
commonly small ecchymoses on various portions of
the limb and trunk are revealed at the time that the
patient is examined. These ecchymoses or subcu-
taneous bleedings make their appearance sponta-
neously and independently of trauma. In keeping
with this fact are probably the metrorrhagia, excessive
menstruation, epistaxis, hematemesis variously ob-
served. Trophic changes in the form of ulcerations,
blebs, and bulla have been noted. It is important to
add that, there is quite commonly a marked dryness
of the skin. In women there is frequently present
a history of relatively early cessation of the men-
strual function.
Among unusual complications, noted in adiposis
dolorosa are changes in the joints. Cases showing
such changes have been noted by Renon and Heitz
and by the writer. It appears that the changes are
in part due to the fatty infiltration and that this fat
is painful to pressure. In other cases it is probable
that an actual synovitis is present and in one of the
writer's cases, distinct changes were revealed in the
cartilage and bones by the z-ray. Price has also
noted changes in the joints confirming these findings.
Price together with Hudson also noted changes in the
bones — in the dorsal vertebrae and in the ribs — the
changes being evidently trophic in character. Their
existence was confirmed by the skiagraph. Price
and Hudson called attention to the possible signif-
icance of these findings in view of the frequency of
pituitary changes in adiposis dolorosa.
The course of adiposis dolorosa is essentially chronic.
The progress is slow, the patient being better or worse
by turns according to the occurrence of paroxysms of
pain. In well-established cases, the suffering is con-
tinuous, subject always to more or less marked
exacerbations. In the majority of cases the patient
becomes exceedingly obese, the weight often running
from two hundred to three hundred pounds. In the
nodular form, the weight may undergo very slight
if any increase.
The tendon reflexes may be normal or increased.
Most frequently they are diminished and sometimes
absent. Occasionally the skin reflexes are lost.
Coincident gross nervous or other disease has, as
may be expected, been noted a number of times.
Thus hemiplegia and aphasia coexisted in one
case; in another sclerosis of the columns of Goll
and in another still involvement of the lateral
tracts.
Pathology. — Up to the time of writing, eight autop-
sies have been held. These indicate that in adiposis
dolorosa there is some disturbance of the internal
secretions, excessive formation of fatty tissue and
an interstitial neuritis of the nerve fibers contained
in the deposits.
Price has summarized the results of the various
autopsies as follows:
Cases I and II. — Dercum: Macroscopic disease of
the thyroid, the glands being enlarged and the seat
of calcareous infiltration.
Case III. — Dercum: Irregular atrophy of the
thyroid, extensive interstitial neuritis of peripheral
nerves in fatty deposits, degeneration in the columns
of Goll.
Case IV. — Burr: Glioma of the pituitary body;
colloid degeneration with atrophy and absence of
secreting cells in many acini of the thyroid gland;
131
Adiposis Dolorosa
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
interstitial neuritis of terminal filaments; sclerotic
ovaries.
Case V. — Dercum and McCarthy: Adenocarcinoma
of pituitary body, thyroid normal, right suprarenal
gland hypertrophied, hemolymph glands, interstitial
neuritis, undeveloped testicles.
Case VI. — Guillain and Alquier: Hypophysis
doubled in size with marked increase of connective
tissue in the glandular portion and changes suggesting
an alveolar carcinoma; thyroid hypertrophied with
increase in connective-tissue stroma.
Case VII. — Price: Inflammatory changes in thyroid,
with marked increase in the interstitial connective
tissue, one whole lobe being especially infiltrated,
the other showing compensatory hypertrophy. In-
flammatory changes in hypophysis, with presence of
a condition suggesting alveolar or glandular carcinoma,
interstitial and parenchymatous neuritis, sclerotic
ovaries.
Case VIII. — Price: Marked increase in the con-
nective tissue of the thyroid gland, dilatation of the
acini, with infoldings of the cuboidal epithelial lining.
The same changes in the hypophysis as were found
in Cases VI and VII, but less marked. No abnor-
malities of the adipose tissue.
Delecq thinks that disease of the thyroid, testicle,
ovary, and pituitary body may be causes of adiposis
dolorosa. Von Schroeter concludes that adiposis
dolorosa is due to a dysthyroidismus. Pineles regards
the disease as a result of the disturbance of function
in numerous blood glands and that there are present
hypothyroidism, genital atrophy, and changes in the
hypophysis.
The thyroid gland, it will be noted, showed unmis-
takable changes in seven of the eight autopsies.
These changes are very interesting and are well
illustrated by the findings in the third autopsy of
the writer in which the gland was submitted to
microscopic examination. The changes observed
were indicative in part of the hypertrophy and in
part of atrophy. In certain portions of the gland,
numerous small acini appeared to be in process of
development. Exceedingly large acini distended by
deeply staining colloid material were also present,
while plications and papillary outgrowths of the
walls of he acini seemed to be an attempt to increase
the secreting surface. Other portions of the gland
were distinctly atrophic. It is not impossible that
there was present a compensatory hypertrophy
accompanying degenerative changes in other portions
of the gland. The findings resembled those obtained
by Halstead in the thyroid of a dog after partial
extirpation.
It is not improbable that qualitative changes of
function of the thyroid gland play a role. Substances,
the result of deranged thyroid action, may be formed
which may, on the one hand, prevent the proper
oxidation of the hydrocarbons of the foods and tissues
and on the other may act as a cause of neuritis and
nerve degeneration. Whatever the explanation, it is
interesting to recall the diminished sweating and the
occasional slowness of speech and mental irritability.
The interpretation is of course difficult; the obesity
and the dryness of the skin suggest thyroid deficienev,
while the flushing of the face, the occasional tachy-
cardia and the psychic symptoms would point rather
to thyroid excess, and it is safer perhaps with Pineles
to regard the condition as one of dysthyroidismus.
Among the most significant findings, however, are
the changes noted in the pituitary bod}'. In five of
the six cases in which the pituitary was examined, it
was found diseased. Thus Burr described a glioma
of the pituitary, Dercum and McCarthy adeno-
carcinoma, Guillain and Alquier changes suggesting
an alveolar carcinoma, and Price changes likewise
suggesting alveolar or glandular carcinoma in two
cases.
In considering the possible role of the pituitary
body, we must bear in mind the recent interesting
researches of Harvey Cushing with regard to the
carbohydrate function of this organ. It apparently
stands in the most intimate relation with the assimi-
lation of the carbohydrates so that if its anterior
lobe is destroyed in animals, carbohydrate tolerance
and assimilation are greatly diminished or lost. The
pituitary body is thus brought into relation, though
perhaps indirectly with a fat producing or fat destroy-
ing function. In the light of other observations, this
subject assumes a new importance. Froelich has
shown that instead of the symptom-complex termed
acromegaly, lesions of the hypophysis may be asso-
ciated with an adipositas universalis and genital
atrophy. In other words, hypopituitarism may lead
to adipositas. Further, curious and remarkable inter-
relations of function — seemingly antithetical — appear
to exist between the pituitary and the pineal gland,
the pineal gland appearing to have a fat producing
and a fat destroying function inversely to the pitui-
tary. For a detailed presentation of the subject,
which here would lead us too far afield, the reader i<
referred to Otto Marburg's interesting paper on
" Adiposis Cerebralis, a contribution to our knowledge
of the pathology of the pineal gland." 5
If the pituitary is diseased in adiposis dolorosa, it is
not surprising that changes should also be found in
the thyroid; it is unnecessary to point out that these
two glands are closely interrelated as regards their
function. Experimental extirpation of the thyroid
in animals has been found to be followed by pituitary
enlargement; it would seem that disease of one gland
would mean sooner or later disease of the other.
An examination of the fatty deposits reveals not
only the structure of fatty tissue, but also the signs
of great nutritional activity. Fragments removed
during life by the Duchenne trocar in the writer's
first case and submitted to microscopical examina-
tion presented the appearance of a connective-tissue
embryonal in type. The cells were voluminous, fusi-
form, and containing large nuclei while the inter-
cellular spaces were filled by a transparent substance
apparently without structure. On the whole the
appearance was that of a lymphoid tissue. In some
fragments fat cells were numerous and among these
were cells which evidently had not undergone com-
plete fatty transformation. In the autopsy recorded
by Dercum and McCarthy, the fatty nodules were
submitted to microscopical examination.
The capsule was composed of several layers of well-
developed connective tissue. Within this capsule a
looser areolar tissue was met. This tissue was highly
vascular, and between the vessels was a reticular
tissue, denser in some areas than others and inclosing
a large number of mononuclear cells, a few pi
nuclear cells, and large numbers of cells stained a
tawny color by the Van Gieson stain. Scattered
through the granular, tawny masses, many of the
mononuclear type of cells could be found. In other
areas, granules of blood pigment in clumps could be
seen. Wherever the connective-tissue trabecule
penetrated into the congested fat nodule, this same
fine, reticular structure, holding in its meshes rich
plexuses of blood-vessels, and between these a fine
reticulum of connective tissue filled with a light
yellow granular material, with nucleated yellow cells,
small mononuclear cells, polynuclear cells, and num-
bers of degenerating red blood cells, could be seen.
Some of these cells reacted to many of the staining
reagents as do nucleated red blood-corpuscles, but
to the Biondi-Ehrlich triple stain they appeared
more as mononuclear leucocytes.
Diagnosis. — The diagnosis of adiposis dolorosa is
exceedingly simple. It is based upon the presence
of pain — spontaneous, paroxysmal or elicited by ma-
nipulation — in fatty masses having the physical pecu-
liarities described above. The affection is readily
differentiated from myxedema because of the non-
132
REFERENCE HANDBOOK OF THE MEDICM, SCIENCES
Adirondacks
juvoh cmenl of Ilii" face .-iml hands and because u! I he
absence of pain in myxedema. When the tumor
masses arc numerous and quite small, they may
suggest von Recklinghausen's disease, i.e. neurofibro-
matosis, but the fact that the nodules arc found to be
tabulated under palpation, that they are spontane
ously painful and almost never occur on the face or
hands serves to make the differentiation; again in
neurofibromatosis, the tumor masses are only later-
ally mobile; they are small, very hard, and often
grouped along the course of the nerve trunks like a
string of beads. In adiposis dolorosa, the tumors
are mobile in all directions and are irregularly
distributed.
The differentiation between adiposis dolorosa, and
simple obesity lies in the fact that in the latter affec-
the fat is distributed throughout all the tissues
does not heap itself up in separate lipomatous
ma ises such as is the case in adiposis dolorosa, oven
in the so-called diffuse form. Besides there is an
absence both of pain and of crises of any kind.
( Ordinary obesity is painless ami is a matter of gradual
development, while the peculiar paroxysmal charac-
ter presented by both the pain and the swellings of
adiposis dolorosa is unmistakable.
Prognosis. — The affection is essentially chronic. It
lasts as a rule for many years. Eventually, however,
a bedridden period sets in, general exhaustion super-
penes, degeneration and failure of the heart muscle,
pulmonary congestion, or disease of the kidneys may
terminate the picture. It must be borne in mind
also that these patients present a greatly diminished
resistance to infection.
When the affection is in the early stage, the out-
look is much less gloomy; indeed at times the prog-
nosis is distinctly favorable. Early cases are dis-
tinctly amenable to improvement and indeed an
arrest of symptoms or relative cure may sometimes
be brought about. Cases far advanced, with ex-
tensive deposits and presenting marked asthenia and
especially when complicated with a tendency to
Subcutaneous hemorrhages and hemorrhages from the
mucous membranes are very unpromising; indeed, in
such cases treatment proves to be of little avail.
Treatment. — In cases in which the disease is not
too far advanced, the writer has had marked success
by employing the following measures. First he places
the patient in bed, secondly he withdraws as far as
Eossible the carbohydrates from the diet, and thirdly
e administers cautiously but in increasing doses,
thyroid extract; beginning usually with one grain,
three times daily, and increasing to three grains, three
times daily — rarely five grains. In order to control the
pains, he has made liberal use of aspirin or novaspirin.
At times he has fallen back upon sodium salicylate
with sodium bromide in full doses, especially during
paroxysms of pain. As a rule these measures, if
persisted in for several weeks or better still for a
number of months, are followed by a marked loss of
weight and a marked subsidence of pain. In three
of the writer's cases the improvement was both
marked and persistent; in two a permanent arrest of
symptoms ensued.
The rest should be absolute and should extend over
several months. The patient should be weighed
when treatment is begun, and at intervals thereafter.
Jt should be remembered that a diet, no matter how
rigid, will of itself make no impression in adiposis
dolorosa; it will fail absolutely. It is of course wise
to institute a careful diet, but patients do better
when the diet is not too strict. Inasmuch as the
affection is attended by a marked asthenia, the diet
should be nutritious It should consist of the red
meats in moderation, the white meats freely, the
succulent vegetables, eggs, and skimmed milk. The
latter can be used between meals and if necessary
also at meal times.
As soon as the tenderness permits, gentle massage
should be instituted; sometimes this can never be
employed, in other eases it can be instituted com-
paratively early and there can be no doubt thai in a
measure it favors the diminution of the swellings,
especially if the patient can bear deep kneading.
Bathing between blankets as in ordinarj m i treat-
ment should also be carried out, but of themselves
baths accomplish nothing in adiposis dolorosa; in-
deed the physical exertion and manipulation attend-
ant upon the application of ordina ry hydrotherapeutio
measures in these cases exhaust the patient.
The treatment should extend over a period of
many months and the patient should be kept under
observation for several years. F. X. Derci m,
I: i FEUENCES.
1. Vitaut: Maladie de Dcrcum. Thesede Lyon, [901.
2. Frankenheimer: .tour. Amer. Med. Asso., 1908, i.. p. 1012.
3. Price: Amer. Jour. Med Sciences, May, 1909,
4. Leon Poirier: La Maladie deDercum.MontpelHer, 1910.
5. Marburg: Deutsche Zeitschrift fur Nervenheilkunde, 1908.
Bd. xxxvi p. 111.
Adiposity. — See Obesity.
Adirondacks. — This extensive forest and lake
region is a plateau studded with mountains and lakes
:d situated in Northern New York, between lat. 42°
30' and I 1 30', long. 74° to 7.5° 30' W., being, roughly
e timated, 1 25 miles square.
The average elevation is 1,000 feet, the mountain
peaks varying from 2,000 to 5,000 feet, trending in
general toward the southwest in several irregular
ranges. The northern and southern boundaries are
gradual slopes to the St. Lawrence and Mohawk valleys
respectively, while the eastern is more abrupt to Lakes
George and Champlain, and the western less so to
Lal^e ( intario.
Geologically, this region is related to the Archean or
earliest formation, with glacial drift and moraines
much in evidence. The soil is chiefly light sand,
which forms a feature of importance in determining
the climate and character of the forest growth.
The lake shores, lowlands, and valleys are wooded
chiefly with fir, pine, white cedar, tamarack, red
spruce, and balsam. The lesser elevations and foot-
hills have deciduous trees in greater proportion, such
as sugar maple, birch, beech, poplar, mingled with
a few evergreens, while the majority of the peaks are
wooded to the top with firs and spruces.
The combination of dark-green-clad mountains and
numerous island-dotted lakes gives at all seasons a
landscape of great beauty.
Large tracts of forest are owned by the State and
individuals for permanent preserves, insuring pro-
tection for fish and game and conserving the water
supply. Temporary camps are permitted on Stale
land, and during the trout and deer seasons great
numbers of sportsmen find delight in these haunts.
Modern camp life for the invalid or convalescent in
the Adirondacks is a pleasure hardly surpassed, when
all the luxuries are available.
The climate has long been noted for its invigorating
qualities. The winters are usually cold and dry, the
summers cool but moist, though relatively dryer than
coast climates or lowlands.
The porous soil, elevation, and coolness render the
moisture less apparent, though the rains are very fre-
quent in summer. Meteorological data for a number
of years are now available for the comparison of
different sections of the plateau. The mean annual
temperature for the whole region is 42. s° F. ; average
total precipitation, forty-two inches.
The prevailing winds are west and southwest, being
much varied and retarded by the mountains and im-
mense areas of forest. The coast winds do not reach
inland far enough to affect the climate, but Lake
( intario modifies the western slope, while the northern
part is influenced more by the St. Lawrence valley
133
Adirondacks
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
winds, which, especially in winter, sweep across the
level plains of Canada from the west.
The precipitation is greater on the southern and
western slopes than in the interior and northern
portion of the Adirondack plateau, though local con-
ditions appear to influence the amount greatly. Thus
at Saranac Lake, in the northern center, the average
annual precipitation is thirty-four inches, yet in the
foii'st, within a few miles, it is manifestly much
greater. At the same place the annual mean tem-
peral lire was 41.7° F., and for the four winter months
19.5° F., with an average of ten rainy days for the
winter. The mean summer temperature was 62° F.
Quoting from the Annual Report of the New York
Weather Bureau, 1896: "The Adirondack plateau is
subject mainly to the same influences which deter-
mine the climate of the St. Lawrence valley, excepting
that the central and eastern portions of the highlands
are not reached by the lake winds. A very broken
and heavily timbered surface offers great obstructions
to the circulation of air currents, and hence the
summer temperature, although the- lowest in the
State, is somewhat higher than would otherwise be,
due to the elevation of the region. *****
" So far, then, as present records show, the whole of
Northern New York has substantially the same
average winter temperature, except as certain deep
valleys are subject to a local cooling through an accu-
mulation of the colder and denser air. In summer the
warmth of the highlands decreases at about 0.3 degree
per hundred feet of elevation above sea level, and
the average temperature of the Adirondack region at
that season is thus reduced to nearly the same level
as that which prevails on the seacoast of Northern
Maine; the days, however, being wanner and the
nights cooler than in the coast region."
There is an excess of cloudy weather in November,
December, April, May, and frequently at other
seasons; the virtues of the climate being attributable
to coolness, altitude, aseptic atmosphere, and freedom
from dust, rather than to the amount of sunshine.
The suitability of the climate for the cure of early
tuberculosis has been amply demonstrated, and arrest
or amelioration of advanced cases is secured by a
prolonged residence, when the powers of resistance can
be stimulated. It has been found beneficial, particu-
larly in summer, for chronic bronchitis and asthma
dependent upon it, also for hay fever. The winter
is equally good, if not better, for early tuberculosis.
It is unsuited for rheumatics, renal cases, and patients
beyond middle life.
The principal resort, Saranac Lake, is generally
known because of the Adirondack Cottage Sanitarium,
founded by Dr. E. L. Trudeau, for tuberculous
patients of moderate means. This establishment has
one hundred rooms, and was the first people's sana-
torium of its kind in America. Twenty-five per cent
of all cases and from sixty to seventy-five per cent,
of the incipient class are discharged apparently cured.
A list of the various resorts in the Adirondack
region with their respective elevations, is appended.
Further information can be found in Solly's " Medical
Climatology," in Knopf's "Pulmonary Tuberculosis,"
in nuicis book , etc.
Resort. Elevation.
Mini,- Lake 1,535 feet.
Lake Placi.l 1,863 feet.
Tupper Lake 1,546 feet.
Keene 1,000 feet.
I llizahethtown 759 feet.
Old Forge 1,684 Fei t
full, in Chain 1,700 feet.
Paul Smith's 1,623 feet,
Saranac Inn 1,560 feel.
North Elba 1,68 i
Chazy Lake 1,500 feet.
Blue Mountain Lake 1.S00 feet.
Schroon Lake 806 feet.
During the past ten years numerous public and
private institutions have been established in and
about Saranac Lake. The most important are the
New York State Hospital for Incipient Tuberculosis
situated at Raybrook, two miles east of Saranac
Lake; capacity, 350; free to residents of New York
State. Stony Wold Sanatorium, Lake Kushaqua,
N. Y. ; women and children; capacity, 100; semi-
charitable. Sanitarium Gabriels, Gabriels, N. Y.;
capacity, sixty; semicharitable.
E. R. Baldwin.
Adolescence. — The term adolescence denotes that
portion of an individual's life, vegetal or animal,
during which it is becoming adult or mature. The
Latin term adolescere seems to have been allied to
alere, to nourish, and this idea still enters the general
notion of adolescence as the period of growth and full
development. For the majority of English-speaking
people, at least, this term covers the period between
the ages of fourteen and twenty-five in males, and in
females twelve and twenty-one. It includes therefore
puberty and years following puberty until the menial
and physical aspects of the adult may reasonably be
said to have become complete.
Individual differences are, however, here as uni-
versally elsewhere, conspicuous, and the practitioner
is bound to keep in mind the well-known fact that any
particular patient may be either precocious or re-
tarded. These differences appear on the surface of the
literature to be more common in girls than in boys,
for many instances of sexual maturity, as indicated at
bast by menstruation, fully developed breasts and
other sexual organs, etc., have been reported in indi-
viduals only a few years or even a few months of age.
Retarded adolescence is probably still more common
but with far less disastrous results usually to the
future happiness of the woman. The physical signs
of puberty and later adolescence are generally so
conspicuous that little chance of harmful error in any
bodily direction normally exists. In those rarer
eases, however, in which the mental efficiency ami
capabilities are uncorrelated to the physical evolu-
tion, mistakes with unfortunate consequences are
liable to be made by teachers and by parents. This
diseorrelation is a subject that needs scientific
study.
As writers have pointed out repeatedly, this pre-
eminently important whole period of life, likewise,
has as yet received but a small part of the study and
research it deserves; but there are indications that
physiologists, psychologists, and hygienists are at
last awakening to their dutiful privilege in this respect.
President G. Stanley Hall is the one conspicuous
exception to this generality, so much so indeed that
his treatise ("Adolescence," 1907) is likely to remain
for some years yet the magnum opus in this particular
scientific field, much as is Havelock Ellis's "Psy-
chology of Sex," in that somewhat closely allied sub-
ject. The present writing is much indebted to both
of these compendiums, especially to the former, ami
to them the reader is respectfully referred for greater
wealth of detail and statistics. If one search the
medical libraries for adequate information on the
physiology and pathology of adolescence, one will he
properly surprised at the contrast between the abun-
dance of publications on childhood and their paucity in
relation to the no less important developmental con-
ditions of adolescence. One of the pressing needs in
medical literature is a really adequate exposition
of this subject detailed with special reference to
every phase of the professional theory and practice;
this would afford one more set of adaptations of
the general principles of Medicine to particular con-
ditions.
Somatology. — It is customary in discussions of
134
REFERENCE HANDBOOK OF THE MEDICAL SCIENI I 3
Adolescence
puberty to devote considerable care and space to the
tabulation of statistics on growth, growth of tissues,
of organs, and of Individuals, sel forth in about every
useful way both in absolute numbers and in percental
relationships. So frequently of late have summaries
of these averages been published in many kinds of
books that it seems unnecessary to reproduce them
at length. Stanley Hall speaks of about sixty such
iv valuable memoirs and tabulations" of growth.
for a summary, F. Burk: American Journal of
hology. April, 1898, pp. 253-326.) As respects
stature, the table made out by Prof. Franz Boas of
Columbia from his own measurements and those i
Bowditch, Porter, Peckham, and West, of 45,151
boys and 43,298 girls resident in Boston, St.Louis,
Milwaukee, Worcester, Toronto, and Oakland, is of
fundamental value and is, therefore, here repre-
d as the American standard at the ages repre-
sented:
Growth
Number at
each age
Height
Weight
Vgi
Actual,
.
ental
in nun
■
in kilns
hut'
16
30
37 . 23
2 15
8.01
1 I..-.1
17
I ;i
2 ) 76
1.15
18
211
0.70
1 . 56
7. 11
19
153
7 99
3.18
5.49
20
73
7.69
0.50
5.29
21
•1!)
6 in
0.34
2 s7
5.60
22
27
5.22
, ,
23
12
1.92 0.26
3 . 1 5
21
13
0.16
1 . 92
3.02
25
i
1.28 2.42
6.18
12.76
.71)
1.19
8 l-'i
Boys.
lirls.
Approxi-
mate
average
Number of
Average height
Absolute an-
Percental
Number of
'■• height
Absolute an-
Percental
observations
for each year,
nual increase,
annual
observations
ch year,
nual increase.
annual
•
inches.
inches.
increase.
inches.
inche
increase.
.". . ')
1 ,535
41.7
2 .
5.3
1,260
41.3
2.0
4.8
6.5
3,975
43.9
2.1
l.s
3.61S
43.3
2.4
5.5
i ..>
5.379
46.0
_' s
6.1
4.913
45.7
2.0
4.4
8 . 5
5,633
IS S
1.2
2.5
5.2S9
47.7
2.0
4.2
9.5
5,531
50.0
1.9
3.8
5,132
49.7
2.0
4.0
5,151
51 . 9
1.7
3.3
1,827
51.7
2.1
4.1
ll.. r )
1,759
53.6
l.S
3.4
1,507
53.8
2.3
4.3
12.5
I.-' 15
55.4
2.1
3.8
4,187
56.1
2.4
4.3
13.5
3,57) 1
..» i . . »
2.5
4.3
3.411
58.5
1.9
3.2
14.5
2,518
60.0
2.9
4.8
2,537
60.4
1.2
2.0
15.5
1.481
62.9
2.0
3.2
1 ,656
61.6
0.6
1.0
16 5
753
64.9
1.6
2.5
1.171
i.J J
0.5
O.S
17.5
129
66.5
0.9
1.4
790
62 . 7
229
67. t
As concerns weight, Burk's table, made from the
weighing of 69,000 children in Boston, St. Louis,
and Milwaukee by* the same observer-, is as follows:
The relative sizes and activities of the various
tissues and organs characteristic of adolescence,
although of importance to the physician very often
Boys.
Girls
Age
Average for each
\ 1 isi ilute annual
Percental annual
Average for each
Al isolute annual
Percental annual
age, pounds.
increase, pounds.
increase.
age, pounds.
increase, pounds.
increase.
6.5
45.2
43.4
7.5
49.5
4.3
9.5
47.7
4.3
9.9
8.5
54.5
5.0
10.1
52.5
4.8
10.0
9.5
59.6
5.1
9.3
57.4
4.9
9.3
10.5
65.4
5.8
9.7
62.9
5.5
9.6
11.5
70.7
5.3
8.1
69.5
6.6
10.5
12.5
76.9
6.2
S.7
78.7
9.2
13.2
13.5
84.8
7.9
10.3
■s.S.7
10.0
12.7
14.5
93.2
10.4
12.3
9S.3
9.6
11.9
15.5
107.4
12.2
12.8
106.7
S.4
S.5
16.5
121.0
13.6
12.7
112.3
5.6
5.2
17.5
115.4
3.1
2.8
18.5
114.9
The late Professor Edward Hitchcock of Amherst
College, the American pioneer in this work and in
other work relating to physical education, measured
T4J different students (males), at that institution,
belonging to the classes between 1885 and 1901 and
summarized the results as in the following table. This
obviously is complementary to the preceding tables,
for it takes the development to the full limits of the
time of average adolescence
for purposes of accurate diagnosis and the general
understanding of conditions, is too long and compli-
cated a matter for insertion here, consisting as it does
of very numerous facts and statistics from which it
would be difficult to choose. Stanley Hall's monograph
already referred to contains the most complete exposi-
tion of the subject known to the present collaborator,
occupying seventy-eight pages of the first volume of
the work; to this compilation the reader is referred.
135
Adolescence
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Psychology. — The mental characteristics of the
adolescent receive everywhere extensive description,
of course, incidentally in fiction, and have been dis-
cussed more intensively but unsystematically by many
competent scientists, and of late still more technically
through knowledge gained by the new method of
psychoanalysis. None of the scientific accounts is
truer to the life than that of G. Stanley Hall and
therefore we shall not hesitate to quote from him,
first reminding the reader that many of these psy-
chological considerations, some of them general and
hard to analyze as they are, are of preeminent impor-
tance in medical affairs of many kinds, somatic as well
as those more psychical in classification. In adoles-
cence, fully as much as elsewhere in the life time,
bodily and mental relations are interdependent and
inseparable, neither being fully understandable with-
out knowledge of the other, for each is part and par-
cel of one indivisible personality. It is high time the
medical profession put this basal fact, so fully realized
as true by every observant and educated student of
humanity, into practice and used it habitually as a
principle of diagnosis and of treatment, as already
indeed do the most broadly educated of our physicians,
more and more. Nowhere more than in adolescence
i- this interdependence of dependent variables con-
spicuous and important, both mind and body being
then eminently plastic and impressionable to stimuli
within and without.
"Psychic adolescence," says Stanley Hall, "is
heralded by all-sided mobilization. The child from
nine to twelve is well adjusted to his environment and
proportionately developed; he represents probably an
old and relatively perfected stage of race maturity,
still, in some sense and degree feasible in warm cli-
mates, which, as we have previously urged, stands for
a long continued one, a terminal stage of human devel-
opment at some post-simian point. At dawning
adolescence this old unity and harmony with nature
is broken up; the child is driven from his paradise mil
must enter upon a long viaticum of ascent, must con-
quer a higher kingdom of man for himself, break out a
new sphere, and evolve a more modern story to his
psychophysical nature. Because his environment is
to be far more complex, the combinations are less
stable, the ascent less easy and secure; there is more
danger that the youth in his upward progress, under
the influence of this excelsior motive will backslide in
one or several of the many ways possible. New
dangers threaten on all sides. It is the most critical
stage of life, because failure to mount almost always
means retrogression, degeneracy, or fall
Youth loves intense states of mind and is passionately
fond of excitement. Tranquil, mild enjoyments are
not its forte. The heart and arteries are, as we have
seen, rapidly increasing in size, and perhaps heightened
blood pressure is necessary to cause the expansion
normal at this stage. Nutritive activities are greatly
increased; the temperature of the body is probably a
trifle higher. After its period of most rapid growth,
the heart walls are a little weak, and peripheral circu-
lation is liable to slight stagnation, so that in the
interests of proper irrigation of the tissues after the
vascular growth has begun, tension seems necessary.
Although we do not know precisely the relation be-
tween blood pressure and the strong instinct to tingle
and glow, some correlation may safely be postulated.
Ii is the age of erectile diathesis, and the erethism
that is now so increased in the sexual parts is probably
more or less so in nearly every organ and ti- lie
The whole psychophysic organism is expanding,
stretching out, and proper elasticity that relaxes and
contracts and gives vasomotor range is coordinated
with the instinct for calenture or warming up, which
is shown in phenomena of second breath in both phys-
ical and mental activity. In savage life this period
is marked by epochs of orgasm and carousal, which is
perhaps one expression of nature's effort to secure a
136
proper and ready reflex range of elasticity in the cir-
culatory apparatus. The "teens" are emotionally
unstable and pathic. It is the age of natural inebria-
tion without the need of intoxicants, which made
Plato define youth as spiritual drunkenness. It is a
natural impulse to experience hot ami perfervid
psychic states, and is characterized by emotionalism.
We here see the instabity and fluctuation
now so characteristic. The emotions develop by
contrast and reaction into the opposite. We will
specify a few of its antithetic impulses now so marked.
1. There are hours, days, weeks, and perhaps months
of overenergetic action 2. Closely con-
nected with this are the oscillations between pleasure
and pain — the two poles of life, its sovereign masters.
The fluctuations of mood in children are rapid and
incessant 3. Self-feeling is increased,
and we have all degrees of egoism and all form- of
self-affirmation. ..... 4. Another clearly re-
lated alternation is that between selfishness and
altruism 5. Closely connected with the
above are the alternations of good and bad conduct
generally 6. The same is true of (he
great group of social instincts, some of which resl
upon the preceding. Youth is often bashful, retiring.
in love with solitude 7. Closely akin
to this are the changes from exquisite sensitiveness
to imperturbability and even apathy, hard-hearted-
ness, and perhaps cruelty .s. Curiosity
and interest are generally the first outcrop of intel-
lectual ability. Youth is normally greedy for knowl-
edge, and that not in one but in many directions.
9. Another vacillation is between know-
ing and doing. Now the life of the study chant -.
and the ambition is to be learned, bookish, or there
is a passion to read. He would achieve rather than
learn 10. Less often we see one or more
alternations between dominance by conservative
and by radical instincts 11. We find
many cases of signal interest in which there is a
distinct reciprocity between sense and intellect, as if
each had its nascent period 12. Closely
connected with this is the juxtaposition of wisdom
and folly We have already seen that the
body growth is not symmetrical, but to some extent
the parts, functions, and organs grow in succession,
so that the exact normal proportions of the body are
temporarily lost, to be regained later on a new plan.
The mind now grows in like manner. It is as if the
various qualities of soul were developed successively;
as if the energy of growth now stretched out to new
boundaries, now in this and now in that direction."
This quotation from a master of the subject is
justified in the extreme importance of this aspect of
the adolescent individual — preeminent over the body,
often in directions to which the physician desires to
turn his attention more and more each year as he
gradually learns better how indivisible is the psycho-
physical nature of mankind. Nowhere else, certainly,
than in adolescence has the mind, its feelings and its
thoughts, stronger dominance over the somatic
phases of the evolving life — over nutrition, circula-
tion, reproduction, movement, secretion, the bodily
half of us all. Later in life, body, as it hardens, tends
more to dominate mind, but in adolescence ii i<
eminently impressionable to every mental influence.
We have repeated it for emphasis, for it constitutes
the keynote of all real understanding of adolescei
Another inherent factor that must be noted con-
cerning this period of life is somewhat related to this
one — we refer to the rapid growth and evolution and
activity of the two-phased individual. This vivacity
of the whole being, both as protoplasm and as com-
plete animal, both as body and as mind, makes the
youth or maiden, as compared with the child or the
adult, much more apt to go astray off the beaten I nek
of the average, of the so-called " normal." In a some-
what metaphorical sense, it is a irmtter of momentum.
i;i:i i;i:i:\ci: ha.xuhook of Tin: mfdicai. sciences
Adonis
Just as a rapidly moving oar meets usually with worse
disaster when il leaves the rails than does one moving
slowly, so many adolescent conditions, verging at
[ea i on the aberrant, become conspicuous and
often distinctly pathological, because of the rapid
changes going on in the living tissues and in the
mental action oi the adolescent. Perhaps the most
conspicuous illustration of this tendency is to be seen
in the distortions of the skeleton (mentioned below).
l'.v iiiot.oov. — We have already noted the paucity
dual descriptions and discussions of the diseases,
mental and bodily, of adolescence. One reason for
tins has been the obvious fact, borne out alike by
general medical observation and by elaborate sta-
tistics, that while the morbidity of adolescence is
large, larger than thai of any other parts of life
early infancy and senescence, the mortality of
this period is low, in fact the lowest of the whole life,
especially between eleven and fifteen (Hartwell).
Another important reason of this widespread medical
defect in the study of adolescence has been stated by
Hall concisely in these terms: "The general reason
for this neglect is that medicine has been chiefly
concerned with the study and practical treatment of
pronounced diseases, and has not yet come to rest on
the broad basis of biology, which is its natural and
scientific foundation. Practitioners, too, have been
occupied, both at home and in hospitals, with grave
cases and have had little time and less motive to
CorTsider preventive medicine or the more general
problems of regimen and hygiene, personal, domestic,
or public. Perhaps occupation with flagrant symp-
toms tends to give diminished interest, if not distaste,
for the milder and incipient manifestations of disease
which require sharper diagnosis and a higher quality
of mind to detect." This is wisdom of the highest
practical and theoretic importance, but these con-
ditions of defect mentioned are now certainly in
process of elimination from all adequate medical
education, for biology is rapidly becoming the mother-
science of scientific medicine. (See for example the
writer's recent pioneer "Laboratory Course in Phys-
iology based on Daphnia and Other Animalcules,"
in the Biologische Zentralblatt, Bd. xxxii, Nr. o. S.
285 291, May 20, 1912).
One large part of the pathological conditions of
adolescence is commonly thought and discussed as
"functional" defects, those especially that depend
ultimately on maladjustment to the rapid evolution
of mind and body and which more immediately are
obviously conditions only a little beyond fatigue
coming from overuse. Examples of this that will
occur to every reader are chlorosis, eyestrains, and
kyphosis (roundback).
t If the diseases which are most common during
adolescence many are chronic conditions that reach
their worst later on in adult years. Others are com-
mon to childhood and adolescence — holdovers, as it
were, from their more proper and earlier epochs when
the susceptibility' or liability to them is greater.
No classification of the diseases of adolescence is
adequate owing to the perfect unification of the
psychophysical nature of man, but it might be con-
venient, none the less, to divide them into classes
more or less corresponding to the physiological sys-
tems of the individual. We should then have groups
of infectious fevers; of blood and circulatory diseases;
of joint and skeletal diseases; of digestive and meta-
bolic diseases; of nervous diseases; of skin diseases;
and of genital diseases.
The infectious fevers most often seen in adoles-
cence, perhaps, are pulmonary tuberculosis in the
acute form, rheumatic fever, typhoid fever, acute
anterior poliomyelitis, rotheln (German measles),
diphtheria, mumps, and meningitis in all its forms.
Of these typhoid fever is at its worst in adolescence,
and the life-ravages of acute rheumatism on the heart-
valves are beyond computation in many parts of the
world. It should be noted that poliomyelitis, although
most unfortunately railed infantile paralysis, in the
recent widespread epidemics has frequently attacked
adolescents, their susceptibility being probably under-
estimated by the profession as well as by the laity,
in part perhaps owing to its old-time name.
The bl 1 and circulatory diseases, perhaps d
conspicuous between the ages of tweh e and twenty-
three, are simple anemia, chlorosis, albuminuria,
acute myocarditis, endocarditis, tachycardia, arrhyth-
mia, brachycardia, palpitation, pharyngomyeosis,
lymphadenitis, epistaxis, and edema "I the larynx
Of these the anemias are the most characteristic of
adolescence.
Among the numerous conditions of joint at id bone
disease seen most frequently at the age which we are
discussing, are scoliosis, kyphosis, genu valgum,
genu varum, pes planum, acroiliac disea e,
tuberculosis ossium, chondr a, acromegaly, giga
tism, infantilism, and the rickets of adole cence.
Metabolic diseases proper I the class is a very indefi-
nite one by its nature) peculiar to adolescence do not
exist, but among those most commonly met with
perhaps, in addition to those already noted, are myx-
edema, goiter, exophthalmic goiter, diabetes insipi-
dus, and Addison'.- disease. Abnormal conditions
related to the digestive apparatus more or less
directly, seen in adolescents, are dyspepsia, gastric
dilatation, enteroptosis, gastralgia, floating kidney,
gastric ulcer, appendicitis.
The nervous diseases are numerous and important,
as might be expected from the unbalancing effects of
the strains and stresses incident to the rapid changes
and violent emotions of this period of life. Neuras-
thenia, cephalalgia, epilepsy, catalepsy, hysteria,
chorea, spasmodic asthma, "psychic infantilism,"
acute dementia, early stages of syringomyelia, demen-
tia precox, cerebral embolism, spinal apoplexy,
Friedreich's disease, cerebellar ataxia, spasmodic
spinal paralysis, are among the most, important.
The skin diseases of adolescence are of no little
practical importance, being very common, some of
them, indeed. Acne in various forms, eczema,
urticaria, psoriasis, keratosis, lupus, furunculosis,
verruca vulgaris, seborrhea are among the most
conspicuous of these.
Gonorrhea and syphilis are, of course, the most
important of the genital diseases of adolescence, with
import for the human race scarcely yet appreciated,
even by our profession.
In closing this brief outline of this significant period
of life, one of the most interesting from every point of
view, the extreme importance of the new awakening in
sexual common knowledge of all kinds, and in eugen-
ics as its outcome, cannot be too strongly urged. In
this direction lies apparently one of the physician's
most splendid opportunities, for the very root of
adolescence is the sexual evolution and sexual
maturity. George V. N. Deaeborn.
Adonidin. — Adonin. A glucoside obtained from
several species of Adonis, chiefly from the root of A.
vernalis L. It is a light-yellow powder, without odor,
but intensely bitter, very hygroscopic, soluble in both
water and alcohol. Moisture must be carefully ex-
cluded from the containers. As it exists in commerce,
it is a mixture of variable degree of purity. Its action
is described under Adonis. The dose is 0.004 to 0.016
gram (grain T V to \).
Picradonidin is merely the very pure form of
adonidin. H. H. Rusby.
Adonis. — False Hellebore (family Ranunculaeecc).
The carefully dried and preserved herb of Adonis
vernalis L., one of some sixteen species in the genus.
It is a small plant, growing wild in Southern
137
Adonis
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Europe, and somewhat cultivated as an ornamental
flower. Owing to the instability of its active con-
stituent, adonidin, it should be carefully preserved in
a cool and dry place and should not be kept on hand
too long. The plant is poisonous.
Besides the active constituent described above, it
contains aconitic acid to the extent of ten per cent.
The action of adonis is apparently due altogether to
the adonidin, which exists to the extent of 0.02 of
one per cent. Its effects are for the most part
exerted upon the circulation. Its first and chief
action is to stimulate the vasomotor centers and thus
greatly increase blood pressure. Next it stimulates
the heart directly, increasing both its rate and force,
and thus still further increases the blood pressure.
This pressure then reacts against the heart and may
slow it. If the dose is larger, the inhibitory centers
are stimulated, and this markedly slows the heart.
The same causes render it a powerful indirect diuretic.
The vasomotor stimulation is not long continued, and
is succeeded by depression, as is to a less extent the
direct cardiac stimulation, the two together causing
a sudden fall in blood pressure. If the dose is a
poisonous one, death will occur with the heart in
diastole. Large poisonous doses cause vomiting and
purging. The treatment of poisoning is entirely
physiological and symptomatic and is practically the
same as in digitalis poisoning, except that the stage of
reaction may be expected much more quickly.
Adonis is used in exactly the same way as digitalis,
as a cardiac and arterial stimulant, and is liable to
the same contraindications. The greatest difference
of opinion exists as to which is preferable, but it
appears established that adonis, at least in the form
of adonidin, acts more quickly, though the action is
not so prolonged, and is more apt to be followed by
reaction. No attempts have been made to ascertain
whether the tissue of the heart muscle is permanently
changed in quality or quantity by adonis, as appears
to be the case with digitalis.
Adonis is best given in the form of tincture or fluid
extract, which are miscible with water, or :is adonidin.
The dose of adonis should represent 0.05 to 0.25
gram (grain i. to iv.). It is best to begin with a
small dose and increase gradually.
H. H. Rushy.
Adrenal Glands. — See Suprarenal Glands.
Adrenalin. — Trade name of a substance derived
by Aldrieh and Takamine in 1901 from the suprarenal
glands of the ox, and containing the active principle
of the internal secretion of these glands. It has the
empirical formula C 10 H 15 NO 3 (Takamine) or C 9 H 13 -
NO, (Aldrieh), and occurs as a grayish or light brown
finely crystalline powder, of a somewhat bitter ami
benumbing taste, slightly soluble in w-ater, insoluble
in alcohol, ether, and chloroform. The form in
which it is commonly used is the solution of adrena-
lin chloride, which is a 1-1 000 solution of adrena-
lin chloride in physiological salt solution, with the
addition of 0.5 per cent, of chloreton. For a de-
scription of the physiological action and therapeutic
uses of this and other adrenal gland extracts see
Epinephrin and Suprarenal glands.
Aedinae. — A family of mosquitos, Culicidce, in which
there is a straight proboscis, short palpi in both sexes,
plumose antenna? in the male and pilose in the female.
The mosquitos of the genera in this family are usually
found in jungles, and they are suspected of being hosts
of the malarial germ and also carriers of Filaria es-
pecially F. perstans. See Insects, poisonous.
A. S. P.
Aegidius Corboliensis, Petrus. — Pierre Gilles de
Corbeil, as he was known in France, was born in the
twelfth century. He studied medicine at Salernum,
in Italy, was the regular medical attendant of Philip
Augustus, and was a professor in the Medical Faculty
of Paris. His writings on various medical topics (on
the urine, on the arterial pulse, on compound drugs,
and on the signs or indications of disease) were gener-
ally accepted, for a long period of years, as of the highest
authority. Printed editions were issued at Padua
Mist), at Venice (1494), at Lyons (1505, 1515,
1526), and at Basle (1529). Some idea of the import-
ance attached to the writings of Aegidius may lie
formed from the fact that an entirely new edition of
the first three works mentioned above was printed at
Leipzig as recently as in 1S26. A. H. B.
Aerophagy. — Aerophagia, from ii/p, air, +4>iyw,
1 eat. This term has come into general use quite
recently, not being mentioned in Gould's Dietianary
of 1904, though frequently encountered in periodicals
early in the present century. It is, however, practi-
cally identical with the habit of cribbing in horses,
long and well known, and under various designations
has been described in human beings for many years.
For the most part, however, it has been confused with
ordinary belching of gas formed in the stomach.
The inclusion of some air in food, drink, and secre-
tions swallowed is inevitable, especially during hasty
eating and drinking and in continued, forcible
attempts to clear the throat of mucus. The amount
included seems to depend upon the conformation of
the fauces and pharynx. The subsequent belching
of at least part of the air thus swallowed is a normal,
conservative process.
True aerophagia is a habit neurosis of two quite
distinct types: (1) The literal swallowing of air and
its subsequent eructation; (2) an inspiratory spasm
with closure of the glottis — hiccough or singultus—
with the added feature that for some unexplained
reason, the esophagus becomes patulous and dis-
tended under the thoracic suction due to the action
of the diaphragm and extrinsic muscles.
The inclusion of the second type is justified, partly
because the essential pathological element is the habit
and the symptoms are similar; still more because of
the gradual transition from the former to the latter
type through (a) the combined (obviously not syn-
chronous) occurrence of swallowing and sighing; \l>)
the interruption of the sigh by a closure of the glottis;
(c) the suction of air into the esophagus almost
without deglutitional movements.
Normal aerophagia implies the entry of air into the
stomach. Whether air enters the stomach or not in
the first type of pathological aerophagia, depends on
the distensibility or actual dilatation of the esophagus
(the last a rare complication), and the length of the
deglutition stage. The patient, almost always — and
the physician often — is unaware of this stage and
hence regards the condition as an eructation of gases
developing in the stomach itself. Cases in which only
one or two swallows are taken, followed by the
eructation of a mouthful (approximately fifty cubic
centimeters) of air, do not usually furnish deglutition
sounds at the cardia and probably no air reaches the
stomach. When the two stages are both prolonged
auscultation usually shows that air enters the stomach
and, even if this sign is absent, a large quantity of air
must have been thus stored, unless the esophagu- is
considerably dilated. The more closely cases approach
the second, singultic, type, the less likelihood is there
of penetration of air into the stomach. The question
must, therefore, be determined for each case and it
must not be forgotten that as there is always con-
siderable gas developed in the intestine and not very
rarely in the stomach, the aspiration and expulsive
efforts of both types of aerophagia are apt to be
complicated by true belching.
The diagnosis, which is mainly a matter of differ-
138
REFERENCE HANDBOOK OF THE MEDICAL SCIEN( I -
Aerothempeutlcii
entiation from ordinary belching in the first type
:unl from hiccough withoul esophageal distention in
the second, rests on the following points: (1) Careful
observation of the muscular action, elevation of the
thyroid, etc.; ('-') Estimation of the amount of gas
eructated as by merely noting the duration of an
attack, by collection in some simple form of trap, as
a glass inverted over a basin of water, etc.; (3)
auscultation over the pharynx, esophagus, anil
stomach; (4) inhibition of the phenomenon by closure
of the month or nares or both.
ASrophagia is probably always essentially hyster-
ical, though not necessarily to the extent of involving
moral perversion or manifestations in other more
eral ways. The exciting cause may be almost
any emotional or physical disturbance; or, as
usually in cribbing horses, the phenomenon occurs
in periods of quiet and is interrupted by any form
of activity or by the same causes that, in other in-
stances, act as excitants. To some degree, a great
variety of organic or functional disturbances may ad,
at times as predisposing, at others as exciting causes.
Nasal polypi, any throat lesion of an irritating nature,
chronic colitis, pelvic disease, gallstones, movable
kidney are mentioned with special frequency.
fermentative dyspepsia and hyperchlorhydria with
its irritation, usually falsely ascribed to the pressure
of gas in the stomach, sometimes genuinely accom-
panied with gas due to the interaction of gastric and
upper intestinal contents (carbon dioxide) logically
lead to esophageal reflexes and hence occasionally to
rophagia. From the nature of the underlying
exciting and predisposing causes, it is scarcely
essary to state that women are more often affected.
Treatment. — Removal of these various causes and
antispasmodic and general hygienic treatment are
indicated, but often fail. It is important that the
patient understand the mechanical, if not the neurotic
ors involved. Drinking water, a light luncheon,
gargling the throat, shutting the lips tightly, and if
— ary the nostrils, interrupt the actual aerophagia,
but do not necessarily either terminate the attack or
produce a cure. The result obviously depends on
personal factors, notably the duration and fixity of
tla' habit and the degree of self control, spirit of
cooperation, or contrariness of the patient. The
passage of the stomach tube or esophageal bougie
almost always accomplishes a cure, if persisted in,
partly by the effect of massage in diminishing spasm,
partly from dread of reintroduction of the tube. Local
analgesics to the throat, applied on the esophageal
sound or injected through the stomach tube into
the esophagus, thermic and various electric forms of
treatment are also of value, probably more by increas-
ing the force of suggestion than by direct therapeutic
effect. A. L. Benedict.
Aerotherapeutics. — The term "aerotherapeutics"
is employed with varying significance by different
writers: thus, for example, Williams' uses the term
as the application of climate in the treatment of lung
disease; others apply it to the use of air artificially
attenuated or compressed by various mechanical
devices, such as the pneumatic cabinet. (See Pneu-
matotherapy). Here, however, the term will be used
in the more simple sense, as the application of plain
outdoor air in the treatment of disease.
Since the open-air treatment of pulmonary tuber-
culosis has become so universal and the results there-
from have been so striking, the attention of the
physician and surgeon have been directed to its use
in the treatment and hygienic management of other
forms of tuberculosis, notably surgical, as well as in
ether non-tuberculous diseases. Not only in diseased
conditions but in health as well the cult of the outdoor
life, if it may be so denominated, has become popular,
and the sleeping porch and outdoor living room are
often in evidence; ami it i.^ generally acknowledged
by those who have accustomed themselves t<> open-
air conditions, whatever the Season of the year, that,
the genera] health is thereby maintained at a higher
standard, sleep is more refreshing and colds and
other infections tire less frequent.
The literature upon the subject of fresh air and its
application has grown apace, and lie- attention of
h" pita] and school authorities, health boards,
factory inspectors, architects, as well as physicians
and sanitarians have been increasingly directed to
its importance. "If fresh air," they say, "is SO
valuable for the sick, it must be equally valuable in
keeping a man well." There is hardly a disease or
abnormal condition which is not benefited by the
open-air treat m«nt; preeminently so are the various
forms of tuberculosis, pneumonia, anemia, and var-
ious conditions of depressed vitality, which, unless
they receive timely remedy, may result in active
tuberculosis.
It is to be understood, and this must be emphasized,
that the open-air treatment means out of doors, or
as near an approximation to it as can be obtained,
and in speaking of fresh or pure air, out of door air
is meant. Of course, no air practically obtainable
is absolutely pure. Generally, out-of-door air must
be that supplied in the place or locality where the
patient is or has to be. If, for example, he is ill with
pneumonia in a city, he can only have as good outdoor
air as the city affords. We can, as we do in many
instances, send patients to various health resorts — in
the mountains, on the sea-shore or to other climatic-
ally favorable localities for the purpose of obtaining
purer air than can be found at home; or for obtaining
a peculiar variety of air, like the rarified air of the
mountains or the salt-impregnated air of the ocean;
or for other especial climatic characteristics desired;
or, again, because outdoor air can be had under
more agreeable conditions, as, for example, in the
warmer latitudes during the colder months of the
year. Nevertheless, open-air comparatively fresh
and active, or at least that which will serve our
purpose, can be obtained, fortunately, almost every-
where, for the majority of invalids cannot go far
afield to seek it. The roof of a city house, the piazza
of an apartment, a shack or tent in the yard, a
window tent, and many other devices will furnish
it; or we can approximate to open-air conditions
in large rooms, with windows on two or more sides
and an open fireplace. It must also be borne in mind
that the therapeutic application of the open-air treat-
ment must be directed in the same careful and pains-
taking way as with other therapeutic measures, and
hence be under the direction and supervision of the
physician.
In this article the open-air treatment will be con-
sidered in its application to:
(a) Pulmonary tuberculosis.
(b) Surgical and other forms of tuberculosis.
(c) Pneumonia and other infectious and respiratory
diseases.
(d) Various conditions of malnutrition, anemia, and
other dyscrasias.
(e) Organic diseases.
Pulmonary Tuberculosis. — The so-called "open-
air" treatment of pulmonary tuberculosis is the
established treatment of this disease at the present
day. In a word, it consists in affording the patient
pure outdoor air to breathe continuously, both night
and day, keeping him out of doors by day and having
his bedroom windows open by night, or better having
him sleep also out of doors. It is hardly necessary
to add that at the same time due attention should
be paid to diet, rest, hydrotherapy, and to all that
pertains to the hygienic well-being of the patient;
hence this method is also, and perhapsmore correctly,
termed the "hygienic-dietetic" treatment. This
treatment has been brought to such a degree of
139
Aero therapeutics
REFERENCE HANDEOOK OF THE MEDICAL SCIENCES
perfection that it may almost be said to be independ-
ent of climate; that is, it can be successfully carried
out wherever there are pure air free from dust,
protection from wind, and a moderate amount of
SU nshin< — climatic conditions which are obtainable
almost everywhere outside of large centers of popula-
tion and even there it can successfully be carried out,
as is constantly exemplified in tuberculosis classes
and otherwise. It seems a very simple matter to
conduct such a treatment, but experience has shown
that constant supervision is necessary, aided by the
example of others, in order to keep the patient up,
day after day, summer and winter, to this treatment
in all its strenuousness; hence the great value of
sanatoria and their constant and rapid increase in
number. Even though this treatment is in a measure
independent of climate, it is not to be asserted that
all climates are equally valuable, for it is obvious
that the greater the number of favoring climatic
elements, the more perfectly the treatment can be
conducted, and the more successful it will be. Hence
such resorts as Davos, Colorado Springs, California,
Asheville, the Adirondacks and many others of
superior climatic excellence are especially favorable
for this mode of treatment, provided the other
essential factors, such as diet, etc., are at hand. It
may be thought that this treatment can be accom-
plished by simply instructing the patient to keep out
of doors; nothing could be more fallacious than this.
In the first place, the patient, in many cases, will
not keep out of doors all day of his own volition.
If he is out for a few hours each day, he is prone to
think that he is fulfilling his instructions. Further,
he is too often left to himself to determine whether he
shall remain at rest or take exercise while in the open;
generally he does the latter, sometimes from ignor-
ance, sometimes for the want of any proper place
where he can remain at rest. Here, again, comes in
the value of the sanatorium where all these details
are carefully looked after.
The theory of the outdoor treatment in this disease
is, of course, evident; the object is so to improve the
nutrition of the pulmonary tissue and general system,
and so to harden the patient and thereby increase
his resisting power that he will no longer present a
favorable soil for the tubercle bacillus. It is also
claimed for this treatment that it will increase tissue
metabolism, so that fibroid transformation of tuber-
culous tissue may be hastened, or the encapsulation
of caseous areas effected.
Are all cases of pulmonary tuberculosis suitable for
the open-air treatment? Obviously not, for all cases
are not susceptible of an arrest or improvement; and
the object of this treatment is to cure. Although
it is difficult, if not impossible, in many cases and in
the various stages of the disease, to form a probable
prognosis, still in general it may be said that advanced
cases with mixed infection and septic symptoms —
cases of very extensive disease, those in which the
tuberculous process is accompanied by acute symp-
toms and other complications, or those in which the
recuperative power seems to be lacking, and the whole
system appears to have collapsed — are unfavorable
cases and unlit ted for the severe regime of the continu-
ous open-air treatment. Fresh air, of course, should
be afforded all cases, as to everybody else, sick or
well; but this can often be best done in a well-venti-
lated room, where the patient is made comfortable
and kept at rest. If some of these apparently hope-
less cases later exhibit more favorable symptoms and
develop greater recuperative power, they then can
more properly be subjected to the complete open-air
treatment.
I, est there may be some misunderstanding, it is
well again to state what may seem self-evident, viz.,
that the open-air treatment in all its rigorousness
means practically a continuous outdoor existence.
Day after day in all kinds of weather one must be
exposed to the open air, and the windows of his sleep-
ing-room must be kept open day and night, summer
and winter, or better, as is now so generally the custom,
sleeping outdoors. This does not mean that one
shall sit out in a rain or snow storm, but on a veranda
for example, which affords shelter from the storm and
wind and yet is open to the air. The writer, for ex-
ample, had a patient at Rutland, Mass., who, during
a New England winter, spent eight hours daily out of
doors, always slept in a cool room, with open window .-.
and bathed his chest every morning with cold water.
As has been said above, a well-equipped sanatorium
affords the best opportunity for taking the open-air
treatment, and medical supervision is always at ham',
to insist upon it; at the same time it is practicable, b
very many cases, to devise at the home of the patient
an arrangement lor this treatment. A properly pro-
tected veranda, preferably facing the south; a tent
with a wooden floor and properly ventilated; a shed
or wooden chalet simply and cheaply constructed,
serving also as a sleeping-room by night — all of these
afford opportunities for the "treatment." If the
physician is at all ingenious he will readily invent
some way by which this can be accomplished, for
there is almost always something in or about tin
patient's house that can be utilized for this purpose,
and the devices for securing open-air life are innumer-
able; vide "Some Plans and Suggestions for Housing
Consumptives"; "Fresh Air and How to Use It"
(Carrington), published by the National Association
for the Study and Prevention of Tuberculosis.
It is hardly necessary to say that a patient used to
an indoor life, as the great majority of them are, must
be somewhat gradually accustomed to a constant
open-air exposure, but it is marvellous how perfectly
they establish the habit, and how complete is the
endurance which they attain. Knopf 2 quotes Andvoid
of Tonsaasen, Norway, as saying that he leaves hi
patients on their chairs, wrapped in furs, for from
live to nine hours a day at a temperature of-25° ('.
(-13°F.).
The number of hours during which the patient re-
mains out of doors depends largely upon the location
and latitude of the locality where he is. At Davos,
for example, the sun rises late and sets early, on account
of the surrounding mountains, so that a winter's day
is only about four or five hours long. In Falkenstein
the patients remain out of doors for from seven to ten
hours a day all the year through; at Rutland, Mass.,
for about eight hours; at Colorado Springs for from
seven to eight.
The effects upon the patient of this prolonged stay in
the open air are striking. Appetite and weigh! in-
crease; cough and expectoration diminish; and if there
is any rise of temperature at any part of the day, this
is likely soon to disappear. The patient also experi-
ences a sense of well-being and invigoration, together
with mental exhilaration. After a course of open-
air treatment one is no longer content to live indoors
or sleep with closed windows.
It may be pertinently asked if patients do not catch
cold under this constant open-air exposure. On the
contrary, experience has proved that they are less
likely to do so than when they live under constanl
protection with the consequent unavoidable exposure
to impure air. The constant exposure to pure germ
less air, however cold, when one is properly clad, does
not render one susceptible to catching cold, as Nansen
so strikingly proved on his Arctic expedition.
In concluding this portion of the subject, it is well
to reiterate that the open-air treatment is not the
whole treatment of pulmonary tuberculosis. In
addition, there must be an abundance of nutril
and properly prepared food; rest; a most careful
avoidance of over-exertion either mental or physical;
moderate exercise under careful supervision, and in
suitable cases; and due attention to the skin by the use
of various hydrotherapeutic measures. In brief, all
140
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Ar-in therapeutics
tlic hygienic measures conducive to increasing the
resistance of the individual to the infection, must be
adopted.
Surgical and Other Forms- of Tuberculosis. — Insti-
gated by the success obtained in the open-air treat-
ment of pulmonary tuberculosis, general and the
orthopedic surgeons have been led to apply the same
methods in the treatmenl of surgical tuberculosis,
particularly that of the bones, joints, and glands in
children and young persons, sometimes in conjunction
with operative measures and sometimes without them,
and the results have been as striking as with pulmon-
ary tuberculosis. Prof. Halsted of the Johns
Hopkins University go< s so far as to say that most
of surgical tuberculosis will recover without
ration if they are given a fair opportunity in the
open air, 3 and lie further emphasizes the importance of
d cures by the intensive employment of the out-of-
door treatment by making it continuous, night and
day, this being especially important with children
affected with joint tuberculosis.
It is a question whether seaside or country air is
I favorable for such cases. Seaside sanatoria
existed for a long time on the coast of France
and England and other countries in Europe, and more
recently a few have been established in this country,
njotably "Sea-Breeze" at Coney Island; and excellent
rtsults have been obtained. Likewise apparently
gbod results have 1 n secured in the Adirondack^
and elsewhere inland. Probably it does not make
very much difference provided the air is fresh and
pure and a rigorous application of the open-air regime
is enforced, i.e. the child being exposed continuously
to the open air.
At Leysin, Switzerland, which is some 4,000 feet
above sea-level, the writer recently saw children in
Rollier's Sanatorium suffering from various forms of
surgical t uberculosis, especially of the bones and joints,
treated by exposure of the naked body to the sun and
open air; the deep color of their bodies, bronzed by
the intense rays of the sun in the attenuated air of
that altitude, made them look like North American
Indians. The excellent general condition of these
children, as evidenced by their well-nourished appear-
ance, healthy complexion and exuberant spirits,
and the rapid improvement of the local conditions,
testified to the success and value of the treatment.
Rollier attributes much of his success to the influence
of the sun baths, but one must remember that the open
air includes sunshine to a greater or lesser degree.
The technique of the open-air treatment in surgical
tuberculosis is essentially the same as that in the pul-
monary form. It must, however, be absolute and
continuous, for, as Halsted says, a rapidly growing
boy, with tuberculosis of the knee joint, for example.
might lose a great deal in the length of the affected
limb unless the cure were rapidly effected.
Tuberculous peritonitis is another form of the dis-
ease peculiarly amenable to the open-air treatment, as
are also tuberculous glands; and many cases recover
under this treatment without surgical interference —
indeed, in all cases of internal tuberculosis other than
pulmonary, the open-air conditions of living are of
great value even if they are not the determining
factor in the cure or arrest. It is all important thai
such accommodations shall be provided as will
enable the patient to obtain fresh air continuously, be
it again repeated, and this means sleeping out of doors
at night as well as living out of doors during the day.
Pneumonia and Other Infectious and Respiratory
Diseases. — The provision of open-air conditions is now
quite generally accepted by the profession as an essen-
tial part of the hygienic care of pneumonia, and the
more favorable results obtained attest the value of
such procedure, as heroic as it at first seemed. Even
with infants and young children the open-air treat-
ment is fearlessly employed, and its value has been
abundantly proved by Northrup, the pioneer in the
use of outdoor air with children suffering from pneu-
monia, and by many others. The patient i either
placed directly on! of dooi i'l aii open porch or
loggia, or in a lame room with wide open windows,
i he bed being placed eith i bet een •. indov, or
close to them, no mailer what the season of the year
may 1"-. The e ential thing is to allow the pain at
an unlimited supply of "free, fresh, (lowing i
and the physician must determine in each individual
case how this can be I be accomplished. Instead of
the application of oxygen as a last resort the patient
under the open-air treatment is obtaining a goodly
supply of ii continuously and from the beginning.
In winter the patient should, of course, be prop*
protected, and when this is .lone, he will suffei BO di -
comfort, whatever the temperature of the air, al-
though the nurse will have to be clothed with thick
winter garments. The effect of such constant ex-
posure to outdoor air is better and more restful
sleep, easier respiration, less cyanosis, and fe i
nervous phenomena.
In other acute infectious diseases an essential part
of the hygienic management should always be a
bountiful supply of pure, fresh, outdoor air, either in
a large, well- vent dated room, in a well- vent dated tent ,
or an open porch. That was a wise old school physi-
cian who said that if he had typhoid fever he wanted
to be put under a tree with a jug of milk beside him.
In acute bronchitis, especially in children, it is
quite as important to supply an abundance of fresh
air as in pneumonia, and essentially the same plan
should be pursued in doing so as in the latter disea e.
"Outdoor treatment (in acute bronchitis) should be
a routine practice" says Musser.
In chronic bronchitis and asthmatic conditions the
open-air treatment can most comfortably be carried
out in the warmer latitudes, such as in Southern
California, the West Indies, Florida, the various re-
sorts of the Southern Pine Belt, or on the Mediterran-
ean coast of Italy, France, or Northern Africa. In
many cases the open-air life can be properly insti-
tuted for such conditions, occurring so frequently in
the feeble and aged, only in climates milder and more
equable than the cold and changeable one of the North
in winter. Some cases of chronic bronchitis do best
in a dry, warm climate and others in a warm, moist
one. When for any reason the patient cannot change
his climate in winter, he can often arrange an arti-
ficial mild climate in his own house by confining him-
self to a large room with a Southern exposure, pro-
viding for free ventilation and a sufficient amount
of moisture in the air. Thus he will obtain compara-
tively fresh, warm, moist air, and a reasonable amount
of sunshine.
In the various chronic diseases of the upper respira-
tory tract, such as pharyngitis, laryngitis, and rhinitis,
the open-air treatment is again applicable; and often a
change of climate where outdoor life is more easily
obtained is desirable; and in choosing a resort the
climatic characteristics must be taken into considera-
tion in conjunction with the individual needs and
local conditions.
Convalescents from pleurisy with effusion will
obtain a more rapid expansion of the compressed
lung by the open-air treatment in high altitudes,
provided the heart has recovered its former integrity
and there are no extensive or firm adhesions. At all
events, whether in a high or low altitude, pure, fresh
air is most important in the after-treatment of
pleurisy.
Various Conditions of Malnutritions, Anemia, and
Other Dyscrasias. — A residence in the mountains or
at the sea-shore has long been recognized as perhaps
the most important element in the successful treat-
ment of malnutrition and anemia, particularly in
children and young women. Although, probably,
either the mountain or sea. air will produce more
rapid results, yet any locality where pure, fresh air
141
Aerotherapeutics
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
is obtainable will avail. Care must be taken, however,
thai a really outdoor life is followed. "It is little
use," says Trudeau, "merely to tell people to live
out of doors, they must be made to do it, and suita-
ble accommodations must be provided so they can
do it."
Depressed vitality, from whatever cause, conva-
lescence from acute diseases and surgical operations,
generally respond rapidly to the outdoor life in the
country, mountains, or sea-shore.
The beneficent effect of mountain air upon condi-
tions of debility, anemia, and malnutrition are
strikingly illustrated by a modest institution at Ste.
Agathe, Canada, in the Laurentian Mountains, called
" Brehmer Rest" or "Preventorium," where young
women suffering from the conditions noted above, in-
cident to life in the city, in shop or factory, conditions
which are so often the forerunner of tuberculosis, are
subjected to the open-air treatment for weeks or
months, until the normal standard of health is re-
st ured. Undoubtedly many cases of tuberculosis are
thus prevented, and how much more satisfactory is
this than a longer period in a sanatorium after the
active disease has developed. Such an institution is
rightly named a "Preventorium."
The open-air school and the open-air school room
have rapidly come into favor for anemic, illy-nour-
ished school children, as well as those with latent
tuberculosis. In such schools the children are practi-
cally out of doors or in rooms with the windows wide
open, throughout the year, well protected, of course,
during the colder months. Instruction alternates
with periods of rest, which is taken in the recumbent
position. Nourishing food is also provided. Thus
education goes on coincidentally with the open-air
and hygienic treatment which is restoring the health
to its normal standard.
Organic Diseases. — In organic cardiac, vascular,
or renal disease life is often prolonged and a more
comfortable existence afforded by residence in such
a climate as will permit of an outdoor life. A
moderately warm, equable, sunny climate would
appear to be that of choice. In renal disease sudden
changes of temperature and wind are to be avoided.
The debility and degenerative changes of old age are
mitigated and produce less discomfort if one can
live easily out of doors in an equable climate which
makes the least possible demand upon the limited
vitality. Such a climate as that of Southern Cali-
fornia is ideal for the aged.
In various functional nervous disorders, such as
neurasthenia, insomnia, and neuralgia, much benefit
is derived from exposure to pure, fresh, open air.
Sometimes mountain air and sometimes that of the
sea-shore will prove most beneficial. Each case
must be judged by itself and that climate selected
which seems best to satisfy the individual condi-
tions.
Thus it is seen that there is hardly any abnormal
condition or disease that will not derive benefit from
the open-air treatment, and in many diseases it will
be the determining factor in the recovery. The
supreme importance of fresh air breathed in the
open is so obvious that it seems strange that it is so
often ignored even by the physician. Modern
civilization has so accustomed man to an indoor
existence that outdoor life almost seems unnatural
to him, and when he is ill, to be placed under open-air
conditions appears to him and his friends as a danger-
ous expedient. It often requires much reasoning and
persuasion on the part of the physician to be allowed
to institute the open-air treatment. The reader is
referred to "Fresh Air and How to Use It," by Car-
rington, published by the National Association for
the Study and Prevention of Tuberculosis for an
excellent detailed description of the various methods
of applying the open-air treatment.
Edward O. Otis.
References.
1. Williams, C. Theodore: Aerotherapeutics, London, 1S94.
2. Knopf, S. A.: Prophylaxis and Treatment of Pulmonary
Tuberculosis.
:;. Transaction of the National Association for the Study and
Prevention of Tuberculosis, 1906, p. I'M.
4. Northrup, W. P.: Cold Fresh Air in the Treatment of Pneu-
monia in Infants and Children, Medical Record, Feb. IS, 1905.
yEsculapius. — The Latinized name of 'AitkXtjiros the
legendary Greek god of medicine, the son of Apollo
and the nymph Coronis. Homer mentions him as a
skilful physician, whose sons, Machaon and Podalirius.
characterized by the poet as "blameless physicians,"
were sergeons "in the Greek camp before Troy. To
Fit;. 52. — Statue of ^Esculapius in the I'ffizi Gallery in Florence;
ii is said to be a copy of a statue by Myron, of the later Greek
period.
Homer ^Esculapius was still onlv a hero, a "cunning
leech," but later he was deified by Greek tradition, lus
worship being well established by the fifth century,
B.C., at Athens. He carried his art to such a degree ol
perfection as to be able even to raise the dead: thus
Zeus, fearing he might abolish death altogether and
depopulate Hades, slew him with a thunderbolt.
The temples dedicated to ^Esculapius were always
located in some conspicuously salubrious spot, out-
side the limits of the town or city, as on the summit
142
REFERENCE HANDBOOK OF THE MEDICAL SCIENi
Agar-agar
of a mountain or in the midst of a sacred grove.
Nobody was permitted to die on the consecrated land
surrounding the temple, nor could any woman give
birth in a child within these limits. Further] •<•,
repeated purifications were required of all those who
desired to approach the temple for the purpose of
consulting the god. All who were healed offered
sacrifice and hung up votive tablets, on which were
recorded their names, their diseases ami the manner
in which they had been cured. As these tablets were
carefully preserved, the priests — the custodians of the
temples —came, in the course of time, to have at hand
a veritable library of reference, in which all the medical
knowledge of that period was carefully stored, ready to
be consulted on any convenient occasion. A.H.B.
1 villus — Buckeye; Horsechestnut (fam. Hippo-
caatanacece). A genus of about a dozen species, of
America and Asia, growing mostly north of the
Equator. The bark and seeds of JE. hippocastanum
1... native of Asia, but largely cultivated for ornament
in all temperate countries, have been much used in
domestic practice in the treatment of malaria and
rheumatism. Both contain considerable tannin, but
the activity appears to reside in the bitter glucoside
lin (0,,H,„O 9 +1.5PLO) which is crystalline,
white, soluble in water and alcohol, and antiperiodic
in fifteen-grain doses.
The seeds of the red buckeye, M. pavia L., of the
southern United States, are reported to have caused
fatal cases of poisoning in children, the sj'mptoms
being those of poisoning by saponin. It is even said
that the former species has acted similarly.
H. H. Rusbt.
.'Ether.— See Ether.
Aetius. — A Christian physician, born in Amida in
Mesopotamia, who flourished in the early part of the
sixth century. He studied at Alexandria and became
?ourt physician at Byzantium. He belonged to the
sect of the methodists, yet inclined at times toward
the practice of the empiricists. He wrote in Greek a
treatise on medicine in sixteen books, for the most
>art, and the most valuable part, a compilation from
carious authors, chiefly Oribasius and Galen. His
jwn contributions were those of a superficial observer
ind obscure writer. The treatise, however, is on the
ivhole a valuable commentary on the works of the
Dlder writers, such as Galen, and furnishes a rich
naterial for the history of the medical science of
tntiquity. Eight books of the Greek original, edited
Dy Comarus (q.v.) were printed at Venice in 1534,
tnd a complete Latin translation, also by Comarus,
>vas published at Basle in 1542. A. H. B.
.•Etna Springs. — Napa County, California.
Location. — At the upper end of Pape Valley,
sixteen miles northeast of St. Helena.
Access. — By rail via Southern Pacific Company's
trains via Oakland and Vallejo Junction; or via the
Napa Valley Route, steamer and electric cars to St.
Helena, and thence by stage or automobile over a
.veil-graded, picturesque road. There is no hotel
tmilding, but a number of attractive cottages are
provided for guests.
Gardens, orchards, and vineyards supply fresh
vegetables and fruits for the table. In the fall a
season is given to the " Grape Cure." There is also
i dairy.
This resort, known as the "American Ems, "is
delightfully situated at an elevation of 1,000 feet
above the Pacific, in the midst of wild mountain sur-
roundings. The mountains are well stocked with
game, and the streams afford good fishing. Many
forms of exercise and amusement are provided.
There are a number of excellent springs in the neigh-
borhood, those u ed for drinking purposes having a
temperature ol 98 I : those employed for bathing
show a temperature of 106° F. The following analy-
sis of .Etna Spring was made by Professor \\ . T.
Wenzell:
Chains in ic.i (J. S. Wink GALLON, 231 CUBIC I
Chloride of i ;;n no
Nitrate <>t potassium.. u titm
Silica f potassium . 0.780
Borosilicate "i pota - ium . 0, 150
I'., irate of sodium 19
Carl ate ol sodium 21.870
Chloride of sodium . . is. 550
Sulphate of sodium ... 0.020
< ' i rl lonate <>f calcium . . . 0. 750
Sulphate of calcium. - . 0.290
Carbonate of magnesi m, . 550
Carbonate of iron.. - 0.210
Oxide of iroD . 0.100
Amnion i:i . 006
Organic matter 140
Alumina 2.130
Total grains 96.760
Temperature. 72° F.
Specific gravity (at 69°F.), 1.00317.
Carbonic acid gas, 313 cubic inches.
The following analysis of American Ems was made
by Professor J. A. Bauer, chemist:
Grains in One Wine Gallon of 231 Cubic Inches.
I -rains.
Bicarbonate of magnesium 13.85
Bicarbonate of sodium 75 . 22
Bicarbonate of calcium 10.45
Sulphate of sodium 7 . 73
Chloride of sodium 28 . 65
Silica 0.65
Total erains 136.55
Temperature, 9S° F.
Caroonic acid gas, 58 cubic inches.
The water is sparkling and invigorating, with a
noticeable electrical element, and possesses a decided
tonic influence as well as slight aperient properties.
It is a good type of alkaline-saline-carbonate water
and, as will be observed, resembles the waters of
Ems to quite a marked extent. This water is in-
creasing in favor on the Coast, and has already
acquired considerable reputation in renal diseases.
Good results have also been reported in cases of
rheumatism, diabetes, and neuralgia as well as in
those of dyspepsia, torpidity of the bowels, hepatic
disorders, skin affections, and uterine disease.
Several other springs are found close by. Besides
those above mentioned are the Iron Spring, much
resorted to for anemia and wasting affections, the
Bath House or Artesian Spring, the Soda Spring, and
the Iadora Spring containing soda, magnesia, and iron.
Emma E. Walker.
Agamofilaria. — A name given to certain immature
parasitic nematode worms, the adult stages of which
are unknown, bvit which belong to the family Filari-
idoe. See Nematoda. A. S. P.
Agamodistomum. — A name given to certain imma-
ture distomes which are sometimes parasitic in the
human eye. See Trematoda. A. S. P.
Agar=agar. — Vegetable gelatin. The name of a
large number of East Indian sea weeds which are used
in the manufacture of "vegetable gelatin"; also the
name of this gelatin. The general nature of these
substances is similar to that of chondrus, or Irish moss.
It is one of these species which yields the material for
the Chinese "bird's-nest pudding." Agar-agar is
143
Agar-agar
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
manufactured chiefly in China, the sea weeds being
sent there from other conn! ries for this purpose. It is,
however, more or less manufactured in other count ries
also, especially in Japan, and it is the latter variety
which is chiefly used for bacterial cultures. In the
country of its production, agar-agar is very largely
used for food, both alone and as an ingredient of
jellies. It is also very largely employed as a sizing
in silk manufacturing. It occurs in thin, transparent,
colorless sheets, a great many bound together, or as
bundles of long shreds, or in the form of irregularly
square sticks, nearly a foot long. The latter form is
that generally used in bacterial work. It is less
transparent than either of the others, and is not so
white.
Agar-agar consists almost wholly of gelose, a sub-
stance the solution of which cools to a jelly, which is
much more stable than that of gelatin, requiring a
higher temperature for melting. It is said that a
solution of 1:500 of water will yield a stiff jelly.
Gelose is precipitated by alcohol, but not by tannin.
Gelasine is merely a variety of agar-agar.
Agar-agar has no medicinal properties, its uses being
wholly nutritive and mechanical. Its paste is some-
times used as an ointment base. Recently it lias been
employed in the treatment of constipation. It is ad-
ministered for this purpose in dry form in the food; ab-
sorbing water in the intestine it forms a jelly mass
which increases the bulk of the feces. This mechanical
action is sometimes supplemented by the addition of
a laxative, as e.g. cascara sagrada in the preparation
known as regulin. H. H. Rusby.
Agaric, Purging. — While agaric; Touchwood; Spunk;
Timler. The decorticated hymenium of Polyporus
officinalis Fries (Boletus laricis Linn.; order, Basidio-
mycetes, Hymenomycetes). This is a large fungus
growing upon the stems of the European larch and of
one or two other conifers. It forms large hoof-
shaped masses upon the sides of the trunks, and pene-
trates with its mycelium deep into the wood. When
young, these bodies are soft and juicy, but when fully
grown, hard and of a consistence between spongy and
corky. Agaric is collected in Europe, Asia Minor,
etc., and usually prepared by drying and peeling. It
is in yellowish-white, friable, light, and spongy
irregular balls and lumps, from the size of an orange
to that of a coconut and larger. It has evidently
been peeled, and the surface is finely rough and dusty
with minute separated particles. The texture is
rather firm, but soft; it can easily be reduced to a
coarsish powder by friction or by rubbing on a
sieve, but is difficult to pulverize finely; its microscopic
structure — a tissue made up of interlacing, thread-
like cells — explains its peculiar consistence.
Agaric has a heavy fungous odor, and a slowly de-
veloping, bitter, nauseous taste, which is at first
sweetish. Its powder is very irritating to the eyes and
nose, and produces violent sneezing. As it is also
light and dusty, persons employed in beating it in
mortars are obliged to resort to devices to prevent its
rising.
It contains nearly one-third of its weight of resinous
matters, extractible by strong alcohol, and these can
be separated further into three or four simple resins.
The active principle is agaric or agaricic acid. Com-
mercial agaricin is a concentrated extract of agaric,
and constitutes an impure and indefinite mixture of
the resins, but the Agaricin of the German Phar-
macopoeia is agaric acid.
Agaric, as its name indicates, was originally used
chiefly as a cathartic, but such use is rare at present.
1 1 i-. now rather considered that purgation is indicative
of over-dosing. It is, in fact, but little employed in its
own form, while agaricin and agaricic acid are growing
in favor as remedies for the control of sweating,
especially in phthisis. The dose of agaric is 0.02 to
0.06 gram (grain iij. to x.). More than this acts as a
purgative. (See also Agaricic Acid.)
H. H. Rusby.
Agaricic (or Agaricinic) Acid. — (CV.H^Os + H.,0.)
The active constituent of agaricin. It occurs as a
white, almost tasteless powder, soluble in alcohol and
with some difficulty in water, and may be given in
doses of 0.02-0.03 gram (grain £ to A), for the s: •
purposes as those for which agaricin is used. (See
Agaric.) H. H. Rusby.
Agathin. — Cosmin-salicyl-alpha-methyl-phenyl-hjr.
drazone, C 6 H s CH 3 N,.CH.CH 4 OH. This compound
results from the reaction between the basic alpha-
methyl-phenylhydrazin and salicylic aldehyde. It
occurs in colorless crystals, or in greenish-white
crystalline flakes; is odorless, tasteless, insoluble in
water, and soluble in alcohol and ether. It was
introduced by Roos as a remedy for rheumatism,
and has been found effective in this disease and in
neuralgia. It has been known at times to produce
headache, but the claim is made that it neither
depresses the heart, nor gives the general symptoms
of salicylism. Dose: gr. iij. to x. (0.2-0.6) from three
to six times a day. W. A. Bastedo.
Age. — (Lat. cetas). The age of a person is usually
reckoned as the period which has elapsed since his
birth. This method, although the most convenient,
does not represent the true length of life. The new
organism is formed by the union of an ovum and a
spermatozoon, and the individual life really begins
at the time of that union. (See Impregnation.)
Practically, it is best to divide the span of life into
two main epochs: (1) antenatal, and (2) postnatal,
Age during the first epoch is reckoned from the time of
fertilization (conception), and, during the second,
from the date of birth.
There are three principal ways of expressing age.
The usual method is in terms of time (chronological
age). Age may also be expressed in terms of develop-
ment (anatomical age), or in terms of functional
activity (physiological age).
Variability is a fundamental property of lhing
things, and is manifested at all times of life. This is
as true for the rates of developments as for other
characteristics, and, for this reason, the chronological
age does not correspond exactly to the anatomical or
to the physiological age. Ages expressed in these
three ways are correlated, but the correlation is not
so close as is usually supposed. (See Variation.)
The antenatal epoch may be divided into two
periods: first, the embryonic period; second, the fetal
period. The first lasts from fertilization until the
organs are clearly formed, about sixty days; the second,
or time of intrauterine growth, from the end of the
embryonic stage until birth at about the two hundred
and seventy-first day.
The postnatal epoch is divided in various ways
by different authorities (Chamberlain, 1900). The
scheme given below is modified from the scheme of
Tigerstedt (1906), and has eight periods. (1) The
new-born baby, tilt the falling of the umbilical cord on
the fourth or fifth day. (2) Early infancy, to the
seventh or ninth month when the first teeth erupt.
(3) Later infancy, lasting to the appearance of the
first permanent teeth at about the seventh year.
(4) Childhood, from permanent dentition to the onsel
of puberty at about the thirteenth or fourteenth year.
(5) Adolescence, till the full stature is attained al
about the twenty-first year. (6) Maturity, the period
of complete functional activity, ending at about the
forty-fifth year with the decline of the sexual function
(7) Middle Life, extending to the waning of the phys-
144
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Akp
i ca ] and mental functions thai indicates the gradual
ition to old age. (8) Senescence, marked by
,uii, 1 degenerative changes which finally end in
death.
Estimation of the Age of Fetuses.- The duration of
pregnancy is reckoned usually fr the first day of the
menstrual period, but in order to determine the
irobablc age of the fetus, it is necessary to make
certain deductions. These will depend on which part
if the menstrual cycle furnishes the most favorable
:onditions for fertilization.
The menstrual cycle normally occupies twenty-
it days, and is divided into four periods. These
ire — (1). the intermenstrual time, a period of about
fourteen days, during which there is very little
hange in tin- mucous membrane of the uterus;
he premenstrual period of six or seven days, a
lime of proliferation and thickening of the mucous
membrane; i:l) the menstrual period, three to five
lavs, with extensive degeneration of the mucous
membrane resulting in a decrease of thickness; and
ue postmenstrual period, during which time the
mucous membrane is regenerated.
( >v ulation, apparently, may occur at an} - time during
this cycle, but, according to the Reichert-His theory,
the generally accepted theory, the most fre-
quent time of ovulation is toward the close of the
premenstrual period, and if fertilization takes place
immediately the menstrual period which would
v is inhibited. Therefore, the probable age of
the fetus is obtained by subtracting twenty-eight
lays from the time since the beginning of the last
menstrual period. Mall (1910), on the other hand.
concludes, from data collected by Leuchart, that, when
copulation occurs late in the menstrual cycle, the
spermatozoa may reach the surface of the ovary, and
there await the appearance of the ovum, and that, if
fertilization follows in the premenstrual period, it does
inhibit menstruation. If copulation occurs after
istruation, the spermatozoa may meet the ovum
and fertilize it on its way down the tube. He regards
the latter as the most probab e event, because in
1,200 cases, it was found that the duration of preg-
nancy was ten days longer on the average when
reckoned from the first day of the last period, than
■ hen reckoned from the fruitful copulation. Most
pregnancies begin during the first week after menstru-
ation. If the fruitful copulation has occurred late in
the menstrual cycle, the apparent duration of preg-
nancy, as calculated from the last menstrual period,
is longer than when copulation has taken place earlier
in the cycle. From a large number of records of
duration of pregnancy, reckoned from the beginning
of the last menstrual period, Mall concludes that the
mean age of a child at birth is 271 days. Its average
length is fifty centimeters.
Thus, when the menstrual history is known, the
age of the fetus can be estimated by taking the time
elapsed since the beginning of the last menstrual
period, and correcting this for the probable time of
conception.
When, however, the menstrual history - is unknown,
recourse must be had to tables showing the rate of
growth of the fetus. Three standard measurements
are used to express the size of a fetus. These are the
crown-rump, or sitting height, the crown-heel, or
standing height, and third, the neck-breech, ehiefly
useful for embryos from four to seven weeks old.
This last measurement has been made in various ways.
Mall i 1910) recommends that the upper point of this
line be taken where a line drawn through the middle of
the lens and the auditory meatus, the oculoauricular
line, intersects the dorsal surface in the median plane
of the body. Graphic tables (Mall, 1910, Figs. 115
and 146) appear to show- a close correlation between
the crown-rump height and the crown-heel and
neck-breech measurements respectively. Just how
• the relation is, however, it is not possible to say,
Vol. I.— 10
for the coefficients of correlation have not been cal-
culated and ii i ei afe to rely on graphic method
alone lor statistical deductions. (See Variai
While these three measurements would appear
io be practically interchangeable, Mall regards the
crown-rump measurement a- the best standard for
the present, and next to it the crown-heel. Having
obtained an exact measurement of the fetus, the
age can be estimated by comparison with a table
made from data concerning embryos and fetuses of
known menstrual history, showing the relation
between size and age. Mall (1910, p. 199 and I ig
1 17 and 1 Is) gives such a table. It is assumed that
fertilization most frequently occurs ten days after
the beginning of the last menstrual period. With
this assumption, the table gives, for each week of
antenatal life, tin- mean menstrual age, the mean
crown-heel and the- mean crown-rump measurements
in millimeters, as well as other data useful for esti-
mating age. This is reproduced in part in Table 1.
Table I. — For Estimating: Act. of Ff.tcses.
Mull, 1910).
Probable
age in
days.
Mean
menstrual
age.
Mean length
of the embryo,
crown-heel.
mm.
Mean length
of the embryo,
crow n-rump.
mm.
7
1 1
21
31
.5
.5
28
37
2.5
2.5
35
43
5.5
5.5
42
:i
11
11
49
59
19
17
56
65
30
25
63
72
41
32
70
79
57
43
77
S6
76
53
si
94
98
68
91
100
117
81
98
108
115
100
1115
111
161
111
112
121
180
121
119
128
198
134
126
136
215
145
133
113
233
157
110
150
250
167
117
157
268
180
154
165
2S6
192
161
171
302
202
16S
177
315
210
175
185
331
220
182
192
345
230
189
199
358
237
196
205
371
245
203
212
384
252
210
219
400
265
217
228
115
276
224
234
125
2S4
231
241
436
293
238
24S
44S
301
215
256
460
310
252
262
470
316
259
271
4S4
325
266
276
494
332
270
2S0
500
336
The New-born Baby. — This critical period of life
lasts from birth until the umbilical cord shrivels and
falls off, usually about four or five days.
At the beginning of the period there is a sudden
change in the methods of respiration and nutrition.
The supply of oxygen and food from the maternal
blood is cut off, the first air is inhaled into the lungs,
and the first food taken into the stomach. The
accumulation of carbon dioxide stimulates the res-
piratory centers to their first effort, and, when once
begun," respiration is rapid, about 35 per minute.
The filling of the lungs causes a profound change in
the circulation. Blood, which before that event had
passed from the pulmonary artery directly through
145
Age
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
the ductus arteriosus into the aorta, is now directed
into the right and left branches leading to the lungs,
and returned to the left side of the heart through the
pulmonary veins. The ductus arteriosus begins to
contract immediately upon the establishment of
pulmonary respiration; and partly by this means,
and partly by a thickening of its walls, becomes
closed by the sixth or seventh day. The changes in
the fetal circulation do not take place all at the same
time. The first to be completed is the closure of
the distal ends of the allantoic, or umbilical, arteries;
and the last is the closure of the foramen ovale of
the heart, which may remain incomplete for months.
The movements of the child during this period are
largely of the random type. There are few estab-
lished reflexes during the first week, but Darwin
found that sneezing, hiccoughing, yawning, stretching,
sucking, and screaming were well performed during
the first seven days. (Hobhouse, 1901, p. 40.) The
sucking movements are reflex rather than instinc-
tive, and, at first, are often made at random, the baby
frequently sucking at the wrong place (Hobhouse, p.
42). The senses at this time appear to be defective.
The new-born child is said to be wanting in a true
olfactory sense, and its eyes are oversensitive to
light, and probably do not form clear images (Cham-
berlain, pp. 77-79)
That the changes in mode of existence incidental
to birth produce a crisis in the life of the child, and
present new conditions to which the child adapts
itself with difficulty, is shown by the loss of weight
which normally occurs during the first few days,
and by the high rate of mortality. Earliest infancy,
as well as other periods of human life, has its charac-
teristic diseases, but, 'unfortunately, statistics of
morbidity are lacking, and the relative frequency
of diseases can only be judged by means of the statis-
tics of death. The Mortality Statistics, 1910, pub-
lished by the U. S. Bureau of the Census ( Bulletin 109) ,
show for the first time in the United States the mor-
tality due to each of the principal causes of death
during each of the first six days of postnatal life.
For the year 1910 there were reported 36,351 deaths
of infants less than a week old. Of these 16,197
died as a result of premature birth, and more than
half of these deaths occurred on the first day. The
next most important cause of death was congenital
debility, of which 5,943 cases occurred in the first
week, and 2,007 during the first day. Malformation
comes next, with 1,437 deaths during the first day,
and a total for the first week of 4,380. Convul-
sions and syphilis complete the list of important
causes of death of the new-born. Here we see
natural selection rigorously at work weeding out the
unfit as soon as they leave the protection of the
mother's womb.
Early Infancy. — Having survived the dangers of
birth, the infant resumes its growth, and during the
next few months undergoes a growth more rapid in
proportion to size than at any other period of post-
natal life. In fact, after this early maximum, the
relative rate of growth gradually diminishes, except
for a considerable rise at the time of puberty, until
the complete stature is attained in about the twen-
tieth year (see Growth). The skeletion is still carti-
laginous to a considerable extent. Recent studies
on the development of the wrist bones by Pryor
(1906, 190S) and by Rotch (1909) have shown that
the epiphyses are usually wholly cartilaginous, and
the carpal bones do not exhibit any centers of ossi-
fication in the early part of this period. The move-
ments now change from random and reflex to more
adaptive and complicated instinctive actions. Bo-
manes (1892) has pointed out that some of these are
remarkably simian in character; for example, the
position of the feet and great toe, and the grasping
iniivement coupled with extraordinary development
of strength in the hands. The child has a marked
tendency to grasp any object, especially hair, which
comes into contact with the hands, and, at three
weeks of age, can, by holding on to a horizontal bar,
support its own weight for a half to more than two
minutes. The sense organs soon become completely
functional, and the eyes show the maximum power
of accommodation. The face changes from stupid
passivity to an animated expression, and the cries
change from disordered sounds to expressions of emo-
tion and desires intermingled with laughter and tears.
Although this development of the baby brings with
it a rapid decrease in the chances of death, this period
of early infancy has its grave dangers. During the
first month, congenital debility and premature birth
are still important causes of death. Cases of diarrhea
and enteritis and of bronchopneumonia appear with
rapidly increasing frequency, and, during the greater
part of the period, become the most important causes
of death. The maximum number of deaths from
bronchopneumonia and pneumonia occur during the
second half of the first month. Diarrhea becomes
the most dangerous disease in the second month,
and continues as such until the end of the period,
reaching its maximum in the fourth month.
Later Infancy. — This period begins with the
eruption of the first tooth and ends at the first appear-
ance of the permanent dentition with the eruption
of the first true molar. It extends from the sixth
month to the sixth year.
The usual ages at which the teeth of the temporary
dentition appear, according to Legros and Magitot,
are as follows (Hill, 1909, p. 138):
First inferior incisors Sixth month.
First superior incisors Tenth month.
Second inferior incisors Sixteenth month.
Second superior incisors Twentieth month.
First inferior premolars Twenty-fourth month.
First superior premolars Twenty-sixth month.
Second inferior premolars Twenty-eighth month.
Second superior premolars Thirtieth month.
Canines Thirtieth to thirty-second month
The replacement of the cartilaginous skeleton by
bone is incomplete at birth, and makes important
advance during the period of later infancy. Pryot
has studied the development of the bones of the hand
and wrist by the or-ray method. Rotch (1909), using
the same method, has confirmed Pryor's results con-
cerning the wrist bones, and proposes to use the
stages in their development as indices of anatomical
age. From a study of 289 children, Pryor (190S)
has constructed the following table showing the varia-
tions in the order of appearance of the carpal boms,
doubtful cases being omitted.
Table II. — Order of Ossification of Carpal Boxes.
o
a
c
to
S3
PS
a
u
,C
a
P
g
'S
a
3
O
ci
a
1
m
'o
-c
a
ej
a
CO
-6
'o
N
ft)
a
S
a
,3
'5
o
Q.
i
'5
1
23S
5
9
5
236
219
12
i
10
176
3
8
7
-
8
SO
36
30
6
2
27
59
31
-
6
l'.l
21
51
8
Totals
243
2-11
229
204
129
12 1
119
i u;
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Arc
Rotch (1909) finds that the Lower epiphysis of the
adius begins to ossify soon after the unciform, and the
ower epiphysis of the ulna appears after all the
ither carpal' bones except the pisiform. Counting
hese two epiphyses in with the eight carpal ossifi-
cations, we may modify a table given by Rotch
J. c, p. IS) as follows.
Tadle III. — Staoes of Anatomical Age as Indicated by
the Ossifications in the Wrists.
Stage.
Number of
centers.
Approximate age in
years.
A
2
&— 1
B
3
(?— 2
C
4
6*— 31
D
5
9— 3i
d 1 — 41
E
6
9 — 11
0^-51
F
7
1
d 1 — 53
G
8
9 — 51
6 1 — 63
H-J
9
9— 62
c*— 71 to
K-.U
10
9—101-
d"— 12J-
The data in regard to six and chronological age
in this table are taken by Rotch from observations
made by Pryor.
Rotch (1909) gives the record of his own observa-
tion on 133 children showing sex, weight, height, num-
of teeth, development of the wrist, mental con-
dition, and approximate age in years. These children
were selected as being normally developed. Besides
being of an average height and weight and healthy
looking, they were known to have had no disease
that could cause an enlargement of the carpal bones
and epiphyses, and they had not shown any con-
dition that would tend to retard the normal devel-
opment. From his results Table IV has been com-
piled. This shows the relation between chrono-
logical age, sex, number of teeth, and number of ossi-
fications in the wrist. The columns in this table are
divided into squares, each square is subdivided into
two sections, and a diagonal line crosses each section.
The "argument" is the chronological age, and the
tabular entries are the numbers of individuals having
the numbers of teeth or wrist bones indicated at the
heads of the columns. The numbers in the upper
section of each square refer to teeth, in the lower
section, to wrist bones. In each section, the number
on the left of the diagonal indicates males; on the
right, females.
These observations, although too few for statis-
tical analysis, indicate that the development of the
temporary dentition is relatively rapid, being com-
pleted by the end of the second year with little show
of variation. The development of the wrist bones
is a more gradual process, and is very variable in
respect to chronological age. But by the time the
first molars of the permanent dentition have erupted,
the majority of children show at least eight ossi-
fications in the wrist, the complete number except
for the epiphysis of the ulna and the pisiform. In
some cases the epiphysis, too, has appeared. As
Crampton (1908 0) has said, the question of the
value of Rotch's criterion of anatomical age can be
settled only by establishing a correlation between the
stages of development of tile wrist and the progress
of other organs or functions. The material for such
a correlation is, however, not yet available.
Two events that especially distinguish man from
the lower animals occur during this period. These
are the acquirement of speech, and the assumption
of the upright position. The change from inarticulate
cries to the formation of words is a gradual one. At
the beginning of this period, the infant lias learned
to make dental articulations, and its babbling takes
the form of syllables such as da, I", "'". and toward
the end of the first year, or at the beginning of the
second, the first words are spoken, mamma, /'»/'«,
to which some more or less vague meaning is attached.
This is tin' commencement of the imitative period,
when the child attends to the words it hears, and
tries to reproduce them. The preparation for walking
is largely concerned with the growing strength
in the legs and arms of the child. Attention lias
already been called to the relatively great strength
of hands and arms of a new-born baby. _ With the
rapid accumulation of fat, however, the infant soon
becomes, too heavy to support its own weight, and
can only wave its arms and legs. As the muscles
become stronger and larger, the ability to support
the weight gradually returns. The child can sit up,
then it can creep, and soon it learns to pull itself to a
standing position beside a chair. Then it takes the
first tottering steps, and finally, in the third or fourth
year, it begins to walk easily.
At the beginning of this period, there is a gradual
diminution in the mortality from the infections of the
endodermal organs — the digestive tract and the re-
spiratory aparatus. Whether this is due to natural
selection or to a gradual acquirement of immunity,
it is impossible to say. Diarrhea, while diminishing
considerably, still remains the chief cause of death
to the end of the second year. It has active com-
petitors in diphtheria and croup which, grouped
together, reach their maximum frequency in the
second year, and, with scarlet fever as a second, are
left the chief causes of death in the fourth and fifth
years.
Childhood. — This period starts when the eruption
of the first true molars has taken place and ends with
the onset of puberty. Permanent dentition, with the
exception of the third molars or "wisdom" teeth,
which come later, is established during these years.
The times at which these permanent teeth appear as
determined by Legros and Magitot are given in the
second column of Table V. The columns to the
right give the sex. age, and variability as tabulated
by Crampton chiefly from data collected by Boas.
At the beginning of this period, the wrist bones are
in Rotch's stages, G or H; at the close of the period,
they have probably reached stage M. At stage K
the first appearance of the pisiform is noted. The
other stages after H still need more exact definition
to make them available for statistical treatment.
Hall (190-1, p. 9) says of this age: "The years from
about eight to twelve constitute a unique period of
human life. The acute stage of teething is passing, the
brain has acquired nearly its adult size and weight,
health is almost at its best, activity is greater and more
varied than ever before or than it ever will be again,
and there is peculiar endurance, vitality.and resistance
to fatigue. The child develops a life of its own outside
the home circle and its natural interests are never
so independent of adult influences. Perception is
very acute, and there is a great immunity to expo-
sure, danger, accident, as well as to temptation.
Reason, true morality, religion, sympathy, love, and
esthetic enjoyment are but very slightly developed.
Everything, in short, suggests the culmination of one
147
Age
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Table IV. — Number of Teeth and Wrist Bones in Relation to Age and Sex.
Teeth.
Wrist.
1-2
A- 2.
3-4
B = 3.
5-b
C-4.
7-8
D=5.
9-12
E = 6.
13 -IS
F=7.
17-20
G=8.
24
H-J
= 9
25
K-M
= 10
►.&
1— G months
5 ^*^
J>^ 1
5 ,''
7-11 months-
3 .^
1 ^^
^-^ 1
1 -^
1 i^^
^-^ 1
1-2 years
2 ^*^
^^ 1
1 ,^
_^^
1 ^^^
*^^
3 ,'''
,-' 1
,''' 1
1
,-'' 1
2-3 years.
4 ^-^^
^-^ 4
>>
,-*' 1
3 ,-'
,-'' 1
1
,''' 2
C
e3
c
_
3-4 years.
":f —---.'
^'^" 2
,-'"' 1
1 "''
„,-'' 1
.,-"' 1
4 -^
_______?,
,-''' 1
J
4-5 years
5 ^-^
^-^ 5
,-''' 1
1 ,--'
,-' 3
2 -^
,.--"' 1
1 ,-'
1 ^,'-
5-6 years.
________
,--' 1
______
.______.
,""'' 2
,-'' 2
,-'' 1
6 -7 years
1 ,-''
,-'' 1
^^ 3
^^4
-'""' 3
>--'' S
7—8 years.
1 ^-^
7 ^^
s^ 2
o
2 ,-'
4 ,--'
8-9 years.
4 ^^
4 ,--'""
9 -10 years.
>-^
5 ^^
o
2
5 ^""'
--'' 3
1 .-'l
-'' 1
10 -11 years.
/^ Z
5
5 --''
.--' 1
,-'' 2
11— 12 years.
4 ^^
^"^ 5
1
>"\
12-13 years.
4 -^"''
^^ 4
s' 1
4 ,--''
--''' 5
Table V. — Age of Eruption op Permanent Teeth.
Teeth.
Age.
Sex.
Mean
age.
o-6 years
6-7 years
8 J years
0-10 years
10-11 years
11—12 years
12-13 years
1 8-25 years
Second incisors
First premolars
Second premolars ....
[%
it?
7.0
7.5
8.9
9.5
9.0
9.8
1 .6 years
1 . 4 years
2. 1 years
2 . 1 years
2. S years
1 . 6 years
1 6
it?
(_,
I t?
5
1 t?
11.2
11.3
12.8
13.2
19.3
22.0
1 .4 years
Second molars ......
Third molars
1 .0 years
1 . 6 years
2 . years
2 . 1 years
1 . 8 years
The Greek letter aigma (") j s the symbol for the standard devia-
tions, a measure of variability (see Variation),
1 IS
stage of life. As if this represented what was once
and for a very protracted and relatively stationary
period, the age of maturity in some remote, perhaps
pigmoid, stage of human evolution, when, in a warm
climate, the young of our species once shifted for
themselves independently of further parental aid."
The relative immunity from disease at this age is
shown by the mortality statistics. Of 805,412
deaths reported in 1910 (IT. S. Census Bulletin 109),
17,943 were of children aged five to nine years, and
only 11,736 at the ages of ten to fourteen. During
the first five years, the most frequent cause of deatn
wns diphtheria (2,938); scarlet fever was second
(1,731); tuberculosis of all kinds, third (1,422); and
pneumonia, fourth (1,138). In the second five
years, tuberculosis becomes the chief cause of death
(all kinds, 1,634); typhoid fever, second (8
appendicitis, third (718); and diphtheria, fourth (709).
Adolescence. — The period from the onset of puberty
EEFERENCE HANDBOOK OF THE MEDICAL SCIENCES
A ci-
lo the attainment of maturity is called adolescence,
. 1M ,I the corresponding age in years is generally con-
sidered to be from twelve to twenty-one for girls
and from fourteen to twenty-five for boys. (Cramp-
ton (190S 6) defines puberty as the moment when the
sexual life begins. In girls, this time is plainly
indicated bv the first menstruation; in boys it is not
so easily determined, but i.s indicated by the appear-
of'the secondary sexual characters. These are:
first, the growth and pigmentation of the hair upon
.-
MO
....
'
,0.1
HO
no
ii
3'.'
347
»i«
II
100
irj
102
/
ft]
I?
1
1
i nrvo of Frequency of 3,500 Cases of First Menstruation
(observed by Heinricius in Finland) .
the pubic eminence and in the axilla? in both sexes;
id, the development of the beard and change
-ire in boys; and, third, the development of the
ts in girl's, and the deposition of subcutaneous
giving the pleasing rounded contours so charac-
teristic of young womanhood.
The chronological age of the first menstruation
differs in various countries and in the individuals of
each country. From the numerous collections of
statistics quoted by Hall (1904, p. 474-8), it would
appear that the average age in southern Asia is be-
tween twelve and thirteen; in southern Europe.
thirteen and a half to fourteen and a half; central
Europe, fourteen to fifteen; and northern Europe,
between sixteen and seventeen. In the United
Mates, a number of investigators have found an
average age of about 13.6; others place the age
a i 1 1.5. While the average age does not necessarily
coincide with the age of greatest frequency, they may
lie Dearly the same. This is shown by 3,500 recorded
cases collected by Heinricius (1SS3) in Finland. His
results are given in Table VI.
Table VI.
Age, years.
v. ol cases.
11 1J 13 14; 15 16 17 18 10 20 212:2
933 135 440 765 S46 560 347 198 102 11 12
L
2:; 2:, 21;
4 1
The average age is 15.82, and the tabular age of
atest frequency i.s sixteen, and when the curve of
variation is plotted (Fig. 53), it is seen to be a slightly
^kew curve. (See Variation.) A similar curve is given
bv the statistics of 3,000 Prussian girls, collected by
bullies (1886) and quoted by Hall (1904, p. 475).
Marro (1901) has collected the statistics of the signs
of puberty in girls, including not only menstruation,
but also the appearance of pubic hairs, of axillary
hairs, and the development of the breasts. These
results have been presented by Crampton (190S 6)
in a table reproduced below, which, for each year
between the ages of nine and a half and eighteen and
a half shows the percentage of girls that exhibit each
of thesefour signs of puberty. The lineal the IhiII.hu
of the table has been added to show the relative fre-
quency of first menstruation at each ■<■ !
AGE
9.5
10.5
11.5
12.5
13.5
14.5
15.5
KS.5
i i .5
18.5
/fy '
-^-*
^-**
00
ty
//
///
/
-//
o 00
<
1-
2 50
en
w in
I
i
i
h
f
fi
(4
J^'
AXILLA MENST.-
■ BREASTS^- K-
Fio. 54. — Integral Curves showing the Percentage of Italian
(Jirls who at Each Age had Attained Each of the Four Signs of
Puberty. (From statistics by Marro.)
Table VII. — Percenta
IE OF
Italian'
Puberty.
jIRLP
Showing
St ;\-. OF
Age in years. . .
9.5
10.5
11.5
12.5
13.5
14.5
1 ', . 5
16.5
17.5
IS. 5
Pubes, '.
3
3
9
35
57
76
S9
100
Axilla, % ...
3
3
6
16
12
64
74
90
or,
Menstr'ation %
3
3
3
15
55
67
77
96
100
Breasts, f ";
3
3
7
13
to
71
82
96
96
First .Menses. . .
3
12
10
12
10
19 4
The curves plotted in Fig. 54 show the same facts
in graphic form. From examination of the table
and curves, it will be seen that half of the girls had
menstruated before the end of the first half of the
fifteenth year. The pubic pubescence appeared
somewhat earlier, while the axillary pubescence
and the breasts developed at about the time of the
first menstruation, sometimes a little earlier, some-
times a little later.
A similar table from the same sources and the
curves (Fig. 55) plotted from it, show that in a group
of Italian boys studied by Marro, pubic pubescence
had appeared in fifty per cent, by the end of the
first half of the sixteenth year. The axillary pubes-
cence becomes evident nearly two years later, and a
year later still the mustache begins to grow.
Table VIII. — Percentage of Italian Bots Pi-bescent at
Various Ages.
12.5
13.5
14.5
15. i 5.
16.5
17.5
18.5
14
29
59
77
100
100
11
9
33
57
88
1
29
43
60
149
Age
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Crampton lays great stress on the pubic pubescence
as an indication of physiological age. He defines
pubescence as the process of becoming covered with
hairs, especially the pubic pubescence. A pubes-
cent is an individual undergoing this process, which
presents three phases. The first is the appearance
of an evident and rapid growth of fine hairs upon the
[00
o
BO
80
70
60
£50
o
UL
Ld
a. 40
30
20
10
12.5
13.5
14.5
AGE
15.5 16.5
17.5
18.5
19.5
/
/
/
j
/
/
1
1
1
1
1
1
1
/
i
1 /
I
i
i
i
■
1
1
; /
/
/
/
S
^
AXILLA
Fig. 55. — Plotted from data given in Table VIII. (After
Cramptou.)
pubic eminence, the second is the pigmentation of
this hair, and the third is the acquirement of its
characteristic twist or kink. A prepubescent is an
individual in whom this process has not become
evident; a postpubescent is one who by reaching the
third phase, has completed the process. From an
examination of 3,835 high school boys in New York
City, Crampton obtained the data presented in
Table IX.
ossification of the epiphyses which is completed with
the cessation of growth at the end of this period.
In regard to the mental condition of the adolescent
Hall says: "Adolescence is a new birth, for the
higher and more completely human traits are now
born The functions of every sense
undergo reconstruction; and their relations to other
psychic functions change The voice
changes, vascular irritability, blushing, and flushing,
,„ ^" 1 /"'
-^ ~3?
-o ,Z Z .
/ /
/ /
A /
/ /
/ I
/ j
™ / 1
~7^r '
,/ jf"
s
'" 12.25 12.75 13.20 13.75 11.25 11.75 15.25 15.76 16.25 1G.75 17.25 17.75
AGE; HALF YEAR MEAN
Fig. 56. — Integral Curves showing at each age the percentage
of New York High School Boys in each of the three phases of
Pubescence. Plotted from Table IX.
are increased. Sex asserts its mastery in field after
field. There are new repulsions felt toward home
and school, and truancy and runaways abound. The
social instincts undergo sudden unfoldment, and a
new life of love awakens. It is the age of sentiment
and of religion, of rapid fluctuation of mood, and
the world seems strange and new. Interest in
adult life and in vocations develops. Youth awakes
to a new world, and understands neither it nor
himself."
The death rate during adolescence is still low, but
considerably greater than during childhood. Of a
total of 805,412 deaths reported in the registration
area of the United States during 1910, 19,772 occur-
red between the ages of fifteen and nineteen years.
Table IX. — Age of Pubescence in High School Boys of New York City (3,835 Cases).
Age, half-year
mean.
12.25
12.75
13.25
13.75
14.25
14.75
15.25
15.75
16.25
16.75
17.25
17.75
Prepubescent
(81)*
69
55
11
26
16
9
5
2
1
(16)*
25
26
2S
28
24
20
10
4
4
2
(21*
6
IS
31
46
60
70
So
93
95
98
100
* Calculated.
This table, represented graphically in Fig. 4, shows
that, in this group of boys, fifty per cent, have entered
the first phase of pubescence by the middle of the
fourteenth year and have completed the process
before the middle of the fifteenth.
The rate of growth, which has been gradually
decreasing during childhood, increases during pubes-
cence, and, according to Crampton, reaches a climax
at or immediately after the change to postpubescence.
(See Groivth.) There is an acceleration in weight
and strength at the same time. Among changes in
the internal organs in puberty may be noted an in-
crease in the size of the heart and in lung capacity,
a loss of fat in boys, and a temporary loss in girls,
a lengthening of the jaw, and an acceleration of I Ik-
ISO
Tuberculosis of the lungs was the chief cause with
5,166 cases. In the next five years, the number
nearly doubled; 9,622 cases. Typhoid fever was
next in importance, and was likewise increasing,
there being 1,681 cases in the years fifteen to i
teen and 2,067 in the years twenty to twenty-five.
Organic disease of the heart, and pneumonia, about
equally important, and both increasing, occupy the
third place.
Maturity. — No sharp line can be drawn between
adolescence and maturity. Between the twentieth
and the twenty-fifth year the fully adult stature is
attained and growth ceases. The change is so grad-
ual as to be hardly perceptible. Now both psy-
chic and physical functions have reached their max-
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Agenesis
iiiHiia development and power. According to Osier
(1905), "The effective, moving, vitalizing work of
the world is done between the ages of twenty-live
and forty." .
The ten years from twenty to thirty is the chief
reproductive period, and therefore at this age most
of the accidents of childbirth occur, t If all the ileal lis
due to the puerperal slate in 1910, 15.5 per cent.
were during this decade. The death rates from
typhoid fever and from tuberculosis both reach their
maximum at this time, but the latter is by far the
most important, causing, in 1910, 35 per cent, of all
the death- in this age.
Middle Age. — The boundary between the age of
maturity and middle age is distinctly marked in
women by the climacteric, or menopause. This i> the
ation of menstruation and oilier sexual functions,
which usually occur rather suddenly between the
of forty-five and fifty. In men, sexual activity
diminishes al about tlie same age, but so gradually
that many men have been able to beget children
at a much later period of life.
These changes are accompanied by other evidences
of the approach of senility. The most noticeable of
i is the turning gray of the hair. The dynamic
ficient of the skeletal muscles begins to diminish
thirty or forty years of life, and the plain muscles
suffer a similar change, as is shown by the diminished
t of the heart, intestines, bladder, and other
organs. The lessened power of accommodation in
the eyes is not so characteristic of this period as is
generally supposed. According to Donders (1858),
the power of accommodation is at its maximum
in young children, when the lens is soft throughout.
It soon begins to harden at the center, and as the
Sclerosis gradually spreads toward the periphery
there is a parallel loss of accommodation. The in-
verse correlation between accommodation and age
when plotted is represented by a straight line. The
range of accommodation, measured in diopters, as
given by Donders is
At ten years 14
At twenty years 10
At thirty years 7
At forty years 4.5
After forty, 1 D less every five years. When the
power of accommodation becomes so limited that it
IS no longer possible to focus the eyes upon a small
object near enough for clear vision, we have the
condition known as presbyopia, which is characteristic
of middle and old age. (See the articles on Accom-
vwdalinn and Refraction and Eye, Dioptrics of.)
The fatal diseases characteristic of middle age are
heart disease, nephritis, and cancer. In 1910, they
caused, in persons between fifty and fifty-nine years
of age, 13.4, 11.7, and 12.1 per cent, of registered
deaths respectively, and in persons between
sixty and sixty-nine 18.2, 12.1, and 11.1 per cent,
respectively.
Senescence. — There is no sharp boundary between
middle life and old age, but an individual may be
said to have become senescent when, by reason of
age, the decline of any of his bodily or mental func-
tions has reached a point that renders him in-
capable of continuing his previous occupation. This
is apt to occur at about the seventieth year. The
theories as to the cause of senility will be discussed
in another article. (See Senility.) During this last
period of life, heart disease reaches its maximum as
a cause of death, and is the principal cause of that
calamity. The next most important cause is cerebral
hemorrhage, resulting from arteriosclerosis, the charac-
teristic malady of old age.
Robert Payne Bigelow.
Rj it i:i NCES.
Cameron, W., 1908, Children' Growth in Weight and Height.
Pfaundler and Schlossmann, l'i e I Children, vol i . pp.
urn 124.
Chamberlain, A. F.. 1900. The i Ihild as a Study in the evolution
• it Man. N. V.; Scribners.
Crampton, ('. \\\, 1908 6. [ical V.gi , b I und intal
Principle. Am. Phys. Educ. Review, voL xiii., pp. 1 n L54, 21 1-
227, 268 283, 34S 161
Donders,F C, 1864, Onthi Iccom dation and
,i,.ii ,,t the I ye. E 1 ] in bj w D. Moore, London: New
Sydenham Soc.
Forsyth, D., 1909. Children in Health and I Phila.:
Blakiston.
i, ter. Sir M., 1891. Textbook of Phj i Ed 6, Pt. 4,
London: Macmiilan.
II II. i ;. s . 1904. Wole ■ i'm.-. N. Y : Appleton.
Heinricius, ('.., 1883. Ueber das Alter binn Eintritl der
Menstruation bei 3500 Weibern in Finnland. Centralblatl fur
Gynakologie, voL vii., pp. 72 73.
Hill, C, 1909. Manual of Normal Histology. Phila.: Saunders.
Ilobhousc, L. T., 1901. -Mind in Evolution. London: Mac-
miilan.
Mall, F. P., 1910. Determination of the Age of Human I Imbryoa
and Foetuses. Keibel and Mall. Manual of Human Embry-
ology, vol. i., pp. 1S0-201.
Marro, A., 1901. La puberte chez l'homme et choz la femme.
Paris: Schleicher
Osier, W., 1905. Commemoration Address. .Johns Hopkins
Univ. Bulletin.
Pryor, J. W., 1005. Development of the Bones "f tin- Hand as
shown by the X-ray Method. Bull. Stale College of Kentucky.
Sec. 2, No. .5.
Pryor, J. W., 1906. Ossification of the Epiphyses of the Hand.
Bull. State College of Ky., See. a. No 1.
Pryor, J. W., 1908. Chronology and t irder of Ossification of the
Bones of the Human Carpus. Bull. State University of Kentucky,
New Sec. 1, No. 2.
Romanes, J. G., 1892. Darwin and after Darwin. Chi< ago:
Open Court Pub. Co.
Rotch, T. M., 1909. Development of the Bones in Early Life
Studied by the Roentgen Method. Trans. Assoc. Am. Physicians,
1909.
Tigerstedt, R., 1906. Text-book of Human Physiology, Ed. 3,
Trans, by J. R. Murlin. N. Y.: Appleton.
U. S. Census Bureau. Twelfth Census, 1900: Special Reports,
Supplementary Analysis and Derivative Tables, 1906.
U. S. Census Bureau. Bulletin 109. Mortality Statistics, 1910,
1912.
Agenesis. — (Agenesia, from a, priv. +7e>«is, origin.)
AVithout generation; without formation; without
parents; unborn; undeveloped; failure of anlage;
possessing no sex. From the latter meaning arose the
conception of sterility or impotence, and the early
use of the term in medicine was restricted to this
meaning. Later, the idea of lack of sexual appetite
became included in this, and the word was used
by French writers especially with the meaning of
anaphrodisia rather than with that of impotence.
The word has now entirely lost its early significance
and has acquired the technical meaning of total
failure of development.
A partial or imperfect development of parts whose
embryonic foundations have been laid is not to be in-
cluded in the significance of this term, but should be
expressed by the words aplasia, hypoplasia, and
hypogenesis. (See also Ateleiosis.)
There is, nevertheless, much diversity of use among
writers as to the exact significance given to each one of
these terms. Aplasia in its original sense means a
failure of restoration or rebuilding, but is now used
with two meanings: that of a numerical atrophy, and
that of a partial failure of development. By some
writers the three words are used synonymously with
the meaning of either partial or entire failure of devel-
opment. A few authors also use these terms with
the significance of atrophy. The present tendency is
strongly in the direction of giving to each word a
distinct place in technical terminology: to atrophy,
that of diminution in size after development; to
aplasia and hypoplasia, that of imperfect develop-
ment; to agenesia, that of total failure of growth of the
151
Agenesis
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
anlage or destruction of the part after it has begun
to develop. Hypoplasia appears to have acquired the
significance of a slight defect of growth; aplasia is
used to indicate more important deficiencies. The
term hypogenesia is now used by many embryologists
to cover all forms of imperfect and arrested develop-
ment, but particularly with reference to arrested de-
velopment of primary and secondary growing points
in the developing embryo.
Fig. 57. — Partial Agenesia of the Bones of the Cranium in
Aneneephalia. a, defect; /<, occipital portion; c, parietal bone;
d, frontal bone. Reduced 1/5. (Ziegler.)
The causes leading to imperfect development may
operate at such an early period in fetal life that
organs or parts may entirely fail of development
(agenesia), or later, before the completion of growth,
so that the affected parts are not of normal size
(aplasia, hypoplasia). Fetal agenesias and aplasias
play the chief role in the formation of monsters.
The extrauterine aplasias affecting the develop-
ment after birth may lead to a reduction of size of
the entire body or extremities, and to an imperfect
development of the sexual apparatus.
Aplasia may affect the entire skeleton so that abnor-
mally short individuals result (dwarfs), or the bones
maybe unsymmetrically developed (partial dwarfism).
The bones of the head are very frequently affected,
giving rise to the conditions known as microcephalus
and micrencephalus. The central nervous system
may show defective development, with or without
changes in its bony covering; one of the hemispheres
may be abnormally small or the entire brain may show
a retarded growth. Next to those of the nervous
system, aplasias of the genito-urinary tract are
most common in occurrence. The uterus or the
entire set of female generative organs, external and
internal, may remain in an undeveloped state at
puberty. The external organs of the male are also
not rarely abnormally small, and in non-descent of
the testicle aplasia of the organ usually takes place.
Parts of the intestine may be so imperfectly formed as
to consist of a narrow canal or a small fibrous cord;
and in the development of the lungs the alveoli of
portions of one or more lobes may be imperfectly
developed. The kidney and liver may also suffer a
greater or less imperfection of growth. Hypoplasias
of the heart and vascular system have been thought
to play an important part in the pathology of chlorosis
and lymphatic struma.
Agenesia for the greater part leads to the production
of monsters or to the development of malformations
which may be of so serious a nature as to preclude the
possibility of extrauterine life. There may be
absence of the cranium (acrania) (Fig. 57), or of the
brain (anencephalus), or of the spinal cord (amyelia).
A complete failure of development of any part of the
skeleton may take place, or of any part of the nervous
system. Agenesia may also result from the failure of
developing centers to unite or of clefts to close; in the
hitter class are to be placed a great variety of mal-
formations (cleft palate, hare lip, exstrophy of the
bladder, spina bifida, cleft sternum, omphalocele,
etc.). Agenesia of a single organ may also arise from
the imperfect separation of two organs which develop
from a single focus (cyclopia), or from the secondary
union of two divided organs. Atresia of the mouth,
nose, ear, anus, vagina, or urethra may also result from
agenetic development of portions of these structures.
Agenesia of the bones of the extremities, of single
muscles or groups of muscles, of the auricular septum,
etc., are among the more common malformations
which permit of extrauterine life.
The tissues composing aplastic organs may be
normal in structure, but there is very frequently
assi iciated with abnormal smallness of the entire organ
a deficient development of its elements or a complete
absence of the more highly specialized ones. In aplasia
of the central nervous system there may be agenesia
of the ganglia cells and nerve fibers; portions of the
brain may be represented by fibrous or membranous
masses. The hypoplastic ovary may show complete
agenesia of its ova; and in the lung there may be entire
failure of development of the alveoli (Fig. 58). Like-
wise in the liver and kidney, portions of the secreting
structures may fail entirely.
The causes of aplasia and agenesia may be either in-
trinsic or extrinsic.
As intrinsic causes may be considered all of those
that arise in the germ either through inheritance or
pathological germ variation, or through disturbances
of the copulation of the sexual nuclei. The inherit-
ance of agenetic malformations may be direct,
atavistic, or collateral. Certain types of faulty de-
velopment, notably those of the nervous system
and genito-urinary tract, occur with a certain fre-
quency in degenerative inheritance (harelip, hypo-
spadias, single kidney, monorehidism, syndactylism,
deficient extremities, etc.). The pathological germ
variation may be the result of the union of two
nuclei, one or both of which are abnormal, or of the
union of two normal nuclei which are not suited to
each other. Premature exhaustion of the growing
point or arrested growth of the same may be due to
a reversionary degeneration with defective constitu-
tion of the biophores, or to an intrinsic quantitative
defect in matricial cells that should normally develop
into certain organs or tissues. Chemical and physical
influences may act upon the ovum or sperm before
Fig. 5S. — Agenesis of the Respiratory Parenchyma of the Left
Lung. The lung consists of dense connective tissue in the midal
of which dilated bronchi are found. (Horizontal section through
the apex of the upper lobe; natural size. (Ziegler.)
fertilization as well as immediately after fertilization,
and we know that agenesis and hypogenesis can be
produced experimentally in this way (Roentgen ray,
action of various chemicals, etc.).
But by far the chief causes of agenesia are extrinsic.
Of these, pressure, jarrings, disturbances in the supply
of oxgyen and nutrition, contaminations of the mater-
nal blood from intoxications and infections, fetal
inflammations, abnormal conditions of the amnion,
152
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Aggresslns
play the most important part. There is very strong
evidence that a large proportion of agenetic malfor-
mations arise from abnormal adhesions between the
embryo and the amnion, or from abnormal pre
exerted by the amnion upon the developing germ.
The head and extremities suffer most frequently from
these causes. Aplasia of the bones is sometimes
associated with thyroid disease. Agenesis and hypo-
genesis are undoubtedly produced by many different
causes; and in any given case of defective development
ji uiay be impossible to determine the particular
etiological factors.
The agenesias of the more important structures of
the body lead as a rule to the production of a non-
viable fetus. Only those failures of development
cting the body in such a degree that life processes
arc not seriously interfered with admit of living after
birth. Dwarfism, agenesia of the bones or muscle- of
the extremities many of the cleft malformations,
esia of the sexual organs, etc., permit of life and
rauterine growth. Some of these may be corn-
sated for by hypertrophy of other organs or parts
of tin- same organ, while others may be improved by
rical treatment. Aldked Scott Warthin.
Ageusia. — (From tv-privative and yev
W.
60.31
March
58.9
si; 7 31.1
35.3
3.3
23 2
3.2
4.0
w.
57.90
April
65 2
89 3 36.3
34.1
2.4
19.3
6.2
3 3
S.E.
52. 7S
M: in
54 2
7S.8
26 6
35.3
2.9
19.0
5.
4 5
58 7;
\Ve possess, then, in this climate all of the attributes
of a health resort favorable for the relief of pulmonary
tuberculosis, except altitude and its accompaniments
— viz., pure dry air at a moderate temperature, a dry
and well-drained soil, an absence of high winds with an
occasional exception, and an abundance of sunshine.
Experience through a long series of years m the treat-
ment of pulmonary tuberculosis at this place verifies
this conclusion. In the writer's opinion, the high-
altitude climates are superior, as proved so far by
results, to those without altitude; but it must never-
theless be borne in mind that not all cases of pulmo-
nary tuberculosis are suitable for the high altitudes,
and in such a climate as Aiken we have a most valu-
able resource for such cases as, from limited vitality
or other unfavorable conditions, are unsuitable, at
least fcir a while, for the high altitudes. Here we can
surely carry out to perfection the modern open-air
treatment, which after all is the essential part of the
climatic treatment of pulmonary tuberculosis.
Moreover, the climate of Aiken is suitable for
patients who are suffering from other diseases, such
as rheumatism and albuminuria; for convalescents
from acute diseases or injuries; and for large numbers
of individuals who, for one reason or another, possess
little physical vigor. Here they can exist in comfort
with a minimum expenditure of vital force.
•Malaria," says the late Dr. Geddings, "is re-
The Highland Park Hotel, which was destroyed by
fire in 190S, has been replaced on another site by tin-
Hotel Park-in-the-Pines, which compares favorably
with the highest class metropolitan hostelries and is
equipped as are few modern resort hotels. The special
feature of the place is the cottage life, and cottage- of
all sizes can be rented, from the simple three-room
cabin to the pretentious villa provided with all
the modern improvements. There are four family
hotels in the town, and also numerous boarding-
houses.
Any account of Aiken would be incomplete without
mention of the small but excellent Aiken Cottage
Sanatorium founded, in 1S96, for the treatment of
cases of incipient phthisis. It is a charity, and is
modelled after the institution of Dr. Trudeau's al
Saranac Lake. The cottages at present are arranged
to accommodate sixteen patients. The treatment
consists mainly in providing good nourishment and
keeping the patients in the open air from seven
to nine hours a day.
The educationaf advantages of Aiken are very good,
there being several excellent junior schools, and a high
school which fits its pupils for college. Churches of all
denominations are to be found here.
In conclusion it may be added that Aiken is situated
upon the Southern Railroad, with three daily trains
from New York, For much of the above account the
156
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Airiliiini
writer is indebted to the late Dr. Mc< iahan, one of the
founders of the Aiken Cottage Sanatorium.
Edwabd < ». Otis.
Allanthus. — A genus of some seven species, in the
family Simarubacece, natives of Eastern Asia and the
East Indies, the A. glandulosa Desf. common in the
Eastern United States. It is in this species thai
Ileal interest chiefly centers.
It has been observed that the tree is odious to flies,
which, it is said, will not approach even decayed meat
when placed among its leaves. Mild poisoning has
been recorded from the habitual drinking of water
into which the roots of the tree had penetrated, and
i\ hidi its leaves had fallen. The symptoms were
those of simple gastric irritation, similar to what
would be caused by the amaroids contained in quassia
and similar drugs. The bark and leaves have been
I medicinally, and are purgative and anthelmintic.
I b.< constituents of the plant are known only in the
mosl general way. An amaroid, a volatile oil, and
i resin are active. The pure resin has been found
purgative, but not anthelmintic, while the oleoresin
is an efficient teniacide. The teniacidal property is
therefore assumed to reside in the dark-green volatile
oil. This oil, taken by inhalation, is a powerful
depressant poison, producing vomiting, dizziness, and
cold perspiration. Taken by the stomach these
effects have not been observed, though due pre-
cautions in regard to dosage should be observed.
The dose of the powdered leaves, as a teniacide, is
0.5-2.0 grams (grain viij. to xxx.), of the oleoresin
0.2 to 0.6 gram (grain iij. to x.).
In India, the juice of the leaves and bark of .1.
exeelsa Roxb. have been used from ancient times as
a tonic, especially in convalescence after parturition.
The bark of this and of A. malaharica D. C, is also
used as a vegetable bitter, in forms of dyspepsia.
II. II. RUSBY.
Ainhum. — (Synonyms: Ainhun; dactylolysis spon-
tanea; Absiigen [German]; Daetiliolisia [Spanish].)
The etymology of the word is usually attributed to
Africa, and is derived from a word meaning to "saw
off." Matas states that the word ainhum is from
the negro patois of Brazil, ainhoum, meaning a
"fissure."
Definition. — Ainhum is a disease of tropical
countries, and is characterized by the gradual painless
amputation of one or more joints of one or more
toes by a trophic process of mixed atrophy and
hypertrophy.
History. — While the first accurate description of
the disease was made by da Silva Lima, of Bahia,
Brazil, in 1S67, as much earlier as 1860 Dr. Clark
called attention to ainhum in the Gold Coast natives.
Since 1S67, a number of observers have reported
upon the disease, notably Duhring and Wile, and
Matas in this country. Zambaco Pacha, in the
Transactions of the 1897 Lepra Conference in Berlin,
writes at length upon the condition in its relation to
leprosy.
Etiology. — The cause of the disease is not known.
It has been found in the negro races in most of the
- reported; it usually occurs in adults, though
de Brun reports a ease at six years of age, and is
essentially a tropical disease, exotic cases occurring
occasionally elsewhere. The parasitic nature of the
disease is maintained by some, but it has not been
proven. Zambaco Pacha maintains the identity of
ainhum and trophic leprosy of the mutilating type.
Hanson suggests that the lesion is due to irritation
from injuries received in walking barefooted, resulting
in the peculiar scarring, like keloid, to which the
negro race is especially prone.
Symptoms. — Prodromes are absent. There may
be some itching, but usually the disease is evidenced
by a slightly constricting band, a furrow, at the
digitoplantar fold of the fifth toe. At times other
toes may be affected. For example, I have seen the
great toe involved, at the New Orleans Charity
Hospital. The furrow gradually becomes more
pronounced, harder in consistency, and more and
more constricting, the confined portion of the digit
increasing in size SO as to lose the shape and form of a
toe. There is absence of inflammation and of sub-
jective symptoms, excepting occasional pain. As
Fig. 61. — Ainhum, End of Small Toe after Amputation. (Enlarged
about 2 1/2 times.)
the constricting band narrows, the toe becomes more
and more tumefied, until finally only a small pedicle
remains. From this the tumor either sloughs off,
is torn or knocked off, or is intentionally removed.
When ulceration takes place, there is a distinct odor,
of a nauseous character, resembling that of the
neurotic ulcer. The pedicle, or base, heals kindly.
The process lasts months — even years in some
instances.
Pathology. — Unna believes the condition to be
"a ring-formed scleroderma with callous formation
of the epidermis, leading to secondary total stagnating
necrosis, resembling artificial snaring of tumors.
There is a primary inflammation with marked hyper-
trophy of the epidermis, the papilla? being narrowed
and elongated. In the papillary body there is
cellular infiltration; the vessels are dilated. The
tumefaction of the toe indicates a stagnation of
lymph and fat, whicli gradually causes degeneration
of all of the constituents of the cutis, a rarefaction of
the bones, and the disappearance of the phalanges.
In this most observers agree.
Differential diagnosis must be made especially
from Raynaud's disease, from paronychia, from the
neurotic ulcer, and from leprosy.
Raynaud's disease is nearly always painful, occurs
seldom on the lower extremities, is quite common on
the upper extremities, and the trophic change is
evidenced most often by the occurrence of preliminary
lesions, e.g. vesicles or bulla?.
Paronychia is inflammatory throughout and occurs
on the ungual phalanx always.
The neurotic ulcer begins as a callosity, is circum-
scribed and deep seated, occurs usually on the plantar
surface of the heel or great toe, and is never located
just at the digitoplantar fold of the fifth toe. It is
157
Ainhiim
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
characterized almost from the start by the loss of the
central tissue and by a persistent slough, exulcerating
and discharging freely.
Leprosy of the mutilating type has points of resem-
blance to ainhum, especially when the latter disease
is well advanced. Leprosy, however, has no prefer-
ence for the negro, and it is not a tropical disease.
The trophic lesions of leprosy are found on any toe
or any finger, usually on the dorsal side. These are
almost invariably associated with other present or
past manifestations. The initial evidence of muti-
lating leprosy is a macule, excoriation, or bulla on
the site of the destruction. The initial evidence of
ainhum is a callous furrow, without inflammatory
redness.
Treatment. — All observers agree that perpen-
dicular and free incision of the circular bands may
arrest the process, but that usually the course of
spontaneous amputation is completed, unless arti-
ficially or surgically produced.
Isadore Dyer.
Bibliography.
Clark: Trans. Epidemiolog. Soc., I860, London.
Da Silva Lima: Ainhum. Amer. Archiv. of Dermat., 1SS0, p.
367.
Duhring and Wile: Ainhum. Amer Jour. Med Sciences. January,
1S81.
Eyles: Lancet, 1886. ii, p. 576.
Walter Pyle: Medical News, Jan. 26, 1S95 (with full bibliog-
raphy).
DeBrun: Annales de Dermatologie, vol. x (1S99), p. 325.
X. D. Brayton: Journal of the American Medical Association,
July 8. 1905.
Air. — To appreciate the various sanitary relations
of the atmosphere, the subject must be studied from
the physical as well as from the chemical stand-
point. In considering the physical aspects of air,
attention must be given to the subjects of atmos-
pheric pressure, light, heat, humidity, and electrical
condition.
Physical Properties. 1. Atmospheric Pressure. —
The air is an invisible gaseous ocean. In it, as in all
gases, there is no cohesion between the molecules.
They are apart from one another, and their tendency
to spring farther apart and occupy more space is so
great that a restraining force is needful to prevent
expansion and attenuation. Air at the sea level,
the bottom of the aerial ocean, is compressed b}- the
weight of the superincumbent air. This weight ex-
presses the influence of gravity on the air as a whole,
or the influence which the earth exerts on the mole-
cules of its atmosphere to keep them from escaping
into limitless space or from being whirled away by
the centrifugal force of the diurnal rotation. The pres-
sure of the atmosphere at the sea level balances a
column of water thirty-four feet high. It forces
water up the cylinder of a pump in proportion as
the air pressure within the cylinder is lessened by the
working of the piston, but the raising power of the
pump is limited by the height mentioned. Similarly
at the sea level the atmospheric pressure balances a
column of mercury 29.92 inches, or 760 millimeters, in
height (at 45° N. latitude), and as this number of
cubic inches of the liquid metal weighs 14.75 pounds,
or 1 kilogram, to the square centimeter, the air
pressure on every measure of surface becomes known.
Generally, however, air pressure is expressed in inches
of mercury as being more convenient than a state-
ment of the actual weight on a given area. The pres-
sure on a surface of one square foot amounts to nearly
a ton. The average man has a surface of about fifteen
square feet, but the fifteen tons of air pressure under
which he moves are unfelt because of the fluidity of
the atmosphere. The freedom of movement possessed
by its molecules transmits their pressure in all
directions. Air permeates all porous bodies, and
the internal pressure in bodies so permeated counter-
acts the external pressure. Noticeable effects of air
pressure are seen or felt only when there are local
disturbances, as when the tissues are pressed by the
weight of the atmosphere into the rarefied air of a
cupping glass.
The higher we ascend into the atmosphere the less is
the pressure, because there is less overlying air to
affect us by its weight. Heights are measured by the
decreased pressure, and balloonists calculate their
distance from the earth by the fall of the mercurial
column in their barometers. At the sea level, under
a pressure equivalent to that of 29.92 inches of mer-
cury, a cubic foot of air weighs 536 grains. Air is
increased in bulk as pressure is diminished. At the
height of one mile, the barometric column falls to
24.5 inches, equivalent to a pressure of 12.04 pounds
to the square inch. Under this lessened pressure, a
cubic foot of sea-level air would expand, other things
being equal, to 29.92-^24.5, or 1.22 cubic feet, and
one cubic foot of this rarefied air would weigh only
439 grains. The pressure at two miles being equiva-
lent to only twenty inches of mercury, one cubic foot of
sea-level air would expand to 29.92-^20, or 1.49 cubic
feet, and the weight of a cubic foot of this expanded
air would be 360 grains. With increased height there
is diminished density, but as the elastic force which
separates the molecules becomes lessened by their sepa-
ration, there may be a certain condition of tenuity in
which this force is unable to overcome those which
operate in restraint. The depth of the atmospheric
ocean has been estimated variously at from 45 to 350
miles or more.
2. Light. — Light from the sun or other sources
passes through the air without illuminating it. Were
it otherwise we should be able to see the air. We see
things by the light which they emit or reflect, but
the air merely transmits. We speak of atmospheric
glows and beams of light, of the blue of the firma-
ment and the radiance of morn, but these pin
relate to the visibility of substances in the air. Light
is transmitted in straight lines, with the exception of
some refraction in the denser strata near the earth's
surface; but as more or less of the light is refused a
lodgment by every substance on which it falls, and
is reflected from one object to another at all angles
and hence in every direction, the whole of the air is
filled with rays which illuminate objects that are not
exposed directly to the source of the illumination.
Molecules of watery vapor and minute particles of dust
suspended in the air give rise to the apparent diffusion
of light in the atmosphere. These account for the
dawning light of morn, and the twilight after sundown.
3. Heat. — Associated with solar light are actinic and
heat rays. The latter are of the highest interest, as
being the cause of the tides, currents, and local move-
ments in the atmosphere. Heat rays pass through
the atmosphere without warming it. The air of high
mountain regions is cold, although the same rays pass
through it which may give a tropical warmth to the
plains below. It is usually said that the temperature
falls 1° F. for every 300 feet of altitude, or about 134
meters for 1° C. This, although not accurate, is
useful. If the temperature, average or actual, of a
given locality be stated, an approximation to the
corresponding temperature of a neighboring plateau
may be calculated. Glaisher, during his balloon
ascents, found the temperature on a cloudy day
lowered 4° F. for every inch of a barometric fall of
eleven inches; and the further ascent was marked by
a more rapid refrigeration. As eleven inchc- oi
mercury indicate an elevation of 12,000 feet, the
average ascent for the Fahrenheit degree was a I
270 feet. On a clear day the thermometer fell 5°
for each of the first four inches of barometric fall,
4° for each of the next nine inches, and 13.5° for the
last three inches of his ascent. The cold is propor-
tioned to the lessened pressure, 4° F. for each inch;
1 ,-,s
REFER EXIT. HANDBOOK OF THE MEDICAL SCIENCES
Air
but as the height to bi> ascended fur each inch of
f ;l ll increases with the ascent, the height for each
degree of temperature increases correspondingly.
Air, in expanding under lessened pressure, lias its
expansion restricted in some measure by the loss of
heat attending the expansion, for the volume of a
gas is contracted by cold. Air expands T J, T of its
volume at 0° F. for each degree of increased tempera-
ture Os+j in the case of Centigrade). Hence 460 cubic
inches or feet or, in general terms, volumes, at 0° F.
expand at 60° to 520 volumes, and conversely by a
reduction of temperature from 60° F. to 6° 520
olumes contract to 460. On these data is based that
which in dealing with air and gases is called the
"correction for temperature." The molecules of a
. ubic foot of dry air weigh, at the sea level, 536 grains.
Under the diminished pressure, at 16,000 feet, these
molecules would occupy a space of two cubic feet,
each foot containing 26* grains; but the coincident
reduction of temperature would so modify this that
the cubic foot of air would weigh 303 grains. The
rarefaction of the atmosphere in mountain regions
is thus seen to be somewhat less than we should be
led to expect by a consideration merely of the
barometric pressure.
Heat, like light, is absorbed in varying proportions
by everything on the surface of the earth, and that
which is not absorbed is reflected at various angles,
so that the air in its lower strata is filled with reflected
rays which become manifest only when they arc
absorbed and increase the temperature of the ab-
sorbing substance. Absorbed heat is radiated to
cooler bodies in the neighborhood, for the tendency
in nature is to an equable distribution. Hence,
besides reflected rays, the air may be filled with rays
of radiant heat, but in all this there is merely trans-
mission, with no appreciable influence on the air
itself. When, however, absorbed heat is distributed
by convection the air assumes an active part in the
process. A warm substance communicates part
of its heat to the air molecules in immediate contact
with it. The air thus heated expands and is floated
upward by the inflow of colder and heavier air
beneath it; and it is thus raised until by admixture
with the general mass of the air its rarefaction is lost,
or until under unusual conditions of placidity it
reaches a stratum of equal rarefaction. The cold air
that replaced it in contact with the heated substance
becomes similarly warmed and borne upward; and
this continued in an uninterrupted sequence gives rise
to an upward current of warm air with inflowing
currents of colder, heavier air on all sides. We
sometimes seem to see this upward current by the
side of a heated stove, when its varying density dis-
turbs the passage of the rays of light from objects
seen through it, and gives a quivering movement to
their outlines. In the sandy districts of southern
Arizona and New Mexico, trees and other objects at
a little distance from the observer are often tremu-
lously distorted to his sight by the upward currents
from the sun-heated surface.
Objects that absorb much radiate much, and those
warmed rapidly by absorption cool quickly by radia-
tion. Color has an influence on these movements, for
black surfaces absorb and radiate better than white.
Radiation and reflection are therefore different pro-
cesses, for white is the better reflector. The radiant
powers of different substances vary much, but it is
unnecessary here to do more than indicate in general
terms the differences presented by land and water in
this regard.
As compared with water, land heats quickly and
cools quickly. The heat does not penetrate but ac-
cumulates in and immediately beneath the surface
Children know how cool is the underlying sand turned
up on the seashore in their holiday play. The surface
is hot by day and cool by night, but at a depth of three
feet there is no diurnal increase of temperature, and
even the heat of a prolonged summer penetrates only
about seventy feet, for well water at this depth has
the same temperature summer and winter.
.Masses of water, on the other hand, heat slowly and
cool slowly; the rays penetrate to the depths. The
temperature of the surface waters of the ocean is never
over 80° F. (26.6° C.) in the tropics, and its diurnal
range is small. In higher latitudes the temperature
is lower, bul the mass of the waters of the ocean, in
both high and low latitudes, is never below 39° I'.
(3.9° O). Thus the air is warmed intermittently by
the land and continuously by the ocean, and its
molecules are kept in motion by the convection which
is in progress.
The solar rays are the only source from which the
air derives its warmth, for, although animal life and
the combustion of fuel develop heat, the heat thus
developed is merely the liberation of energy derived
originally from the sun. Again, although the earth
has an internal heat, this heat is not transmitted
through the crust, for the superficial strata to a
depth of seventy feet are affected by the seasonal
warmth of the sun, and not by the interior heat.
4. Humidity. — The effects of heat on the atmos-
phere are multiplied and varied by the phenomena
attending its action on water. Vapor, invisible as
the atmosphere itself, rises from water at all tempera-
tures. The higher the temperature the more rapid
the evaporation. Thus vapor is absorbed into the
atmosphere, and the amount that can be absorbed
increases with increase of temperature. A cubic
foot of air at 32° F. is saturated with moisture when
it contains 10 cubic inches or about two grains of
vapor of water; but at 100° F. (37.8° C.) the cubic foot
of air can absorb about 100 cubic inches, or nearly 20
grains. The molecules of the vapor find place for
themselves in the intermolecular spaces of the air, but
not without crowding aside the air molecules to such
an extent that saturated air is lighter than dry air.
Air is known to be saturated when the slightest
lowering of its temperature causes a deposition of
moisture. We call such a deposition cloud when in
the air above us, fog or mist when in the air around
us. and dew when deposited at night on vegetation
and other highly radiating surfaces. The dew point
may be found by noting the temperature at which
moisture appears on the outside of a test tube, cooled
by the evaporation of ether in its interior. Usually
an approximation to it is obtained by the wet bulb
thermometer, from which the actual dew point may
be calculated or gathered from Glaisher's tables.
Moisture in the air is expressed as relative humidity
on a scale of which 100 is the point of saturation.
Absolute figures give no satisfaction. With two
grains of moisture in a cubic foot of air the air, as we
have seen, may be very moist or very dry. If the
temperature is 32° F., the air is saturated; if it is 100°
F., the air is so dry that it is ready to take up eighteen
grains more before it becomes saturated.
Evaporation aids radiation and convection in cool-
ing a warm, moist surface. The soldier in a summer
camp moistens the outside of his canteen and hangs it
on a branch that the passing breeze may cool its con-
tained water. Even the surface of the water of the
tropical oceans is cooled slightly at night. It is, how-
ever, not so much by the production of a local coolness
as by the transference of heat from one place to an-
other that the chief influence of evaporation is ex-
ercised. From the surface of the ocean, particularly
in the warmer latitudes, evaporation is going on at all
times. An upward movement of moist, warm air is
continuously in progress. Partial condensation occurs
by the time this air reaches a stratum of its own
density, but the clouds there formed are usually
hurried by air currents to other and colder regions of
the globe before the particles of condensed vapor
become aggregated and fall as rain. The heat
gathered from the tropics is thus distributed to other
159
Air
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
pari- of the earth, the air of which is warmed by con-
densation above as well as by convection from below.
Moreover, the clouds absorb heat radiated from the
surface of the earth, thus preventing its dissipation
into the ether beyond. Every object on the surface
is thus kept warmer than it otherwise would be.
Clouds act as a blanket to keep the air and the earth
under them warm. Any roof, however flimsy, even
the spreading branches of a tree in foliage, is a pro-
tection against the cold of radiation into space. The
great heat of the direct rays of the sun at high alti-
tudes, where the surrounding air is intensely cold, is
attributed to the freedom of the air from intercepting
moisture.
5. Electrical Condition. — Electricity pervades the
atmosphere. It is generated by the evaporation of
water, the friction of the wind on the surface, and of
the molecular constituents of the air each on the
other; but its relations to these constituents are not
clearly understood. It is greatest in cold, dry weather,
but the greatest electrical disturbances are associated
with condensation and rainfall.
( )ur knowledge of the effects of heat and moisture
enables us with but. little effort to recognize the causes
of many meteorologic phenomena that have important
bearings on the well-being and comfort of the human
race. Meteorology is probably the oldest of the
sciences, for man, even in the earliest days of his
racial existence, found it necessary to study the
probabilities; and the weather wisdom of every nation
is embodied in proverbial expressions. The co-
operative work of modern times, made possible by
the use of the telegraph, has enlarged our knowledge
and broadened our views of these phenomena, so that
we now have a useful understanding of the general as
well as the local movements of the atmosphere.
Air Currents. — Extending for a few degrees on each
side of the equator is a region of calm and light varia-
ble winds, known to sailors as the doldrums. Here the
uprising of the moist, warm air leads to condensation
in the higher strata. Heavy rains fall, and the heat
liberated during the condensation rarefies the relative-
ly dry air of the upper regions and develops a swell on
the surface of the atmospheric ocean which divides or
flows over, one-half to the north, the other to the
south, while an inflow in the lower strata restores the
aerial equilibrium. The inflowing currents do not
come from the poles; they reach only from the thirtieth
parallels, and their motion is more or less obliquely
from the east on account of the diurnal revolution of
the earth. A belt of variable winds is found about
the thirtieth parallels. Here the upper current from
the tropics impinges (in the northern hemisphere) on
a northeast upper current from the Arctic circle, and
the swell of their meeting occasions an increased
pressure at this point. Escape for the accumulated
air is found below, southward constituting the trade
winds and northward constituting the regular south-
west winds of the north temperate zone. At the
Arctic circle is another doldrum belt into which flows
the wind last mentioned and a surface current from
the northeast. These, warm and cold intermingling,
produce condensation and rainfall and an expansion or
swell which overflows into a northeast upper current
over the temperate zone, and a southwest upper
current toward the pole. The surface currents affect
the air to a height of 10,000 feet, involving about
one-half of the weight of the atmosphere, and their
velocity averages about fifteen miles an hour. This
constitutes the general circulation of the atmospheric
ocean, but there arc many secondary currents, as that
between land and sea. In fact innumerable causes of
greater heating at one place than at another give rise
to local currents.
The resultant of all the meteorological conditions
constitute climate; but temperature, as being the
most notable condition, is usually adopted to give
formal expression to the character of a climate.
Temperature depends on latitude, altitude, and the
presence of large bodies of water to reduce the daily
and seasonal ranges. One of the first discoveries by
those who collated the meteorological observations of
the medical officers of the United States Army was
the climatic importance of the great lakes. In New
England the influence of the ocean was found to
modify the mean temperature. In the interior of New
York, the daily range increased and the seasons were
strongly contrasted. Farther west, near the great
lakes, a climate similar to that of the seaboard was
again found, but in the interior beyond them, ex-
treme changes again became the rule. Water tempers
the winds which blow over it and loads them with
vapor for subsequent condensation and warmth. The
regular southwest winds of the temperate zone
reaching Europe from the Atlantic and California
from the Pacific Ocean give these shores a climate
markedly different from that of the Eastern coast or
interior of the United States. The air of continental
interiors is dry and the solar rays beat with full in-
tensity on the surface, while at night there is no pro-
tection against radiation into the cloudless skies.
That climate has a powerful influence on the welfare
of man is manifest when we compare the weakness
and indolence of tropical races with the strength and
energy, mental as well as physical, of those of the
temperate zones. Since the earliest ages it has been a
favorite theory that diseases come upon mankind
through the air. But although the tendency of
modern research is to absolve the air from any special
complicity in the propagation of epidemic diseases,
the charge of influencing the human system unfavor-
ably still holds good in certain other respects. Altera-
tions of atmospheric pressure have been regarded by
some medical observers as causing pulmonary con-
gestions, and both compressed and rarefied airs have
been used in the treatment of diseased conditions of
these organs. In hospitals for consumption, how-
ever, where any general influence causing congestion
of the lungs would be manifested by an increase in the
number of cases of hemoptysis, careful observation
has shown that there is no such increase during the
passage of the storm center. The exacerbations of
neuralgic and rheumatic pains coincident with
alterations of atmospheric pressure have established a
popular belief in their relations as effect and cause,
which has received some support from a consideration
of "caisson disease."
The caisson for the Brooklyn tower of the East River
Bridge measured 168 X 102 feet, its interior or working
chambers being fourteen feet in height. It was, in fact,
a huge box sunk mouth downward by laying courses
of concrete on its upper surface. Compressed air
forced into the chambers displaced the water; and
relays of men excavated the bottom of the river bed
beneath it until a rock foundation was reached.
The upper end of each shaft leading to the chambers
was guarded by an air-lock to prevent injury to the
men by a sudden change of pressure on entering or
leaving. Before descending, compressed air from
below was admitted gradually into the lock chamber,
and only when the density was equal to that in the
caisson was the descent made. Correspondingly,
before leaving, a gradual transition from compressed
to ordinary air was effected. On exposure to air
under a pressure of three or four atmospheres, the
skin became pale and shrivelled and the countenance
shrunken, as the blood was forced from the superficial
vessels to those of the bones and the cavity of the
skull. The heart's action increased in rapidity to oxer-
come the impediment to the circulation; but after a
time the system accommodated itself to the altered
conditions, and generally no bad effect was manifested
until the men returned to the colder and relatively
rarefied air of the surface, when many suffered from
pains in the bones, giddiness, faintness, numbni
and even paralysis. A longer time in the lock chani-
160
ItKI'KKKNCK HANDBOOK OF THE MEDICAL SCI] NCES
Air
ber td permit of accommodation to lessening air
, . would have prevented these injurious effect -
Phe diminished pressure at high altitudes is described
by travellers as causing soroche, or mountain sickness,
which is characterized by restlessness, sleeplessness,
ping respiration, anxiety, vomiting, and fainting,
ft is experienced al a height of ten or twelve thousand
when the individual is expending energy by
climbing, but in balloon ascents the effects of dimin-
ished pressure are not felt until twice this distance has
been reached.
Heat relaxes the tissues and depresses the vital
energies. Cold stimulates these energies to make good
loss of animal heat; but if excessive it benumbs
and paralyzes and ultimately destroys by freezing.
When local in its application it disturbs the cireula-
uf the blood, causing a congestion of some internal
in when the surface of the body is chilled and its
els are contracted.
Air at 50° F. (10° C.) saturated with moisture is
colder to the feel than dry air at the same temperature;
it chills by contact. Above 50°, however, it is warmer,
prevents evaporation from the body. At high
tospheric temperatures it is oppressive and induces
exhaustion or sunstroke. As evaporation is
stopped, the system is unable to keep down its heat to
normal of 9S.6° F. (37° C), and when the blood
becomes heated higher than this, dangerous symptoms
leveloped.
i in mical Constitution. — Formerly air was re-
garded as one of the elements. It is now known to be
a composite substance; the properties of its constitu-
ents have been determined, their relations to animal
and vegetable life have been discovered, and traces of
idental impurities swept up by its currents from the
face of the earth have been detected and studied in
their bearing on sanitary conditions. The atmos-
phere, according to the chemist, consists of a mixture
of two gases, oxygen and nitrogen. The former is
active in its properties, combining with many suscept-
ible elements, and especially with the carbon and
hydrogen of devitalized organic matter, constituting,
ording to the rapidity of the process, either oxida-
tion or combustion, and, with the same elements in
the living tissues of animals, constituting one of the
itials for the continuance of life. A certain small
percentage of the oxygen of the air exists in the form
of ozone, but the quantity present cannot be deter-
mined, and even its existence is at times indicated
with doubt by the iodized starch papers, which have
been largely used for its detection, as they are affected
by other matters, as nitrous acid and peroxide of
hydrogen, occasionally present in the atmosphere.
Iodized litmus papers have been shown by Dr. Fox
to be of value as a qualitative test, and as indicating
comparative quantities when known volumes of the
air are aspirated over them. It is certain, however,
ozone has stronger affinities than ordinary oxy-
gen, and that oxidation goes on more rapidly in its
presence than in its absence. It undoubtedly de-
stroys the volatile substances which are evolved dur-
ing the putrefactive process. When foul organic
odors are present, ozone is absent. Hence, when the
presence of ozone is indicated by the test papers, the
air is regarded as free from organic contaminations
susceptible of oxidation. Animals exposed to ozone
artificially produced suffer from irritation of the lungs.
The n ilrogen is regarded as negative, or passive, serv-
ing merely to moderate the activities of the oxygen by
dilution. Mention, however, should be made of the
discovery of the element argon by Lord Rayleigh and
Professor Ramsey. Argon has characters similar to
those of nitrogen; but as its uses in the economy of
nature have not as yet been determined, it must be
left for the present with the nitrogen, with which it has
so long been associated.
In the atmosphere the chemist recognizes also the
presence of small but varying quantities of other mat-
ters such as carbon dioxide, ammonia, and watery
vapor. The percentage composition of dry air i-. by
volume, 79 of nitrogen, 20.96 of oxygen, and 0.04 oi
carbon dioxide; by weight the relative proportions of
nitrogen and oxygen, are 76.99 and 23.01. Nitrogen is
the lightest, carbon dioxide is the heaviest; yet, on
account of the const ant I not ion of the atmosphere and
the tendency of gases to diffuse, there is no separation
into st rat. a richer in nitrogen above and carbon dioxide
below. This power of diffusion possessed by gases is
such that, in places where t here is a continuous genera-
tion of carbon dioxide, it does not accumulate un-
less it is confined as in a room, and even t hen it is dif-
fused through the whole air of the room and not col-
lected by its weight near the floor. The intermingling
of gases by diffusion is shown by I'ettcnkofer's exami-
nation of the air over certain effervescing springs.
Samples from the water level contained 70 per cent, of
carbon dioxide; from 40 inches above the water level,
2 percent., and from 5.5 inches only 0.5 percent. Hence
little difference is found in the percentage composition
of the free air, whether samples be taken from over
the land or the ocean, from the sea level or from a
high altitude.
The oxygen of the air varies but little from its
average percentage, but the quantity of it taken into
the lungs varies with the temperature and pressure.
Much of the depressing effects of atmospheric heat is
probably due to a want of oxygen in the expanded air.
A cubic foot of sea-level air at 32° F. contains 132
grains of oxygen; at 100° F. it contains 116 grains, a
reduction of 12 per cent. Again, the distress felt by
mountain climbers and usually ascribed to lessened
pressure, is probably due in great part to the lessened
amount of oxygen inhaled. A cubic foot of air, at 60°
F. and 30 inches of pressure, contains 124.6 grains of
oxygen. The expansion under a barometric pressure
of 20 inches, corresponding to a height of two miles,
with the coincident contraction by a fall of tempera-
ture to 20° F., would reduce the oxygen in a cubic
foot to 90 grains, a reduction of 2.8 per cent.
The carbon dioxide, C0 2 , familiarly (but incorrectly)
known as carbonic acid, is produced by the oxidation
of carbon in dead and living tissues, and its percentage
in air varies with the local causes which determine
its production. Thus it is greater in the alleys and
streets of a city than in the open country, and as this
gas is soluble to some extent in water, its proportion
varies with the hygrometric and other conditions,
being greater in a damp atmosphere before rain has
fallen than in the air of the same locality after the
aqueous vapor has been precipitated. The air cur-
rents and the diffusive power tend to equalize the
percentage, but as production is constant in some
localities, the air of these must always show a rela-
tively larger quantity of this gas than that of others
remote from such sources. The proportion in the
external air seldom exceeds 4 volumes in 10,000. De
Saussure made many series of observations to deter-
mine the percentage under various conditions. In
an investigation of the ventilation of soldiers' quar-
ters, at Fort Bridger, Wyoming, in 1S74, there was
found in the external air a gradual decrease, day by
day, from 4.5 to 2.6 volumes per 10,000 as the season
advanced, and the surface of the earth became covered
with luxuriant vegetation.
Carbon dioxide is a product of combustion; it will
therefore not support combustion. It is a product
of respiration, therefore it will not support respiration.
In mines, life is in danger when a candle will not burn.
Because workmen in soda-water factories suffer no
inconvenience in breathing an atmosphere containing
as much as two per cent, of carbon dioxide, many have
supposed that this gas is not poisonous, but that, like
water, it drowns fire and life alike by preventing the
access of oxygen. Nevertheless experiments have
shown it to be actively harmful. Animals breathing
it along with as much oxygen as is present in the
Vol. I.— 11
161
Air
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
atmospheric air have the heart's action weakened even
to fainting, and when man is the subject of the experi-
ment, dulness of mind culminates in unconsciousness
or stupor. This, however, is not of much practical
importance, for the sources which furnish carbon
dioxide to the atmosphere generally yield with it
other and more dangerous substances.
Ammonia is diffused from putrefactive processes in
progress on the surface of the earth. It is also pro-
duced, in traces, from the nitrogen of the atmosphere
by electric agency. Its quantity is variable, but
0.1 milligram in a cubic meter of air is a not unusual
amount. This corresponds to a grain in about 23,000
cubic feet. Rain washes the ammonia from the air to
the surface of the earth in amounts varying from 0.2
to 0.5 part per million of the rain water. The im-
Erovement in fields which are permitted to lie fallow
as been attributed to ammonia in the rainfall, but
this ammonia is manifestly inadequate to account
for the masses of vegetation which annually find
nourishment in the soil. The ammonia originating
on or in the soil during the decomposition of its
organic matters is the source of the nitrogen which
feeds the living plants. A trace only of this ammonia
escapes into the air and is afterward washed down
with the rain. Prior to its use by the vegetation
which covers the surface of the earth, it is nitrified by
bacteria which are everywhere present in the upper
layers of the soil. Some of the lower forms of vege-
table life, such as certain alga? and bacteria, absorb
nitrogen directly from the atmosphere. Some legu-
minous plants also fix atmospheric nitrogen in their
tissues, but this is accomplished indirectly through
the medium of parasitic bacteria found in nodules on
their roots.
The ammonia of the air is condensed on exposed
surfaces, and R. A. Smith has suggested that the
quantity of ammonia deposited on a given surface
in a given time may be taken as an exponent of the
sanitary condition of the atmosphere. A glass or
other surface which has been exposed for some time
in an unventilated bedroom, when washed with pure
water will show in the washings the presence of a
readily determinable quantity of ammonia; but the
attempt to demonstrate the relative purity of atmos-
pheres by the quantity deposited on equal and similar
surfaces in equal periods of exposure meets with
failure unless the temperature, the hygrometric con-
dition, and the air movement are the same in both
instances. This concurrence of similar conditions
is difficult, if not impossible, to obtain in practice.
The air constituents which have been mentioned
must be regarded, from the scientific and sanitary
point of view, as individually essential to the consti-
tution of the atmosphere. The oxygen is vital to
animals, its quantity being preserved by the evolution
from vegetation and the equilibrium established
between these two kingdoms of nature. The carbon
dioxide is vital to vegetation, being the source of the
carbon solidified in its tissues; its quantity is preserved
by the evolution from animals and the retrogressive
metamorphosis of the organic carbon of devitalized
tissues.
For our present purpose organic substances may be
considered as those developed by the forces of life.
They include all living bodies and those that have
ceased to live, with many products of the life of the
one and of the decay or decomposition of the other.
With the infinite variety of animal and vegetable life
constantly before us, it is needless to suggest the com-
plex character of organic matters, but, notwithstand-
ing this complexity little more than the elements
contained in air and water enter into their composition.
Animal life depends on vegetable life for its suste-
nance directly, or in the case of carnivorous animals in-
directly. Animals cannot combine the elementary
bodies, but these are taken by plants and formed into
organic substances, which animals are capable of util-
162
izing as food. So complex are all vitalized substances
that but for the preservative influence of their vitality,
their molecules would speedily break up into simpler
forms, and, indeed, when life ceases to protect them
their putrefactive decomposition begins immediately
and ends in their resolution into the very substances
from which they were originally constructed. Nature
moves in cycles. Day follows day and season season.
The seed germinates and the grown plant matures its
seed. Every generation is a cycle, and, in the
instance before us, the elements from which life
elaborated the highest organic structures revert to the
inorganic condition of carbon dioxide, ammonia or
nitrates, and water for use in some succeeding cycle.
Even in the living organism similar changes take
place. No machine works without wear. The
tissues of the animal body are worn by exercise. The
nitrogen of the worn-out tissues is removed by the
kidneys as urea, which speedily becomes converted
into ammonia, while the carbon is oxidized and the
resulting carbon dioxide is carried to the lungs to
be expelled.
During quiet breathing twenty-seven cubic inches of
air enter the lungs at each inspiration, and if the air be
pure nearly six of these cubic inches are oxygen and
only one one-hundredth part of a cubic inch carbon
dioxide. The air expired has less oxygen, more
watery vapor, a taint of organic matter, and some-
what more than a cubic inch of carbon dioxide.
Breathed air, therefore, contains a hundred times
more carbon dioxide than is contained in an equal
volume of the free atmosphere. The frequency and
depth of the respiratory acts vary in the individual
with his condition as to health, exercise, or repose;
and as might be expected, they vary also in different
individuals under the same or similar conditions.
The average excretion of carbon dioxide by the human
lungs can therefore be stated only approximu 1
Giving due consideration to the experimental results
obtained by various qualified investigators, its amount
may be stated to be at least 0.01 cubic foot per min-
ute, 0.6 per hour, or 14.4 in the twenty-four hours.
The energy of the vital actions concerned in respira-
tion, may be appreciated when we realize that in 14.4
cubic feet of this invisible gas we have nearly half a
pound of solid carbon.
Although the inflow into the lungs is interrupted by
expiration at comparatively regular intervals, the
absorption of oxygen and evolution of carbon dioxide
are continuously in progress. The inspiratory inflow
of twenty-seven cubic inches mixes with the air
already in the lungs and freshens it for the use of the
system. Deep breathing washes out the lungs and
permeates them with an air rich in oxygen and com-
paratively free from carbon dioxide. No ma Iter
how pure the surrounding air may be, an individual
may suffer from impure air in his lungs if by seden-
tary habits, or other cause, his breathing becomes
shallow and insufficient.
Allowing sixteen as the average number of respira-
tions per minute, with an air movement of twenty-
seven cubic inches into and out of the lungs, the air
respired in an hour would measure fifteen cubic fi et
and in twenty-four hours 360 cubic feet, and with an
output of 0.01 cubic foot of carbon dioxide per min-
ute the respired air would contain four per. cent, of
this gas. From these data may be calculated the
amount of dilution needful to bring respired air back
to a condition of purity approximating that of the
free atmosphere. If fifteen cubic feet of breathed
air containing 0.6 of a cubic foot, or four per ce
of carbon dioxide, be uniformly mixed with ninety-
nine times its bulk of air containing no carbon diox-
ide, the 0.6 cubic foot of this gas present would
constitute 0.04 per cent, of the mixture; but is
using atmospheric air for the dilution the pereem
of carbon dioxide in the resulting 1,500 cubic feet
would be nearly 0.08, inasmuch as each cubic foot of
REFERENCE HANDBOOK OF THE MI'.HK AT, SCIENCES
Air
the diluting air brings with it the 0.04 per cent, of this
gas which ii naturally contains. Bui as the organic
Taint in respired air which lias been diluted to this
extent is perceptible by its odor to one entering from
the fresh air. it is evident that this dilution is insuf-
ficient Even when the carbon dioxide is diluted to 0.07
cent., sensitive nostrils can detect the presence of
the associated organic matter; but if the 1,500 cubic
feel containing 0.08 per cent, be further diluted with an
equal volume of fresh air containing 0.04 per cent, of
carbonic oxide, the mixture is reduced to O.Oti or six
umes in 10,000 volumes of the air, and with this
dilution of 3,000 cubic feet per hour per person,
sanitarians are satisfied, except in the ease of certain
hospitals.
It is easier to pass 3,000 cubic feet of air without
creating coldness or draughts through a large cubic
space per man than through a small one. If a room
only 300 cubic feet per man, its air has to be
changed ten times in an hour to supply the 3,000
cubic feet of ventilation. If it give 1,000 cubic feet
per man, the air has to be changed only three times.
A linear inflow of less than two feet per second is
lerceptible. With two feet of current air the
area of the inflow to deliver the 3,000 cubic feet would
Ixty square inches.
The amount of carbon dioxide in a sample of air
. termined by adding a known quantity of lime or
baryta water to the air in a large glass bottle or jar,
and' there after finding how much of the hydroxide has
i converted into carbonate. The practical details
1 3 follows:
Make an oxalic acid solution, lc.c. of which is equiva-
lent to one milligram C0 2 . Make also a caustic baryta or
lime solution of equivalent strength. Transfer the al-
kaline solution for storage until required for use to small
bot ties each holdingabout GO c.c.( two-ounce vials), each
of which is corked securely and weighed, and the total
ight of the bottle and its contents marked upon the
1. The air to be examined is collected in a clean
perfectly dry glass bottle or narrow-mouthed jar,
of known capacity. Ten liter bottles are large enough
to give accurate results. A small bellows with a
rubber tube on its nozzle is conveniently used in
tilling the jar with the air to be examined, but
care must be taken that the air entering by the valve
of the bellows is not contaminated by any direct
respiratory streams from individuals present. As
soon as the change of air has been effected, one of the
prepared baryta vials is uncorked and its contents
poured into the jar, which is then closed by an ac-
curately ground stopper, or preferably by a tightly
fitting rubber cork. The baryta solution is then shaken
in the jar, and made to flow all over its interior to
promote its contact with the contained air; but to in-
sure thorough absorption of the carbon dioxide the jar
is usually permitted to stand until the following day
before determining the loss of alkalinity. Meanwhile
the volume of the air operated on is ascertained from
observations made at the time the air was collected.
The height of the barometer and of the dry and wet
bulb thermometers or the dew point must be
known, as well as the quantity of baryta solution in-
troduced into the jar. The last is obtained by weighing
the now empty vial in which it was stored and deduct-
ing this weight from the gross weight marked on
the label. The quantity in grams of the baryta
solution employed must be deducted as cubic centime-
ters from the known capacity of the jar. But in
order that the experimental results may be suscepti-
ble of comparison, it is necessary to express the air
volume in the space which it would occupy when dry
at 0° Centigrade and under a pressure of 760 millimeters
of mercury. Increased pressure diminishes the volume
of air, increased temperature expands it; and the pres-
sure of the watery vapor present must also be taken
into account. The temperature observations furnish
the dew point, and through it, from the observations
of Regnault, the pressure or tension of the aqueous
vapor may be obtained. If \> repre ents this pressure,
/, the temperature in Centigrade degrees, b the baro-
metric height in millimeters, and V the capacity of the
jar, minus the number of cubic centimeters of baryta
solution introduced, the corrected volume will be
equal to
\ '--/>) 273
(273 I '(760
If the observations have been made on Fahren-
heit's scale and in barometric inches the formula is:
V(6-p)491
!».).!).' I1U . dt)
in which dt is the number of degrees between 32° F.
and the observed temperature.
When baryta solution is used to absorb the carbon
dioxide, the action may be considered completed
in half an hour; but with lime water it is better to
suspend further proceedings until next day. Then
take, say, 20 c.c. from the jar, add phenolphthalein,
and drop in the oxalic solution from a burette until
the color is discharged. The loss of alkalinity in
cubic centimeters = milligrams of CO., in the 20 c.c. of
the solution tested, from which the *C0 2 absorbed by
the whole of the baryta solution may be calculated =
milligrams of CO, in the air collected. Convert
weight of C0 2 into volume by multiplying by 0.573,
and for purposes of comparison calculate it into
volumes per 10,000 of the corrected air. It must be
mentioned, however, that the volume of carbon
dioxide found by this experiment is not all carbonic
impurity, but includes that which is naturally present
in the atmosphere. When the result of a contem-
poraneous experiment on the external air has been
deducted from it, the remainder will indicate the
carbonic impurity or the carbon dioxide due to
imperfect ventilation.
An easily applied method of ascertaining whether a
given air contains more than a certain number of
volumes of carbon dioxide per 10,000 is based on the
turbidity caused in lime water by the precipitated
carbonate. If a half ounce of this liquid is shaken
up in an eight-ounce vial filled with the air to be
examined, the appearance of turbidity indicates the
presence of eight or more volumes of carbon dioxide
in 10,000 volumes of the air, and that the arrange-
ments for ventilation in the apartments which fur-
nished the air are not as satisfactory as could be
wished. Bottles of various sizes are used by the
operator conducting this, the household method of
sanitary air analysis, and from the capacity of the
bottle in which a just visible turbidity is produced the
volumes of carbon dioxide per 10,000 become known.
In another method, the minimetric, air is introduced
in small quantity into a vial containing lime or baryta
solution, which is well shaken, with gradual additions
of the air, until the liquid shows a certain loss of
transparency, when the carbon dipxide is calculated
from the quantity of air needful to the production
of this result.
These, although pretty experiments, and described
in full by most sanitary writers, have not come into
general use, because they are not required. As they
yield results which are only approximate, they can-
not take the place of the accurate determination need-
ful in a scientific inquiry, while, as rough-and-ready
methods, their results convey no more information of
practical value than may be gathered unpretentiously
by the sense of smell. A well-ventilated room should
not have more than one or two volumes per 10,000
in excess of the external air, equalling a total of five
or six volumes. When the carbon dioxide amounts
to seven volumes, a want of freshness is recognized
on entering. When nine, ten, or more volumes are
present, the organic odor becomes manifest.
Although the carbon dioxide, as has been stated, is
163
Atr
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
generally accepted as a measure of the respiratory
impurity, it is not an accurate one, for it is more
readily diffused and carried off by ventilating currents
than the organic exhalations which accompany it
from the human system. Whence it comes that the
continued occupancy of an apartment may give rise
to organic odors in its atmosphere, although carbon
dioxide may not be present in large quantity. The
exhalation appears to adhere to walls and other
surfaces, and textures, and to require time for its
dissipation.
But, while the carbon dioxide is not an accurate
measure of the organic contamination in the air of
occupied buildings, its estimation affords the best
means of testing the efficiency of the ventilation.
Sanitary inspectors do not recognize this fact. Sani-
tary chemists have not brought it prominently into
notice. When questions of ventilation are to be
settled, Casella's air meter is used, and the air move-
ment is calculated from its indications and the areas
of inflow and exit. The inspector shows that so
much air has entered or that so much has escaped, to
be replaced of necessity by a corresponding volume
of fresh air through the inflow ducts. But this is not
enough. It must be shown that the air introduced
has effected the purpose for which it was introduced.
This may be done by a calculation based on the
amount of carbonic impurity found by experiment.
The capacity of the room must be ascertained, and
in exact calculations deduction should be made for
the body bulk of the occupants and for the furni-
ture. The time during which the deterioration has
been going on is another factor entering into the
calculation.
The carbonic evolution, 0.01 cubic foot per minute
or 0.6 per hour per person, multiplied by the number
of minutes or hours, gives the amount of the carbonic
impurity expired. When this is divided by the
carbonic impurity found by experiment in 10,000
volumes of the air, the quotient multiplied by 10,000
will express, in cubic feet, the volume of the air with
which the respiratory products have been diluted.
But, as the air volume in the room has contributed
to the dilution, its capacity has to be deducted from
the total to obtain the amount of the inflow. Thus if
the data consist of twenty persons, three hours in a
room having a capacity of 10,000 cubic feet, the
air on analysis showing 14.5 volumes or a respiratory
impurity of eleven volumes, as a parallel experiment
on the external air indicates the presence of 3.5
volumes.
0.6 X20 X3 =36 cubic feet of carbon dioxide expired,
11 : 10,000 :: 36 : 32,727 cubic feet of air concerned
in the dilution.
32,727-10,000 in room =22,727 inflow.
22, . 27 -j-3 =7,576 cubic feet inflow per hour.
75,76 -=-20 =379 cubic feet per hour per person.
In practice it is often found that the inflow, as
determined by the anemometer, is much greater than
that obtained from the chemical results. That the
air enters is certain, and that it fails to be utilized in
diluting the expired air is equally so. In one of the
schools of Washington, D. C, 800 cubic feet per min-
ute entered the room, while but 324 cubic feet con-
tributed to the ventilation. The cause in this
instance was manifest. The temperature of the
inflow was so great that the air rose immediately to
the ceiling, whence it was drawn off by the lowered
windows and foul-air flues.
Impurities in Air. — Carbon dioxide in air, while
essential to vegetable life, must be regarded as an
accidental impurity in its relations to animal life
when present in any locality in excess of that found
in the free atmosphere. The sources from which the
carbon dioxide is derived often yield with it other and
more dangerous substances. These sources are, first,
combustion for artificial warmth and lighting;
second, the resolution or dissipation of dead organic
matter, and, third, the resolution or dissipation of
the tissues of living animals by the respiratory process.
Products of imperfect oxidation are associated with
the carbon dioxide from the combustion of fuel. A
lamp or fire smokes and smells when its oxygen or
air supply is insufficient. The smoke is unoxidized
carbon and the smell an emanation from transition
products. The dangerous product in the combustion
of fuel is carbon monoxide (CO). This colorless and
inodorous gas is highly poisonous, entering the blood
and rendering the red corpuscles incapable of per-
forming their functions even though pure air be
afterward supplied. Death is the result of asphyxia.
In rooms heated by stoves the headache, languor,
and oppression occasionally produced are due to
the escape of this with other gaseous products
through the open stove doors, leaky joints, and
turned dampers. Some experiments of St. Claire
Deville and Troost indicated that the carbon mon-
oxide might even pass through the pores of cast
iron when the metal became strongly heated. The
French Academy, therefore, caused an investigation
to be made of this subject, and the conclusion was
reached that this dangerous gas does pass through the
metal when its temperature reaches a dark red heat.
Since these experiments, air heated by furnaces or
cast-iron stoves has been regarded as injurious. But
doubt has been thrown upon the results of the
French chemists by several later experimenters, and
particularly by Professor Remsen, who has shown
some possible sources of error, and who, having
guarded against these, has concluded that, while
carbon monoxide may be present in the air of furnace-
heated rooms, it must exist in quantities so minute
that it is questionable if it can act injuriously on the
health of those who breathe it.
The deadly nature of water gas as compared with
coal gas is due to its larger proportion of carbon
monoxide. Coal gas contains less than ten per cent.,
while water gas contains thirty to forty per cent.
Water gas is manufactured by playing steam on glow-
ing coke or charcoal, the products being carbon
dioxide, carbon monoxide, and hydrogen. The num-
ber of deaths from leakage of gas has been greatlj
increased since the introduction of water gas. Where
one death was formerly reported in a given time and
population, there are now twenty-five to thirty deaths.
Must of these deaths, however, are attributable to
suicide rather than to accidental poisoning.
In connection with local accumulations of these
gases it should be remembered that they are explosive
when mixed with air. It is therefore dangerous to
strike a light in the room of a gas suicide or to look for
a gas leak in a cellar or basement until after sonic
ventilation has been effected. A mixture of one part
gas to eight parts air is most violent in its explosion.
With one to four there is not enough air for explosion,
and with one to twelve there is not enough gas.
The evolution of carbon dioxide into the air of a
room during the combustion of illuminating gas or oil
is generally underestimated in considering the carbonic
impurity of occupied rooms. Parkes states that one
cubic foot of gas consumed in an hour produces as
much as the respiration of one person. One oil burner
consuming four ounces of illuminating oil per hour
was allowed in United States barracks for every ten
soldiers. The oil consumed pervaded the barrack
room with somewhat more carbon dioxide than was
expired by the ten men. The necessity for increased
ventilation must be considered with the presence of
each lamp or gas jet.
Associated with the carbon dioxide derived from
the oxidation of the carbon of dead and decomposing
organic matters on the surface of the earth, some-
times aggregated locally into manure piles, cesspools,
vaults, drains, and sewers, are certain compounds
intermediate in composition between the complex or-
ganic matter in process of putrefaction and the simply
Kit
REFERKNCK HANDBOOK OF THE MEDICAL SCIENCES
Air
constituted organic substances which arc the re ull
of the completed oxidation. The sulphur present in
certain tissues becomes converted into hydrogen or
ammonium sulphide, while among the nitrogenous
products are many foul-smelling and harmful gases
. apors of an ammoniacal character; hydrocarbons
also are formed. Formerly the reversion of organic
matter to the inorganic condition was supposed to be
due to I he purely chemical process of oxidation by I he
oxygen of the air. Decomposition was regarded as a
slow oxidation at a low temperature, as combustion
was a rapid oxidation at a high temperature; but when
Pasteur showed that meat could be preserved from
putrefaction when exposed to the air, provided the air
was first filtered through cotton wool, this chemical
theory of decomposition had to be abandoned.
Ultimately the saprophytic bacteria were discovered,
:oid now these are recognized as so universally present
and so essential to the disposal of organic matter that
cannot be regarded as an impurity in the air.
They arc the means to an end, one of the great links
in the endless chain of life, and as important in the
wonderful scheme of creation as the carbon dioxide
which they prepare for the future growth of vegetation.
The action of the sulphur gases on the animal system
has been demonstrated experimentally by Barker on
dogs and other small animals. Hydrogen sulphide
produces vomiting and diarrhea, prostration and
coma, which, like the effects of carbon monoxide,
persist after removal from the contaminated atmos-
phere. The exhaustion and coma continue, and death
results if the impression fixed on the blood is suffi-
ciently powerful. But, while this occurred in the
subjects of Dr. Barker's experiments, it is well known
that men may breathe with impunity for a time a
sulphureted atmosphere many times stronger than
those employed by him. Ammonium sulphide,
irding to this experimenter, caused vomiting and
febrile action, quickly followed by the development of
a typhoid condition.
Chronic poisoning by hydrogen sulphide manifests
itself, according to some observations, by gradual
prostration, emaciation, and anemia, with headache,
foul tongue, anorexia, and the occasional eruption of
boils, but it is not certain that these symptoms are
due to this gas and not to organic vapors which
accompany it.
The action of the more complex organic vapors given
off during decomposition has not been determined.
The dogs subjected by Dr. Barker to cesspool air were
all more or less affected, the symptoms being those of
intestinal derangement with prostration, heat of
surface, distaste for food, and those general signs which
mark the milder forms of continued fever common to
" the dirty and ill-ventilated homes of the lower classes
of the community." But the sulphur compounds
already mentioned contributed to these results.
Even the constitution of these organic vapors is not
known with certainty. Dr. Odling distilled half a
gallon of the liquid contents of a cesspool until all
volatile matters had come over. He treated the fetid
ammoniacal distillate with hydrochloric acid, and
afterward precipitated with platinum. The platino-
chlorides of the organic alkalies were found to crystal-
lize in well-defined, flattened, orange-colored tablets,
evidently not the platinochloride of ammonium.
Incineration of this platinum salt yielded 41.30 per
cent, of the metal, while the platinoehlorides of
ammonium, methylamine, and ethylamine gave
respectively, 44.36, 41.04, and 39.40 per cent, of
platinum. The salt formed from the carboammoniacal
vapors was analogous in composition to that formed
with methylamine. But inasmuch as the crystals
were more like those of the ethyl salt, and as a mixture
of the ethylamine and ammonium salts would corre-
spond in percentage composition to that obtained from
the distillate, he supposed that the sewage emana-
tions were ammoniacal and ethylic.
A sei'ies of experiments made by Smart showed
that the volatile matters evolved during the fer-
ment a 1 1 \ o changes in organic substances are of two
different characters, the one vaporous ami ethylic,
but not containing nitrogen if separated from the
ammonia with which if is volatilized anil condensed,
and the other volatile, carbonaceous, and solid, con-
creting on distillation into white, soft, and grea v
particles. The former has a dull, mawkish, not
positively unpleasant odor, the latter a strong and
intensely disagreeable smell.
Marsh gas (Vll t ), a colorless, inodorous, and, fortun-
ately, non-poisonous gas, is largely formed as a tran-
sition product in the decomposition of vegetable
mat ter. It is evolved in the gradual transformation of
wood into coal, constituting in mines the "fire damp"
which is the occasion of so many disastrous explosions.
It explodes, in the presence of flame, when forming
only one-eighteenth of the air of the mine. The re-
sulting gases, carbon dioxide, nitrogen, and vapor of
water, constitute the "after damp" or " choke damp"
which suffocates those imners who have not been killed
outright by the explosion.
Associated with the carbon dioxide of respiration
are certain organic exhalations which differ in con-
stitution, according to the efficiency or imperfection
of the oxidation in the tissues. In diseased condi-
tions of the body these exhalations are thrown out in
greater quantity than in health and the infection of
clisease in some instances accompanies them. They
are exhaled not only from the lungs, but also along
with the perspiration from the pores of the skin. The
quantity of organic matter thus eliminated has not
been determined, but is known to be small. It does
not diffuse like a gas into the atmosphere, but floats,
when there are no currents to disturb it, like an
odorous but invisible cloud. If evolved into the air
of a close room its amount is proportioned to that of
the carbon dioxide exhaled by the occupants, in the
absence, of course, of any other output of this gas.
As vapor of water is deposited from a saturated air,
so these organic clouds become similarly condensed on
walls, furniture, hangings, bedding, clothing, and
other exposed articles. In a room saturated with
organic exhalations the mere renewal of the air does
not dissipate the taint, for the renewed air becomes
immediately affected by the volatilization of the or-
ganic deposits. The necessity for a thorough aeration
is obvious.
The evil effects of breathing respired air are at-
tributed to these organic matters. Many experiments
have been made on this subject, the most striking of
which are those by Brown-Sequard and d'Arsonval,
reported in 1SS9. They connected a series of four
air-tight cages by means of rubber tubing and as-
pirated a steady current of air through them. In
each cage was a rabbit. The animal in the last cage
of the series breathed the air which contained the
respiratory products of the animals in the other cages,
while the animal in the first cage was supplied with
pure air. After a time the animal in the last cage
died as a result of its confinement in the impure air,
and a few hours later that in the cage next to the last
also succumbed. The inmates of the first and sec-
ond cages survived. On placing an absorption tube
between the third and fourth cages, the animal in the
last cage survived the experiment, while that in the
third cage died. This seemed to indicate that the
toxic substance in the air was destroyed by the sul-
phuric acid and was therefore probably organic mat-
ter. These experiments were repeated, with the same
results, by Merkel in 1892. In a Smithsonian con-
tribution, however, by Drs. Billings and .S. W. Mitch-
ell, published in 1895, it is contended from some
experiments made under their direction that in the
air expired by healthy mice, rabbits, etc., there is no
peculiar organic matter which is poisonous to the
animals mentioned, or which tends to produce in
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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
them any special form of disease, and that it is very
improbable that the minute quantity of organic mat-
ter contained in the air expired from human lungs
has any deleterious influence upon persons who inhale
it in ordinary rooms. They concluded also that the
discomfort produced by crowded, ill-ventilated rooms
in persons not accustomed to them is not due to ex-
cess of carbon doxide, nor to bacteria, nor in most cases
to dusts of any kind, the two great causes of such dis-
comfort being excessive temperature and unpleasant
odors. These odors, it is said, may in part be due to
volatile products of decomposition contained in the
expired air of persons having decayed teeth, foul
mouths, or certain disorders of the digestive appa-
ratus, and they are due in part to volatile fatty acids
given off with, or produced from, the excretions of
the skin, and from clothing soiled with such excre-
tions. They may produce nausea and other disagree-
able sensations in specially susceptible persons, but
most men soon become accustomed to them and cease
to notice them, as they will do with regard to the odor
of a smoking car or of a soap factory after they have
been for some time in the place.
There are no microorganisms in the air in the lungs.
They are filtered out of the inspired air, or captured
in mucus and ciliated out before they can reach the
pulmonary cells. We know this to be the case be-
cause when there is no break in the skin in an injury
to the lung from a fractured rib, we may have em-
physema and pneumothorax with hemorrhage, but
no pleurisy. Besides this, Tyndall showed by the
electric beam the freedom of the expired air from par-
ticulate matter.
But that evil consequences do follow overcrowding
and its necessarily vitiated air is well known. Every
schoolboy knows the history of the Black Hole of Cal-
cutta. Evil consequences of a lighter grade are also
recognized as the legitimate offspring of vitiated air.
The breathing of air that has already been breathed
gives rise in succession to feelings of languor and
heaviness, headache, dulness of mind, drowsiness,
dizziness and faintness, sometimes nausea and, if
continued, feverishness. These symptoms indicate a
poisoning of the blood by organic matters which would
not be present in it with free supplies of air to wash
them away. The brain is the first of the organs to
feel the effects of the tainted blood. The mental in-
aptitude of children after two or three hours in a
close schoolroom is easily understood. The waste or-
ganic matters retained in the blood are not necessarily
absorbed from the contaminated air. They may be
due in great part to a suppression of the regular
exhalations and a consequent retention of matters
which ought to have been exhaled. As with moisture
in air, so with these organic exhalations. The air
when saturated refuses to take up more. Again,
their retention in the blood interferes with the oxida-
tion which should go on in the tissues; and the transi-
tion products that are formed, being also retained, add
seriously to the disordered condition. The individual
becomes poisoned by products of his own living
processes.
The human system, however, appears to accommo-
date itself to a certain degree of impurity in the air,
so that, after a time, the breathing of such air ceases
to occasion the feelings of acute discomfort that have
been mentioned. But in their stead a depressed con-
dition of the system is developed, manifested by pal-
lor of countenance and loss of appetite, strength, and
spirits. The vitality of the individual is lessened.
Every draught becomes dangerous to him, and
even the chill from a wall or closed window may cause
serious sickness. He becomes a ready victim to con-
sumption if the germ of that disease is present, as is
so frequently the case in the crowded dwellings of the
poor in our large cities. Health, in fact, becomes
broken and the nervous system prostrated, a condi-
tion in which a resort to alcoholic stimulants often
gives temporary relief at the expense of a more rapidly
fatal issue.
Besides the gases and vapors already mentioned
there are many particulate bodies, living and dead
organic and mineral, floating in the atmosphere. All
are accidental and therefore impurities. More than
thirty years ago, Professor Tyndall made use of an
electric beam as a searchlight for floating particles.
In pure air, made so by specially filtering it, the track
of the ray is invisible, but in the free atmosphere it is
defined with more or less brightness by reflection from
particles ordinarily invisible. If the electric bean
were passed through the air of many of our rooms, we
would hesitate to inhale the aerial turbidity which it
would reveal. The lower strata of the air are tilled
with such impurities, but air at a height of 600 feet
is comparatively pure in this respect. The smoke
clouds, consisting of particles of unburned carbon
which hover over manufacturing cities, seldom rise
higher than this.
It is impossible to do more than outline these float-
ing particles in the most general way, because every-
thing on the face of the earth is susceptible of being
ground into dust and of being swept up by atmos-
pheric currents. Matters, indeed, of an extraterres-
trial origin are present in the form of dust derived
from the destruction of meteors in their passage
through the atmosphere. The inorganic dust con-
sists chiefly of carbon particles, amorphous silicates,
irregular fragments of hard mineral substances, and
salts of calcium, potassium, sodium, and ammonium.
The organic dust includes the detritus of decaying
vegetation, starch cells, epidermal hairs, filaments
from the pappus of the Composite, pollen grains, and
disintegrated woody tissue. The animal kingdom al-
so is represented in the dust by fibers of wool, plume-
lets of feathers, butterfly scales, and other debris of
insect life, together with occasionally epidermal and
epithelial scales. Saprophytic bacteria are present,
and in certain localities pathogenic bacteria as
well. Locality and season influence the quantity and
character of these impurities. Naturally air which
blows over a long stretch of land contains more than
sea air. Cotton is found in nearly every sample of
autumnal air in the Southern States. Pollen grains,
on many occasions, have given a yellow color to the
rainfall. Autumnal catarrh, sometimes called hay
fever, which affects so many people at a certain period
of the year, is attributed by many to this impurity.
Crystals of sodium chloride are notably present in the
air of the seacoast, while in that of cities we find car-
bon particles and crystals of ammonium sulphate
from the combustion of coal. The air of houses
contains fragments of the fibers of clothing and
epidermal scales, while that of hospitals, workshops,
factories and mines, etc., is charged with particles
varying in character with the occupancy and work.
Sometimes the inorganic matters pervade the at-
mosphere of localities in the form of vapor, as in fac-
tories where phosphorus or mercury is in constant use.
The earliest observations on the impurities of air
were made on condensations gathered from the outside
of a vessel containing ice. Subsequently experiments
were made on water which had been shaken with suc-
cessive volumes of air. In both cases a liquid was
obtained which putrefied readily and in which the
presence of living organisms could be identified. R.
A. Smith was perhaps the first to use the latter
method. He put 150 drops of pure water in a
small vial containing air from a cow stable. He
shook the bottle that the water might entangle and
wash out all particles of solid matter from the air.
He renewed the air; and this he did 500 times.
When he examined the water under the microscope,
he was astonished at the immense number of spores
which were visible, along with many other matins
organic and mineral: ami afterward many animalcules
of various kinds were developed in it.
166
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Air
At the present time aerial organic matter is investi-
i,.,] microscopically, biologically, and chemically.
■Jolid particles for microscopic study arc caught on a
r|ass slide lightly coated with glycerin. The general
ractcrs of atmospheric impurities may be ascer-
tained by an examination of I lie rain or snow, for all
e impurities that arc not dissolved or absorbed by
lie rain are washed down by it. But for evaporation,
lensation, and rainfall, the inhabitants of the
h would speedily be stifled in the dust swept up
mi' atmospheric currents. Distant objects, hazy
,ud indistinct in a dry summer air, become sharply
lUtlined in a purified rain-washed atmosphere. In
water suspended impurities may be seen with the
laked eye, and in the gradual melting of a pure white
nantle of snow the stain made by its entangled im-
mrities will appear before it has shrunk to half its
iriginal thickness.
The biological examination resolves itself into a
letermination of the number of bacterial colonies and
ither microorganisms in a given volume of the air.
\ith culture experiments for the study of species.
Official observations at the Montsouris Observatory
tear Paris. Trance, have shown that there are few
lacteria in the air in winter, and that the numbers
acrease through spring and summer to over 100
cubic meter in the autumn. The air of city
I - is densely charged with bacteria. The atmos-
phere is purer in this respect in its upper strata:
tir collected at over 6.000 feet is practically free
rom bacteria and moulds.
Chemistry has done but little to perfect the organic
inalysis of air. With known methods of analysis the
I s obtained by the expenditure of much time and
■are are of small value. If an air specimen contains
tit unusual amount of the organic elements, it may be
orrectly considered as impure, but the nature of the
mpurity is not denned. The carbon estimated may
■ been a harmless particle of soot, or in part it may
lave been essential to the spread of a deadly disease.
Nevertheless, analyses are made as a matter of official
routine by sanitary officers in England and France.
The organic substances are absorbed by aspirating
arge volumes of the air through a small volume of
listilled water, and the liquid menstruum is then inves-
tigated by the processes of water analysis. Professor
Remsen endeavored to improve on this process by
Altering the air through powdered and moistened
pumice before passing it in fine bubbles through the
distilled water. He thus showed that, so far as could
be determined by chemical means, all nitrogenous
aiatter was retained by the filter. But, as germs or
microscopic organisms might have passed through
without thus showing their presence in the absorbing
liquid, owing to the necessarily minute trace of nitro-
gen in them, Smart carried out a series of experiments
which determined, first, that the nitrogenous matter
of air, excluding ammonia from consideration, is
particulate; second, that it consists in large part of
microorganisms; and third, that filtration through
Austrian glass wool effects their removal from the
passing air. The experiments were conducted in a
sterilized apparatus. The air was drawn through a
short glass tube one centimeter in diameter, lightly
packed for two or three inches of its length with the
glass wool. From this it was passed in fine division
through distilled water. After this it was mixed with
steam generated from a dilute solution of alkaline po-
tassium permanganate, the mixture immediately enter-
ing the tube of a Liebig's condenser, where the steam
was deposited, carrying down with it, after nature's
process of air purification by the rainfall, any micro-
organisms which might have escaped removal by
lilt ration or absorption. The difficulties in the way of
sterilizing the various parts of this apparatus were
such that the first experiments, which gave speedy
developments in culture liquids tainted by the filter,
the absorbing liquid, and the condensate, were re-
garded only as the practical expression of these diffi-
culties. The experiments we; I with precau-
tions. suggested as necessary by the previous experience,
and ultimately success attended them.
One of the processes of water analysis to which these
matters were subjected involved the distillation of the
ammonia, which was present in the liquid, and its
estimation by the calorimetric method with Nessler's
solution. Ammonia gives, with this test solution, a
faint straw-yellow color, which deepens, in proportion
to the amount of ammonia present, to a dark sherry
brown, or to a dark haziness or distinct precipitate.
But it not infrequently happened that in testing for
ammonia in the distillate from the pure water in which
the glass wool containing the organic matter of the air
was suspended, as well as in that from the absorbing
liquid which contained most of the ammonia, and in
that from the condensate which contained but a trace,
a citron-green color was produced which masked the
ammonia reaction and rendered its estimation
impossible. Dr. Kidder, of the navy, observed this
interference with the ammonia coloration, and attrib-
uted it to the presence of substances evolved in the
putrefaction of organic matter. He concluded from
the few experiments he made that the amines are not
necessarily concerned in its production, as he found
that butyric acid gave a somewhat similar interference
to that met with in the experiments on air washings.
But the haziness with which the presence of butyric
acid masks the true ammonia color is not the citron-
green coloration which so frequently occurs in the
analysis of foul airs. This is due to the presence of an
ethyl compound which is given off from the carbo-
hydrates while undergoing change. It may be ob-
tained free from the ammonia which ordinarily accom-
panies it and obscures its reaction by submitting the
liquid containing both to the process of nitrification.
It may also be obtained from ammonia and free glu-
cose, and from starch, cane sugar, tannin, salicin, etc.,
after treatment with heat and acids.
In some of the experiments referred to, an air
volume of 100 liters was passed through the interior of
a glass globe which contained liquid sewage and silt,
garbage, or other foul and decomposing materials, and
then through the glass-wool filter, absorber, and
condenser to remove the matters with which it had
become contaminated. Culture experiments showed
the satisfactory removal by the filter of all germs and
nitrogenous matters, ammonia excepted, and chem-
ical tests determined approximately the quantity of
organic matter thus removed. In some instances a
second air volume of 100 liters was drawn over the
organic matter in the globe, and the results obtained
from the filter through which it was afterward passed
did not differ from those of the first experiment on
the same organic matter. From these experiments the
conclusion appears admissible that the volume of air
which is contaminated by a certain decomposing
organic mass is the volume which comes in contact
with it. If no air is drawn through the foul globe,
only that which is contained in it is rendered impure.
This air has its oxygen in time replaced by the foul-
smelling gases of decomposition. Evaporation takes
place from the contained liquid until the stagnant and
enclosed air becomes saturated. The ascensional
force of evaporation carries from the smeared and
half-dried sides of the globe, and from the unsub-
merged solids within it, some of the innumerable mi-
croorganisms with which they are pervaded, and the
air becomes charged with organic particles to an ex-
tent proportioned to its temperature and hygrometric
condition. If a volume of air is drawn through the
globe, it will be contaminated by organic matters
carried away by its own movement and by the in-
creased activity of evaporation produced by it. If
a second volume is drawn through, it will be con-
taminated in like manner, and to the same extent, if
the volume, rapidity of passage, temperature, and
167
Air
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
hygrometric condition are the same in both instances;
and so for a third, a fourth, or more volumes, until
the decomposing mass has become changed by their
agency. This is recognized practically in sanitary
work. The dead are buried that their decomposition
may not contaminate the atmosphere. For the same
reason garbage is collected and removed. A recep-
tacle for foul-smelling and fermenting matter is less of
a nuisance and less dangerous to health when fitted
with an air-tight cover than when freely exposed to
the air, for in the latter case every volume of air which
comes in contact with it is a volume of air polluted.
Sanitary officials in growing cities protest against the
continued existence of small surface streams which of
necessity pass into the condition of open sewers, taint-
ing every volume of air which comes in contact with
their foulness. These are bricked over and the air is
preserved from the impure contact. But in the con-
struction of regular systems of sewerage provision is
made for this contact under the name of ventilation.
The sewers are tapped at regular intervals along the
streets for the exit of the contaminated air. From
the present point of view this ventilation of the sewers
is of questionable benefit. The volume of air rendered
impure, and possibly dangerous, is proportioned to the
thoroughness of the ventilation. Sulphureted gases
may be diluted, and the outflowing air be free from
disagreeable odors, but the very air movement which
effects this may raise invisible clouds of fermentative
and morbific agencies from the foul interior. Ex-
periments on this point would be of value. Those
mentioned above indicate that the communication
with the outer air should be only such as is needful
to relieve tension and prevent the forcing of seals,
and that these air holes should be guarded by some
filtering material. But since the volume of air which
becomes contaminated is that which comes in contact
with the fermenting material, it may be reduced as
well by diminishing the extent of the impure surface
as by cutting off the ventilation. Hence sewers of
small size, as in what is known as the separate system,
are to be preferred, on sanitary grounds, to the large
ramifying tunnels of the combined system. The foul
airs which arise from sewer apertures are matters of
every-day observation. If well diluted with air they
may not affect the sense of smell, but they rise, never-
theless, from the grated covers on our streets, and
may be seen, by the vapor precipitated from them, as
an uprising column in weather which clouds the air of
respiration thrown out from the lungs. With open
streets and lively breezes it is probable that these
exhalations are dissipated, or rather diluted, to
harmlessness, but in enclosed spaces and stagnant
atmospheres the sewer air, which is so carefully ex-
cluded from living rooms by intelligent plumbing,
may enter as fresh air through open windows and
apertures specially devised for its admission. _
Sewer air is atmospheric air with its oxygen dimin-
ished and its carbon dioxide increased to from ten to
fifty volumes per 10,000, and with taints or not-
able amounts of marsh gas, hydrogen sulphide, am-
monium sulphide, and amines or compound am-
monias in which one or more atoms of hydrogen are
replaced by a positive radicle, methyl, ethyl, amyl,
etc. Cesspool air has an excess of these foul-smelling
constituents, for the contents of a cesspool continue
to putrefy, while the sewage in a well-constructed
system of sewerage should be carried away before
putrefaction sets in. Each of the impurities in
sewer air is harmful when breathed in strength, but
not specially dangerous when diluted with atmos-
pheric air, for it is well known that men whose occu-
pations bring them into contact with this contaminated
air do not suffer specially from disease. But sewer air
may be a cause of diarrhea or other gastrointestinal
disturbance; also, general depression or ill health, and
anemia may be due to the same cause. It is believed
by some that other infectious diseases may be ac-
quired from exposure to sewer air, provided always
that the necessary causative bacteria are present
therein.
The air of dwellings is sometimes contaminated
with ground or cellar air drawn up through a porous
soil by the greater warmth of the living rooms.
Ground air contains more carbon dioxide in summer
than in winter on account of the influence of heat in
promoting decomposition of organic matters in the
soil. In general terms it contains in summer more
and in winter less than one per cent, of this gas, or
100 volumes in 10,000 of the air; it may also be
contaminated by other products of decomposition.
Hence may be inferred the inadvisability of furnish-
ing cellar air or air introduced by tunnels into a build-
ing for purposes of ventilation. This applies in par-
ticular to buildings erected on made ground. In fact,
cellars, in default of an impermeable lining, should
have a free circulation of air separate from the venti-
lation system of the superimposed building.
Charles Smart.
R. J. E. Scott.
Air Embolism. — See Embolism.
Airol. — Airoform, bismuth iodosubgallate, bis-
muth oxyiodosubgallate, C H 2 (OH),CO 2 Bi(OH)I. It
is prepared by heating equivalent amounts of bis-
muth subgallate and hydriodic acid, or of freshly
precipitated bismuth oxyiodide and gallic acid, in
water. It is a graj'ish or greenish, light, odorless and
tasteless powder, insoluble in water or alcohol, but
soluble in mineral acids and weak alkaline solutions.
When exposed to the air it gradually takes on a red
color. It is employed as a substitute for iodoform
in the treatment of wounds, ulcers, burns, etc., in
powder, in ten-per-cent. ointment, or in ten-per-cent.
suspension in glycerin and water. The best oint-
ment base for airol is a mixture of seven parts of
anhydrous adeps lanse and two parts of petrolatum.
Air Passages, Foreign Bodies in the. — Nose. — The
presence of foreign bodies in the nose is of common
occurrence. The list of them comprises extraneous
substances introduced either through accident or, in
the case of infants or of insane adults, by design;
sequestra of diseased bone; and parasites. They may
also enter the nasal cavities from behind, during the
act of vomiting or of choking, or in paralysis of the
soft palate. Rarely, as in gunshot wound, they may
pass through the walls of the nasal cavity from with-
out; an erratic tooth may enter the cavity from below.
The history of those of the first variety is usually
as follows: A child of about two, old enough to creep
but not sufficiently intelligent to know better, thrusts
some small, rounded object, such as a bean or a shoe-
button, which it has found upon the floor, into its
nostril. If the child be not caught in the act the
body may escape immediate detection. Soon symp-
toms of chronic inflammation are established. These
are confined to the nostril in which the body is, and
continue until it is removed, the irritation often
being severe and the discharge exceedingly fetid.
The mucous membrane adjacent to the foreign bod;
is in a condition of superficial erosion. The body,
if too firmly impacted to be dislodged by simply
blowing the nose, remains fixed, usually in the in-
ferior meatus, until removed by the surgeon.
Removal should be attempted by means of a hooked
probe or fine forceps, the sensitiveness of the nasal
cavity being borne in mind, and the removal of the body
carefully effected after thorough cleansing of the
cavity "has been effected and local anesthesia has
been obtained, either by cocaine or by suprarenal
extract. In the case of nervous children general anes-
thesia is desirable. Copious hemorrhage, lasting two
or three minutes, often follows, but is generally of little
168
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Air Passacps, Foreign
bodies In
moment. The nostril should be washed several limes
a day with a weak disinfectant. In four or five
days the membrane will often have healed so com-
pletely that no trace of the trouble can be seen; the
discharge ceases entirely, and the cure is complete.
The possibility of the presence of a foreign body in
all cases of fetid discharge confined to one nostril should
always he remembered, and, tin 1 nostril having I n
cleansed with a warm douche, careful examination
should be made with speculum and probe. If l lie
object be lodged far backward, care should be taken
in removing it not to allow it to fall into the larynx
Fig. 62. — Lead Collar-button in the Right Bronchus of a Lad
of Eighteen Years; removed by upper bronchoscopy by Dr.
Chevalier Jackson.
The writer has seen a case in which a button intro-
duced during infancy remained undiscovered in the
nose for thirty-two years.
Rhinoliths are merely calculi formed by an accu-
mulation of the earthy salts of the nasal secretions
around some foreign body or inspissated mucus. Their
presence has given rise to such irritation that they
have been mistaken for cancer. Careful examination
and the history of the case will easily establish the
diagnosis. If the concretion be too large to be readily
removed it should first be crushed. Foreign bodies
of this nature are rarely met with, although one is
reported which weighed 720 grains. Sequestra of
bone, particularly in tertiary syphilis, sometimes re-
main in the nasal cavity after their separation, tints
acting as foreign bodies. They must be thoroughly
removed preliminary to further local treatment.
Parasites. — In tropical countries, seldom elsewhere,
various kinds of flies, of the order Muscidoe, may
enter the nasal cavity, preferably of a patient suf-
fering from catarrh, and there deposit eggs. These
are quickly hatched, causing in succession irrita-
bility, tickling, and sneezing; later, formication, bloody
discharges and epistaxis, with edema of the face,
eyelids, and palate; excruciating pain, generally
frontal; insomnia, and if the condition be unrelieved,
convulsions, coma, and death. Sometimes the larva?
are sneezed out, or may be seen on examination of
the parts. This will, of course, establish the diag-
nosis. Destruction caused by the larvae may extend
to the mucous membrane, the cartilages, and even
the bones of the head, the ethmoid, sphenoid, and
palate bones having been found carious.
Where the maggots have entered the frontal sinus
or the antrum of Highmore, injections of tobacco or
alum, or insufflations of calomel, formerly used, will
be of little avail. Chloroform or ether, preferably the
former, either inhaled or driven into the nasal recesses
in I he form of spray, is the sovereign remedy, as under
it the larva' are not killed, to remain in situ and thus
cause further trouble, but escape with all haste to tin;
outer air. Meanwhile, anodynes should be given
to allay pain, and the patient's strength should be
carefully sustained. Such measures, however, are
serviceable only when tin' ease i,^ seen early and the
Larvae are si ill upon the surface of the mucous mem-
brane. When they have attained their full develop-
ment they burrow into the soft tissues, whence it
seems impossible lo extract them except by Seizing
them bodily and dragging them out. If the desper-
ate character of the situation in severe cases of this
kind, and the impossibility of reaching the seat of
irritation through the natural passages are taken into
consideration, no surgical procedure which promises
relief can be thought too severe. It is therefore jus-
tifiable to open into the antrum or the frontal sinuses
from without, to perform Rouge's operation, in order
to gain access to the upper part of the nasal cavities,
or to open freely into the ethmoid cells. Several
cases in which the patient's life has thus been saved
have been related to the writer in recent years.
Leeches, ascarides, earwigs, and centipedes have
been found in the nose, causing insomnia, frontal
pain, sanious discharge from the nose, lacrymation,
vomiting, and, in some cases, great cerebral excite-
ment. Sternutatories are generally sufficient for
their expulsion.
Tonsils. — Three general varieties of foreign bodies
may be found in the tonsil: (1) Foreign bodies
proper, or substances which have become lodged in
the tonsil during deglutition; (2) tonsillary concretions
or calculi; (3) parasites. The last two conditions are
not common; the first will be described under Foreign
Bodies in the Pharynx.
Tonsillary calculi are formed in the lacunae of a
chronically inflamed tonsil by a perverted condition
of the natural secretions and their retention in the
recess through closure of its outlet. They vary in
size, seldom attaining a greater diameter than three-
fourths of an inch, and consist of phosphate and car-
bonate of lime, some iron, soda, and potassa, with
varying proportions of mucus and water. Hence
they are not necessarily of gouty origin.
The symptoms, generally not prominent, may be
slight pricking of the throat with, occasionally,
dysphagia. The presence of the calculus is sometimes
directly irritating, and may give rise to quinsy,
ulceration of the cavity, and abscess. Frequently,
however, the symptoms are reflex in character. This
is especially true with relation to the ear, in which
organ the existence of a tonsillary calculus may be
associated with various forms of otic congestion and
with tinnitus.
Diagnosis, by ocular examination or by the use of
the probe, is usually easy, and so also is the removal
of the calculus by means of a forceps. Sometimes,
however, the mass is so completely covered that it
is only seen after careful exploration with the probe
or even after the actual removal of the tonsil. In
most cases the latter operation will afford the most
certain cure. Very rarely, hydatids and trichoceph-
ali have been found in the tonsil.
Pharynx. — Foreign bodies are often arrested in
the pharynx, and the variety of these bodies is great.
Certain individuals seem especially liable to this
accident, either from carelessness in eating, from
insensibility of the parts, or from some unusual irregu-
larity in the pharyngeal walls. Foreign bodies of large
size generally lodge in the lower part of the cavity,
where the cricoid and arytenoid cartilages project
backward, or between the base of the tongue and the
epiglottis. Small and sharp-pointed bodies may
169
Air Passages, foreign
IJodics in
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
become fixed at any part of the pharynx, particu-
larly in the tonsils, on account of their exposed posi-
tion and the irregularity of their surface. They
may also be entangled in the pillars of the velum,
or in the lateral folds of the cavity. A large body
may be found stretching across the whole width of
the pharynx.
Symptoms. — These are local pain, dysphagia, and
more or less inflammation, with occasionally ulcera-
ion or abscess of the pharynx; but generally there is
simply localized inflammation and irritation. If an
abscess be formed, the foreign body may escape
through a fistulous opening in the neck, or it may
perforate some important blood-vessel, or may even
penetrate the intervertebral substance and cause
caries of the vertebral bodies.
Fig. 63. — Outer Tube of a Tracheal Cannula, inhaled and lodged
in the left bronchus in a man of thirty-five years, upon whom
tracheotomy for larryngeal carcinoma had been performed; tube
removed by bronchoscopy through the tracheal wound by Dr.
Thomas R. French.
Inflammation of the pharynx may give rise to dysp-
nea, while a large foreign body may cause suffoca-
tion by obstructing the entrance to the larynx.
The diagnosis can generally be established by the
history of the case and by inspection of the pharynx.
In cases presenting unusual difficulty the diagnosis
may be established by the use of radiography.
Nervous patients often insist upon the presence of a
foreign body in the throat despite all assurances to the
contrary, particularly if the pharynx be sensitive,
or if at a certain point there is an inflamed lymph
gland, or if, as often happens, a hard substance may
have caused a slight laceration of the mucous mem-
brane while being swallowed.
Treatment. — The patient's tongue should be well
depressed, and the upper parts of the pharynx carefully
examined in a strong light. If the foreign body
does not then appear, search should be made fin- it
with the aid of the laryngoscope in the region of
th ■ base of the tongue, the glossoepiglottic and pyra-*
form sinuses, and the upper portion of the larynx. If
present, it will generally be found without much diffi-
culty, and should be removed by the finger or by a
suitable forceps or probang. Local anesthetization
of the pharynx will greatly assist in the diagnosis and
treatment of these cases. If dyspnea be urgent,
immediate surgical interference, of a nature suited
to the special features of the case — either tracheot-
omy, thyrotomy, or, possibly, some form of sub-
hyoidean pharyngotomy — may be required. The
sensations of the patient are often unreliable, and
the feeling of irritation caused by the presence of the
body may continue for a long while after its removal.
This may be relieved by swallowing small lumps of
ice, and later, if necessary, by the application of as-
tringents and, in some cases, by galvanism.
Larynx. — By reason of the danger to life which
attends the lodgment of a foreign body in the larynx,
this condition becomes one of the most important in
surgery. The variety of objects found is infinite,
and may be thus divided: Alimentary matters,
introduced during mastication in the act of laughing
or talking, in deglutition, or in inspiration during
vomiting; metallic bodies, such as coins, buttons,
puff-darts, etc.; teeth, artificial or natural; necrosed
bone from neighboring regions, as from the nose in
tertiary syphilis; and fragments of the laryngeal
cartilages themselves, as thrown off in the Tate
stages of syphilis, tuberculosis, and cancer of the
larynx. Foreign bodies in the trachea may pass
upward and become impacted in the larynx; and,
rarely, they may gain access to the larynx directly
from without, by forcible penetration of its walls,
as in the case of bullets. Again, the epiglottis may
become incarcerated in the larynx, or occlusion may
take place from the so-called swallowing of the tongue.
The symptoms vary with the size and position of
the object. Thus a large body fixed in the rinia
glottidis may, unless dislodged, cause almost instant
death. Again, small bodies lodged in out-of-the-way
corners may remain indefinitely, causing nothing
more than cough and discomfort. Dyspnea may
occur days after the entrance of a foreign body, from
inflammation and tumefaction of the soft parts of
the larynx, and danger from the presence of a foreign
body may suddenly become imminent from alteration
in its position. Great peril sometimes arises from
violent spasm of the glottis, due to irritation caused
by the foreign body. Mental anxiety and localized
pain are prominent symptoms in cases in which the
accident does not immediately threaten life, but is
followed by inflammation which rapidly becomes
active.
The diagnosis is established by the history of the
case, verified or otherwise by laryngoscopic exami-
nation or by radiography. The greatest difficulties
arise with children too young to express themselves,
in whom pain in the throat and symptoms resem-
bling croup will often be the only indications ob-
tainable. Here the use of the laryn-gosope, or
direct inspection of the larynx as practised by Kirstein
and his later followers, or radiograph}', will be in-
dispensable. A cautious prognosis must be given,
even after removal of the body, as long as there are
any symptoms of local inflammation.
Treatment. — The offending body should, of course,
be at once removed; if possible, through the natural
passages and by means of the laryngeal forceps,
aided by the laryngoscope, in case the symptoms are
not urgent. Removal may be facilitated by placing
the patient on his back upon a table, with the head
hanging over the edge of the table, in which position
breathing is easier and the law of gravitation becomes
directly helpful. If asphyxia threaten, tracheotomy
should be done at once and the foreign body after-
ward extracted as described above. Bodies which
at first are immovable may sometimes bo loosened by
reducing the local inflammation. In rare cases, when
170
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Air Passages, r»>ri*iKn
Bodies In
the object has become firmly impacted, thyrotomy
become necessary. A case is recorded in which
: , oeedle, transfixed in the larynx, was pushed through
the anterior laryngeal wall, and thus removed.
Trachea and Bronchi. — Any object which can
pass through the rima glottidis may, of course, find
[ts way into the trachea, in the same manner as was
ribed in the paragraph relating to foreign bodies
in the larynx. Sharp objects lodged in the esophagus,
and even diseased bronchial glands, may work their
way through the walls of the trachea, and into its
cavity. It sometimes has happened, through careless-
Mi' by accident, that parts of instruments used in
Fig. 61. — Glass-headed Pin in the Left Bronchus of a Child
[Vo-and-a-half Years; removed by upper bronchoscopy by
Dr. Chevalier Jackson.
intralaryngeal operations, tracheal cannula?, laryngeal
brushes, and even bits of solid nitrate of silver,
have dropped into the trachea. If too large to enter
either main bronchus the body will probably remain
at the bifurcation. Otherwise it will pass into one
bronchus or the other, preferably the right, on account
of its anatomical position, in the proportion of five
to three, and thence travel indefinitely into one of the
more remote bronchial divisions. Asphyxia may
also be caused by the entrance of water into the
trachea, of blood during a surgical operation, of pus
from the bursting of an abscess, of vomited matter,
or of liquid food.
The symptoms will depend upon the nature of the
body and its exact location in the lung. Small
objects have remained encapsulated for years withoul
causing discomfort or serious results. Smooth, rounded
bodies irritate less than irregular ones. Inflamma-
tion of the lungs from a foreign body may occur, and
at the same time the presence of such a body may be
entirely unknown. Large objects and fluids may
eau e death by instanf suffocation, or death may
re nil in the eour-e of a few minutes, the symptoms
pre 'Midi being urgent e not speedily afforded, death, with all the
signs of asphyxia, soon follows. Severe dyspnea, fol-
lowed by relief without extrusion of the foreign body,
indicates thai the body has probably dropped from
the larynx into the trachea. Dyspnea is. of course,
more urgent when the trachea i- occluded than when
the foreign body stops only one bronchus. Physical
signs due to the presence of a foreign body in the
lung may be altogether wanting, but they are gener-
ally more or less distinct. They are the following: whis-
tling or flapping sounds at the point of lodgment,
decreased fremitus, and absence of respiratory murmur
in the lung beyond. The body may change its posi-
tion, passing from one bronchus to that of the opposite
side. A body, small when swallowed, may become
more dangerous through increase in size, either by
imbibition of water or by forming the nucleus of a
concretion. If, however, a hollow, cylindrical body,
such as one of the parts of a tracheotomy tube has
found lodgment in the bronchus, little resistance
may be offered to the passage of the air, no advent it ions
sounds created, and no obstruction caused in the
lung area beyond. In such a case diagnosis by
ordinary means might be impossible. At or about the
bifurcation the body may be seen with the laryn-
goscope. While the laryngoscope may fail to reveal
the presence of the foreign body in the trachea,
it can at least furnish satisfactory evidence that
the object in question is not located in the larynx.
The lodgment of a foreign body in the lung may
result in pneumonia, tuberculosis, abscess, or
gangrene. Or it may become encapsulated and
do no apparent harm. Rarely a body, in several
recorded cases an ear of barley or other grain, having
formed an abscess of the lung, has been discharged
through the wall of the thorax, with complete recovery.
Diagnosis. — The fact that some foreign body has
been inhaled should be established, if possible, and
the site of the body determined. In children and
incompetents, and in cases in which the dyspnea is
urgent, this may not be easy.
In addition to the diagnostic aids already mentioned
there are two which, in comparatively recent years,
have revolutionized this whole subject, turning dark-
ness into light and affording almost certain relief,
when formerly the life of the patient was generally
sacrificed. The first of these is radiography, the
efficiency of which in cases of a foreign body in the
bronchus has proved it one of the most valuable
contributions to science of modern times. By means
of this admirable method it is possible to determine
with almost mathematical certainty the precise
location in the lung of the object inhaled, as well as
its shape, its size, and its special characteristics.
These details of information become invaluable when
the extraction of the object is attempted, as they en-
able the operator to determine what particular
methods and what special instruments may best be
suited to the case. Thus, for example, the procedure
for the extraction of a closed safety pin of small size
would be far more simple than the measures called
for in the removal of a safety pin of large size, open,
and lodged in the bronchus point uppermost.
The prognosis is serious; it depends upon the nature
of the foreign body, the amount of dyspnea, and the
organic lesions which may result. The danger is
greatest at the first, and although it diminishes in
varying degree as time passes, it is never entirely
absent. Even after expulsion of the foreign body
death may occur from the organic disease set up. The
expulsion of one object does not, especially with
171
Air Passages, Foreign
Bodies in
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
children, preclude the possibility of others remaining
in the lung.
Treatment. — The treatment of foreign bodies in the
trachea must be determined by the circumstances of
the case and by the nature of the foreign body.
When the trachea and bronchi are filled with fluid
the patient should be placed upon his back, the head
and shoulders as low as possible, the mouth should be
forced open, the tongue drawn far forward, and the
walls of the chest compressed. Artificial respiration
should be instituted the moment the trachea is suf-
ficiently free to allow of the ingress of air.
The treatment of solid bodies which have gained
access to the trachea or bronchi has been until re-
cently one of the most difficult problems of surgery.
Fig. 65. — Brass Paper-fastener in the Right Bronchus of a
Woman, Twenty-three Years old; removed by upper bronchoscopy
by Dr. Chevalier Jackson.
With the advent of bronchoscopy many of the dan-
g3rs attending it have been overcome and many
lives saved. Thus far, however, the technical diffi-
culties in the application of the bronchoscope have
caused its use to be confined to a comparatively
few experts. Occasion may arise, therefore, when its
aid may not be attainable. In view of this, it may be
well to rehearse the measures hitherto employed. In
general two plans have been pursued. One, an ex-
pectant treatment in which spontaneous expulsion of
the foreign body has been hoped for. Failing in this,
surgical measures have been resorted to. Of the lat ter
the most common has been the performance of a low
tracheotomy.
Analysis of large numbers of cases treated by the
older methods shows that if the object inhaled has
been small in size, regular in contour, and of a smooth
surface, better results have been obtained by waiting
for spontaneous expulsion than through operation.
Thus Roe, of Rochester, N. Y., in a notable contri-
bution to the subject, in which more than 500 cases
of all kinds were studied, reported that in cases oper-
ated upon seventy-eight per cent, recovered. Of all
not operated upon, including the cases in which death
from suffocation followed the inhalation of the object
t |uickly for any operative aid to have been offered,
seventy-three per cent, recovered. Operations by
which the chest wall was nsected and entrance made
into the substance of the lung have almost invariably
proved fatal.
It will thus be seen that surgery in these cases has
met with little success. The most practical method
has been the performance of a low tracheotomy.
Through the opening thus obtained it was hoped that
the foreign body might be expelled by the act of
coughing. Failing in this, attempts were made to
recover it by the aid of suitably constructed forceps.
In cases where this could not be accomplished it
was recommended that the edges of the wound in
the trachea be kept apart, if necessary, for several
days, in order to facilitate the expulsion of the foreign
body should it become dislodged and coughed up-
ward toward the surface of the body. Where such
measures are pursued it is important that the pi
tion of the patient should be considered. If possible,
he should be caused to lie with the head and shoulders
lower than the rest of the body. Thus the pid of
gravitation may be secured and the tendency of the
body to fall backward, after efforts at coughing
which have driven it upward, will be overcome.
Mild sedatives may also be indicated. The admin-
istration of belladonna to lessen the bronchial secre-
tions, as long ago recommended by the writer in
general operations in the region of the larynx and
trachea, is useful. Morphin may also be used. Swain
suggests the hydrobromate of hyoscine as an adjuvant
to morphin.
The conditions demanding speedy operation are: 1.
Urgent and dangerous symptoms, as progressive
dyspnea, or frequently occurring attacks of dysp-
nea or laryngeal spasm, when laryngoscopic exami-
nation fails to reveal the object or shows that
its speedy removal by the natural passages is impos-
sible. 2. When a sharp and irregular body is im-
pacted, as shown by the laryngoscope, in such a way
that immediate extraction is impossible, and when
acute inflammation, and especially edema, are rap-
idly developing, as evinced by increasing dj'spnea.
3. In the case of a foreign body of any nature which
lies loosely in the trachea, and the movements of
which excite laryngeal spasm or coughing of dan-
gerous violence. 4. In the case of a foreign body
which is impacted in either of the primary bronchi,
as ascertained by the rational and physical signs,
particularly by auscultation. In this latter condition
low tracheotomy and immediate direct attempts at
extraction are often successful. Direct examination
of the site, and demonstration of the foreign body in
or at the mouth of a bronchus, by means of the fin-
ger introduced quickly into the trachea, are possible,
and this knowledge renders the subsequent instru-
mental removal of the body more easy. The entrance
of a foreign body into a bronchus to such a distance
as to place it beyond reach through the natural pas-
sages, is an accident of the gravest danger. A num-
ber of cases have occurred of late years in which sur-
gical operation has been attempted by entering the
bronchus through the chest wall from without. All
have proved fatal. 5. Sharp-pointed, hard, and
irregular bodies within the air passages will, as a rule,
demand bronchotomy, provided they are not so
located that they may be reached and removed by
the natural passages at an early moment. The plan
of treatment by inversion of the patient has of late
years fallen into disrepute, and should seldom be
practised, unless tracheotomy can be done at once if
required. In employing it, it should be remembered
that the supine position will favor exit of the body,
particularly if the glottis be in the condition of deep
inspiration. In all cases the diagnostic importance
of a thorough laryngoscopic examination cannot be
too strongly insisted upon.
The development of the method known as bronchos-
copy has effected a revolution in this department,
as to diagnosis, prognosis, and treatment. To the
genius of the late Joseph O'Dwyer of New York is
due the first suggestion bearing upon the subject.
Among other modifications of his intubation tubes
O'Dwyer devised one especially intended for the
expulsion of foreign bodies from the trachea. This
172
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Aix-la-Chapelle
• ibe was of the largesl possible inner caliber, with
hii walls, almost straight in its long diameter and
lung enough to extend well into tlie trachea. Through
ii loose bodies of relatively small size may be coughed
out. This tube is especially adapted for small
children.
UgernOll Coolidge of Boston demonstrated the
cticability of passing a long tube through the
cervical wound and down the trachea in a tra-
oheotomized patient, and of then illuminating by
means of a head mirror the parts of the trachea
below the distal end of the tube. By this means
ign bodies could be searched for in the more
ote parts of the bronchial tract. Later. Kirstein
lit the method of direct laryngoscopy. Finally,
bining the suggestion of O'Dwyer that a long
could 1"' passed into the trachea through the
larynx, with the suggestion of Coolidge that by means
strong light the deeper bronchial tract could be
ifactorily illuminated, Killian of Freiburg modified
the instrument of Kirstein in such a manner as to
produce the bronchoscope, an instrument which,
nidified by Chevalier Jackson of Pittsburg Pa.,
ns to have reached a stage of perfect adaptation
tie uses for which it is designed. (See Bronckns-
i Mosher of Boston, Ingals of Chicago and other
American experts have also contributed to the elabora-
tion of the method. By Jackson's method a strong
trie light is carried at the distal end of the tube.
Be has also devised many special types of forceps
and other appliances, has developed a very succi —
fill technique and has written most instructively upon
whole subject of bronchoscopy, esophagoscopy,
and gastroscopy. Tha art of bronchoscopy is one
which seems to require special experience and skill.
side ring its extraordinary value in the saving of
life, it is only fair to expect that every general hos-
pital be prepared to employ it and that at various
centers throughout the country there may be found
practitioners qualified to extend its aid.
D. Brysox Delavan.
Johnson: Lancet, October 12, 1S78.
Learning: Growths and Foreign Bodies in Air Passages, Diagnosis
and Surgical Treatment. Medical Record, 1879, xv., 20S.
Wagner: Ziemssen's Cyclopaedia.
Holmes' System of Surgery.
Mnrell -Mackenzie: Diseases of Throat and Xose, London, 1SS0.
Elsberg: Archives of Laryngology, vol. iii., p. 275.
Wcist: Transactions American Surgical Association, vol. i.,
Vbltotini: The Operative Removal of Foreign Bodies and X.-w
Growths frrom the Air Passages. Transactions Eighth Inter-
national Med. Congres-.
Lefferts: Transactions Eighth International Med. Congress.
Aiv=Ia=ChapelIe {Aachen), renowned for its hot
sulphur springs, is an ancient Prussian town of 100,000
inhabitants, easily reached from Paris, Brussels, or
Cologne, being only forty-four miles distant from
the latter city. In its ancient and renowned cathedral
"are the famous relics of Charles the Great, who has
been honored as the discoverer of the springs and
founder of the town; but thermal waters at Aachen
were certainly known to the Romans," whose pre-
dilection for baths and hot springs is well known, as
their elaborate remains at Bath, England, and else-
where testify. The springs of Aachen were also
visited in a.d. 756 by King Pepin the Short. The
town is at an elevation of about 565 feet above sea
level, is built on sandy soil, and is fairly sheltered by
hills. Although the town itself has become entirely
modern, its surroundings are very attractive. The
climate is moderately moist. The average tempera-
ture is 54° F.; the mean temperature for the three
summer months is 61.9° F. and for the three winter
months 37° F., and the number of rainy days 110.
The entire city is underlaid with hot springs, and
within a distance of 1,316 meters the water issues
from ten springs. The principal ones are the Kai i i
quelle (the strongest), with a temperature of 131° F.;
tli«> QuirinusquelTe, 122° I'.: the Rosenquelle, 117..".'
I.; and the Corneliusquelle, ill I . The waters of
the various springs are very similar in mineral con-
stituents, differing in temperature and the amount of
sulphur thej contain. The Elisenbrunnen, the one
most used for drinking purposes, derives its waterfront
the Kaiserquelle.
At the larger bath establishments, which are
elegantly fitted up and arranged, there are vapor
baths, inhalation chambers for bronchial and laryn-
geal affections, and other rooms set apart for the
various hydrotherapeutic processes. "The great
advantage of Aix-la-Chapelle," says Baruch, "is the
fact that nearly all the baths are situated in five
hotels, and there is no necessity, as at Aix-les- Bains,
for the patients to be carried in sedan chairs from the
springs to the hotels." In the town is a Zander
Institute, with medico-mechanical appliances for
Swedish gymnastics. Although one can be treated
at Aachen at all times, the two seasons are the
summer, from April 15 to October 15. and the winter,
from November to April. The accommodations are
very good, and one can live in the bath establish-
ments themselves, as has been said.
In 10.000 parts of water, the Kaiserquelle, accord-
ing to the analysis of J. von Liebig, contains:
Sodium chloride 26. 161
Sodium bromide 0.036
Sodium iodide . 005
Sodium sulphide 0.095
Sodium sulphate 2.S36
Potassium sulphate 1 .527
Sodium carbonate 6.449
Lithium carbonate 0.029
Magnesium carbonate 0.506
Calcium carbonate 1 . 579
Strontium carbonate 0.002
Ferrous carbonate . 095
Silica hydrate 0.661
Organic matter . 769
Total 40.750
Carbonic oxide (free and partially free) 5 000
Traces of fluorine, boron, and arsenic. There is probably an
organic sulphide (allyl) present in minute quantity.
The action of the Aachen thermal waters, as indeed
of all thermal waters, is to increase tissue meta-
morphosis and thus to promote absorption of chronic
inflammatory products, as in chronic rheumatism
and gout; but, as Weber wisely remarks, "hot baths
and hot-water drinking are likewise beneficial in these
conditions, and it is not certain that the presence of
small quantities of sulphur adds much to the effect of
hot water"; " the same," he adds, "may be said with
regard to some chronic skin diseases." In another
place the same writer remarks that in other cases
besides those of syphilis the reputation of the Spa is
due not so much to the water as to the energetic
hydrotherapeutic measures, special exercises, massage,
etc., which are employed there.
On account of the chloride of sodium which they
contain the waters are used in catarrhal conditions
of the stomach and alimentary canal and of the
bronchi. There are inhalation chambers, as has
been stated above, for bronchial and laryngeal
affections. The waters are also used in various
affections of the abdominal viscera: in sluggish action
of the bowels and stagnation in branches of the portal
vein, with the resulting dyspeptic troubles; in con-
gestion of the pelvic organs and hemorrhoidal vessels;
and in enlargement of the liver. Chronic skin diseases,
such as eczema and psoriasis, are treated at Aachen
with more or less success, "the results obtained, " as one
author remarks, "being doubtless partly due to the
173
Aix-la-Chapelle
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
medicinal treatment." Besides chronic skin diseases,
the following affections constitute the major part of
those treated at Aachen: chronic rheumatism, gout,
and the stiffness of joints resulting from these
affections; metallic poisoning; and syphilis. Cases of
the latter disease by far outnumber all the rest, for
out of the 20,000 annual visitors at the Spa, 14,000
are said to come there for syphilitic treatment.
"The value of these baths in this disease," says
Baruch, "has produced such an afflux of syphilitics
that the town has obtained quite an unenviable
reputation, which prevents, it is said, purely gouty,
rheumatic, and other patients from frequenting it."
Weber thinks that the reputation of Aix-la-Chapelle
in syphilis has been due in great part to the ordinary
medicinal treatment employed there and to the
attention paid to the subject by the local doctors.
Be this as it may, the success of the Aix method of
treating syphilis is undoubted.
In this country the Hot Springs of Arkansas is
perhaps the most renowned place for the treatment
of syphilis, and so far as the waters are concerned, it
offers essentially the same advantages as Aachen.
Sulphur waters similar to those at Aix are found in
New York, Virginia, West Virginia, Alabama,
Michigan, California, and Ontario, Canada.
Edward O. Otis.
Aix=Ies=Bains. — This is a town of about 5,000 in-
habitants, picturesquely situated in a beautiful valley
on the east shore of the Lake of Bourget, and sur-
rounded by high mountains (the Savoy Alps). It is
about twenty hours from London via Paris and Macon,
eight hours from Turin, four from Lyons, and three
from Geneva. Its elevation above the sea level is
8.50 feet, and 100 feet above Lake Bourget. The
climate is soft and mild, the average temperature
being 55° F. during the year, and the mean summer
temperature 70° F., though it is sometimes hot in
summer. June and September are delightful months.
" Owing to its excellent atmosphere," says Linn,
"people rest well here."
The thermal sulphurous waters, known to the Ro-
mans, for which about 35,000 people visit the town
annually, are derived from two copious springs which
have a temperature of from 107° to 112° F., and which
are called " St. Paul's" and the "Alum." They yield
about one million gallons of water daily. They are
nearly devoid of solid constituents and contain suffi-
cient sulphureted hydrogen to give them the charac-
teristic odor. " The waters of the two springs are
chiefly used for baths, but the 'Alum,' spring is like-
wise used for drinking. For internal use, however,
t he stronger cold waters of Challes, near Chambery,
and of Marlioz are chiefly employed.
" The waters and the various methods of treatment
employed at Aix are of service in cases in which indif-
ferent thermal (or sulphur) waters are of use"; the
methods of treatment are probably the most effica-
cious in producing the results. "The diseases which
receive especial benefit from the Aix treatment are
chronic gouty and rheumatic affections, muscular
rheumatism, sciatica, neuralgia, neurasthenic condi-
tions in arthritic subjects, chronic cutaneous erup-
tions, and chronic catarrhal affections of the mucous
membranes." "In rheumatic arthritis," says A. B.
Garrod, " the value of the Aix course far exceeds, ac-
cording to my experience, that of any other known
spa." Excellent results are also obtained in the stiff-
ness of joints arising from former injuries and from
gouty and rheumatic affections.
The large bathing establishment is the property of
the state, and is one of the most efficient of these in-
stitutions known. There are swimming baths (pis-
cines), fifty douche rooms with conveniences for ad-
ministering massage; six vapor rooms (bouillons);
five hot dry-air rooms (etuves) ; two general vapor
174
baths (caisses); and four apparatuses (Berthollet's)
for applying vapor locally.
There is a special piscina for the treatment of
chronic skin affections by prolonged baths, after the
method of Loeehe-les- Bains. Poor people are cared for
well as the rich. The especial feature at Aix, for which
it is so famous, is the " douche massage," consisting of
the methodical application, by two skilled attendants,
of massage combined with douches. This procedure,
which may be used for the whole body or espei i-
ally applied to the desired part, is carried out in the
following manner: Ihe patient is seated upon a
wooden stool, and two attendants, male or female as the
case may be, pour the water upon the body from a
hose, while at the same time they shampoo, knead,
and rub according to the directions given by the physi-
cian, who accompanies the patient to the douche the
first time, to give instructions as to temperature, force,
duration, and pressure on particular parts. The
masseurs have each a hose under the arm from which
they direct the water over the bather. The "douche
massage" may be combined with passive movements
of special joints, to be followed or preceded by a vapor
bath in the adjoining bouillon. In many cases pa-
tients, after walking to the bathing establishment,
send back to their hotel their clothes, and, at the
close of the bath (which lasts about ten or fifteen
minutes), they are rubbed dry, wrapped in a blanket,
and carried in bath chairs by porters back to their
hotel and put to bed. " The men and women who
perform the douche massage have had their art
handed down to them for many years, as their fathers
and mothers were masseurs and masseuses before
them." The Aix waters have an unctuous quality
which makes them particularly adapted to rubbing and
kneading the musular structures, a quality that is not
found in other waters. While using the waters the
patient's diet is carefully regulated by the physician.
For a more detailed description of the "Aix douche"
the reader is referred to that of Dr. Jean Dardel of
Aix-les-Bains given in Hinsdale's "Hydrotherap\ ."
1910.
Some two thousand douches and one thousand
baths are often given daily during the season.
The sanitation of Aix is excellent and the accom-
modations are ample and satisfactory. The season
extends from May to October, though the baths are
open the entire year. July and August are the most
frequented months. In this country the Hot Springs
of Virginia, and the springs of Richfield and Sharon in
New York State, correspond to the waters of Aix a~
to the class of diseases treated, and the bathing estab-
lishments at these places are modelled after those of
the European spas.
For much of the above description of Aix-les-Bains
the writer is indebted to Weber's "Spas and Mineral
Waters of Europe," 1896; to Linn's "Health Res
of Europe"; and to the article in the first edition of
the Handbook. Edward O. Otis.
Ajaccio. — The principal town of the island of Cor-
sica, with a population of 20,000. It is situated in
the center of a beautiful and well-protected bay open-
ing to the southwest. "Fifteen to twenty miles in
the rear of Ajaccio is a semicircular mountain chain
of granitic formation sloping down to undulating
foothills, and presenting a glowing panorama at sun-
down. During the winter season the distant peak!
of Monte Onto, Rotondo, and d'Oro are capped with
snow, and the chilly northeast wind over the gulf of
Genoa is dried and broken in force before it reai
the western shore, where it is again arrested near
Ajaccio by the sheltering hills surrounding the town"
(A. Tucker Wise: Transactions of the American Cli-
1 1 iat ological Association, 1890). The visitors' quarter
is along the Course Grandival in the northwestern por-
tion of the town, "which is the section most protected
REFEREXCK HANDBOOK OF THE MEDICAL SCIENCES
Alaska
and best sheltered from the winds." "The .soil at
Ajaccio is disintegrated granite, and allows a rapid
disappearance of the heavy .showers which fall during
the autumn. But, unlike the Riviera, this locality
lias only a small rainfall in March."
The water supply is of a pure quality, and is brought
I,, I he town from Carazzi, twelve miles distant. " 'I lie
drainage of Ajaccio is certainly not perfect," says
Wise, "but zymotic diseases are very uncommon."
The vegetation is most luxuriant, and all the prin-
cipal streets are bordered with avenues of acacia,
orange, or citron trees. Bananas, oranges, lemons, a
variety of cactus, the castor-oil plant, prickly pear,
alec. 6g, and olive flourish.
•• 1. at any rate," writes D. W. Freshfield in the
Alpine Club Journal, quoted by Ball, "know of no
such combination of sea and mountains, ot the sylvan
beauty of the North with the rich colors of the South;
no region where within so small a space Nature takes
so many sublime and exquisite aspects as she does in
Corsica. Orange groves, olives, vines, and chestnuts,
most picturesque beach forests, the noblest pine
Is in Europe, granite peaks, snows, and frozen
lakes — all these are brought into the compass of a
journey."
The accommodations now appear to be ample and
satisfactory, both from the standpoint of health and
from that of convenience, whether one desires hotel,
pension, or villa.
As to the meteorology of Ajaccio, the mean tem-
perature during the -winter is about 55° F. with a
small daily variation of not more than 10° F. ; this
is two or three degrees higher than the mean tempera-
ture of the Riviera.
•' During the season (November to April) the ther-
mometer rarely rises above 59°, or falls below 50°"
(Hall). The relative humidity is given by Wise as SO
per cent., and by another authority as varying be-
n 70 and 78 per cent. The average number of
rainy days for the season is stated by Wise to be 30,
and by the writer on Ajaccio in Eulenburg's " Real-
Eneyclopadie," for the months from October to April
inclusive, 40 to 45. During the three rainy months,
ember, January, and February, the average
number is not more than 14, according to Ball. The
prevailing wind is the southwest, which is "a tem-
perate and soft wind, with genial bright weather, and
prevails as a high current throughout the greater part
of the winter, and in spring its continuance for a pro-
longed period is almost a certainty" (Wise). The
southeast wind ("sirocco") is a very depressing one,
producing loss of appetite and sleeplessness. "From
my own personal point of view" says Wise, "I regard
Ajaccio as the most comfortable climate I have ever
visited, with the exception of the winters in the
Bermudas, and, in comparison with Madeira, it is
certainly more bracing and agreeable to the able-
bodied." The climate can be characterized as a
moderately moist, mild, marine climate, with a com-
paratively large number of sunny days, ranking
between Madeira and the Italian Riviera, but warmer
and more equable than the latter. On account of
the hard granite soil there is no dust, and high winds
are infrequent, a contrast to the Riviera. " People who
find the Riviera too exciting," says Huggard, "com-
monly do well at Ajaccio. For young and vigor-
ous subjects the climate usually proves relaxing."
"It has always been a matter of surprise to me,"
says Williams '("Aero-Therapeutics," 1S94), "that
Ajaccio has not been more utilized as an alternative
climate by the Riviera medical men, when their own
has proved too stimulating or too marked by radiation
extremes, for this mild, moist atmosphere, with its
freedom from all but sea breezes, and its good hotels
and quiet surroundings, seems to supply the requisite
and beneficial change."
The phthisical patients for whom this climate is
especially well adapted are those who can afford but
little physical effort in order to exist — cases of
"phthisis of advanced life, with cardiac feeblei
where t he powers ot resistance In eold are at a low ebb,
or there is much emphysema with cold, livid extremi-
ties" (Wise), it is also beneficial for those in whom
"the breathing powers an- greatly diminished or
when a stubborn cough is a prominent symptom."
Those suffering from a dry, irritable, bronchial or
laryngeal catarrh are said to do well here. Certain
cases of incipient phthisis which are unsuited to the
altitude treatment do well in Ajaccio; and the same
remark applies to those affected with nervous irrita-
bility who require a soothing climate.
Ajaccio is reached by .steamer from Nice and from
Marseilles in twelve and a half and eighteen hours,
respectively. Edwahd O. Otis.
Ajowan. — Ajava; Bishop's Weed; IVeed-seed. The
fruit of Ptychotis coptica, D. C. ifam. Umbelliferce),
This plant is supposed to be indigenous to India,
where it has always supplied an important cultivated
crop. The fruit — one of the cremocarps commonly
called "seeds" — is prized for table use, an equivalent
of thyme, as well as for its medicinal properties. It
is employed in all cases requiring a carminative, and
its action is powerful. It has also been much used in
cholera, combined with camphor, on account of its
powerful stimulation of the abdominal nerves, and
for its antiseptic effect. These uses are fully ex-
plained when it is known that the plant contains
four per cent, of a volatile oil rich in thymol, and that it
is largely used as a source of that substance. Its
properties and uses are therefore those of that drug.
The dose is one to two grams (gr. xv.-xxx.).
H. H. Rusby.
Akinesia Algera. — See Acinesia Algcra.
Alaska. — This vast northwestern possession of the
United States, extending over 16 degrees of latitude
and 35 degrees of longitude, and embracing 590,884
square miles of territory, equal to nearly one-sixth
of the area of the United States, exhibits a variety of
from Greenwich
Fig. 66. — Map of Alaska.
climatic conditions and contrasts dependent not only
upon latitude, but upon the topography of the country
and the influence of the surrounding waters and
currents. Two great climatic divisions can be made:
southern or temperate Alaska, which can be sub-
divided into the Sitka, Kodiak, and Aleutian divi-
sions, and northern Alaska or the Yukon district,
175
Alaska
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
embracing the vast region to the north and west of
the Alaskan Mountains.
The climate of temperate Alaska is characterized by
two striking peculiarities: comparative warmth and
great moisture, formerly supposed to be caused by the
Kuro Siwo, the " gulf stream " of the Pacific, but "now
held to be the general eastward drift of the waters of
the North Pacific in the direction of the prevalent
winds." As a result of this condition, the tempera-
ture is greatly modified from what the latitude alone
would lead one to expect, exactly as the climate of
Great Britain, for example, is modified by the gulf
stream. The isotherm of 40° mean annual tempera-
ture, that of the lower St. Lawrence valley, is the
mean annual isotherm of the Southern Alaskan coast
region. Sitka, with a latitude of 57.03°, which is the
same as the latitude of Labrador on the Atlantic coa.-t,
has a mean annual temperature of 43.9° F., which is
only 2.6° lower than that of Portland, Me., and a
mean winter temperature of 32.5°, which is 6.9°
higher than that of Portland, and only a little less
than that of Washington, D. C. " The coldest month
of Sitka, 31.4°, closely agrees with the coldest month
of St. Louis." (Greely.) The extreme range of tem-
perature is from a point a trifle below zero to 90°
above. Similarly, Juneau, in the Sitka district,
northeast from Sitka, has a mean annual temperature
of 40.9° F. The annexed chart of the maximum,
minimum, and mean temperatures of Juneau and
Sitka for the year indicate still further the moderate
temperature of the region.
The second peculiarity of temperate Alaska is
moisture in the form of rain or fog, and in the Sitka
Average Monthly Maxim™. Minimum, and Mean Temperatures (Degrees Fahrenheit) of Juneau and
Sitka for the Four Years 1899-1902 Inclusive.
which results in this enormous rainfall, nowhere else
equalled in the United States, the annual rainfall at
Sitka being more than double that on the Atlantic
coast. At Sitka the rainfall for the three winter
months is about thirty inches, and for the three
summer months sixteen inches.
The Sitka region is the scenic portion of Alaska,
visited by tourists, and here are found immense
glaciers descending into the ocean.
The country is heavily wooded with spruce, hem-
lock, and cedar, and the vegetation is dense. On
account of the sparse sunshine agriculture is difficult,
but many garden vegetables are successfully grown.
In the Kodiak district, which comprises Cook's
Inlet, the peninsula of Alaska, and the Kodiak Islands,
the climate is similar to that of the Sitka region, but
there is more sunshine and less rain, and the seasonal
extremes of temperature are greater. At Kodiak the
annual mean temperature is 40.6° F., and the number
of days of rain or snow for ten months of the year
1899 was 133, and the number of cloudy days 124,
making 2."i7 cloudy and rainy days out of 304. The
monthly mean temperature at Kodiak for eight year3
is as follows:
Kodiak— Lat. 57° 48'; Long. 152° 19'. Monthly Mean Tem-
perature (Degrees Fahrenheit) for Eight Years.
August 55.2
September 50.0
October 42.3
November 34.7
December 30.5
Year 40.6
Januarv 30 .
February 28 . 2
March 32.6
April 36.3
May 4:i 2
June 49.5
July 54.7
Jan.
Feb.
.Mar.
Apr.
May.
June.
July.
Aug.
Sept.
Oct.
Nov.
Dec.
Juneau —
41 7°
0.5
29.7
.51.0
23.3
35.7
43.0°
12.0
29.1
47.3
16.3
34.3
50.7°
6.0
32 . 8
53.6
7.6
35.8
57 2°
29.5
40.6
58.0
2S.3
42.0
66.2°
33.2
46.6
64.7
31.2
44.6
73 . 2°
39 2
56.6
67.7
34.7
50.6
78.5°
44
57.5
7S.5
40.0
55.5
67.7°
41.7
54.2
65 2
39.7
54 4
63.7°
35.7
49.8
65.0
37.7
50.9
58 7°
27.0
43.0
60.0
30.5
45 2
49.6°
19.3
35.9
54 .
23 3
3S.0
47.6°
11.0
32.6
Sitka—
49.7
21 .3
Daily mean
34.3
division, which extends from Dixon Entrance to
William's Sound, the yearly rainfall is from eighty to
one hundred and three inches, and there are on an
average but sixty-six clear days in the year. " 'When
the sun shines, "the atmosphere is remarkably clear,
the scenic effects are magnificent, all nature seems
to be in holiday attire. But the scene may change
very quickly; the sky becomes overcast; the winds
increase in force; rain begins to fall; the evergreens
sigh ominously, and utter desolation and loneliness
prevail." Fogs are exceedingly frequent on this coast
and occur whenever the wind blows from the sea.
(United States Department of Agriculture, Weather
Bureau.) The Sitka district is very mountainous,
and the coast bold and steep with few beaches. On
account of the fringe of islands lying off this coast and
separated by narrow and deep channels called
"sounds," there is afforded an almost unbroken
protected waterway for ocean steamers from Puget
Sound to Cross Sound, one hundred miles or more
above Sitka, with many excellent harbors. The
mountain sides are densely wooded, and the snow
line begins at an elevation of from three thousand
to five thousand feet. The prevailing winds being
westerly and off the ocean, bring the moisture to the
.snowy mountains, which condense it. Hence it is the
combination of the mountains, the prevailing moist
winds from the sea, and the warm ocean currents,
176
In the Aleutian district, comprising the range of
Aleutian Islands, the range of temperature is much the
same, as the following chart of Unalaska indicates:
Unalaska — Lat. 53° 54'; Long. 166° 24'. Monthly Mean
Temperature (Degrees Fahrenheit) for Six Years.
January 30.0 August -"'1 9
February 31 .9 September 45.5
March... .30.4 October 37.6
November 33.6
December 30.1
Year 38.7
April 35.6
May 40.9
June 46.3
July 50.6
According to Harriman (Alaskan expedition), there
were at Unalaska only eight days in the year, during
several years' record, which were entirely clear, the
remaining 312 being cloudy and 271 of these were
rainy or snowy.
The Yukon district, or Northern Alaska, comprises
that vast region of the Yukon Valley which extends
from the Alaskan Mountains to the Arctic Ocean on
the north and Behring Sea and Strait in the west.
" If there is a region more infested with fogs than the
Pacific coast of Alaska," says Harriman,* "it is
Bering Sea." " Here fog is the normal condition,
and clear, bright weather the rare exception. It is
no uncommon experience for vessels bound for the
* Alaska Expedition, vol. ii., 1901.
referexce h\ni>ro<>k of the medical sciences
Alnjlra
I'ribilofs to miss the islands in the fog. and to spend
days searching for them, as for needles in a haystack."
In the interior of this region the climate becomes
colder and drier — extremely rigorous during the long
winter and relatively hot in the short summer. As
one continues north arctic conditions of climate begin'.
On the Behring Sea coast, north of the Aleutian
Islands, the winter climate is much more severe than
of temperate Alaska on the Pacific coast, hut in
summer the difference is less marked. At St.
Michaels, on the south side of Norton Sound, the
mean summer temperature is 50° F., which is but 4°
below that of Sitka: and at Point Barrow, on the
\rctic Ocean, the most northerly point in the United
: s, the mean summer temperature is 36.8° F.
Furthermore, the winter on the Behring Sea coa-t
about the mouth of the Yukon River and the Seaward
Peninsula is somewhat less protracted and severe
than in the interior, although it is still long, and from
iber to May the temperature rarely rises above the
freezing-point.
St. Mr
covered there. It is reached either overland— the
common passenger route from Skagway by rail for
about one 1 hundred mill.- by the White Pass and
Yukon Railroad, and thence by steamer on the upper
Yukon to Dawson -or by the longer all-water route,
which is principally used for freight, by way of the
lower Yukon. I he distance from Skagway to Daw-
son, the principal city of the Klondike (in Canadian
Territory), is five hundred and eighty miles.
The general characteristics of the Klondike climate
are similar to those of Nome — long, extremely cold
winters, with much snow and "brief hut relatively
hot summers." "In midwinter the sun rises from
9:30 to 10 a.m., and sets from 2 to 3 cm., the total
length of daylight being about four hours." (United
States Weather Bureau report.) In June the sun
rises about 1:30 in the morning and sets at 10:30 p.m.,
"giving about twenty hours of daylight, and diffuse
twilight the remainder of the time." "During the
warmer days of summer the heat feels almost tropical ;
the winter cold is, on the other hand, of almost the
Jan.
Feb.
Mar.
Apr.
May.
June.
July.
Aug.
Sept.
Oct.
Nov.
Dec.
Year.
Mean maximum
33.5°
38.0°
32 0°
40 . 5°
48.5°
62 5°
77.0°
65 0°
56.0°
47.5°
37 0°
34 0°
M* tn minimum. . . .
—34.0
—20.0
— 17 1)
—20.5
—7.0
27.0
40
37.0
25.0
6.5
— i.O
—24.0
Mean monthlv. . .
—7.4
—2.3
8.9
19.9
33.1
46.3
53.6
51 .9
43.9
30 . 5
15 6
4.8
26.1°
Kxtreme maximum
44.0
41.0
43.0
46.0
57.0
7.3
7.5
69.0
69.0
54.0
42
45
75.0
Extreme minimum.
-47.0
—41.0
—39.0
—27.0
—2.0
22.0
33.0
32.0
18.0
3
—24.0
—43.0
—47
Mean number of
rainv and snowy
7
4
6
S
9
9
12
14
14
11
9
o
108
Extreme cold, however, as one knows from the
experience of Arctic explorers, is not detrimental to
health, and at Nome, the most populous mining town
in Alaska, the winter is said to be the most agreeable
season of the year, in spite of the fact that in mid-
winter there are but few hours of daylight, the
shortest days giving but about three and a half hours
of dusky light. " With hands and feet warmly
protected, and winter underwear and windproof
miter clothes and exercise, one can comfortably
weather a degree of cold which, in lower latitudes,
would immediately transform him to an icicle. This
is due to the dryness of the cold." ("The Land of
Xome," by Laurie McKee, New- York, 1902.)
The accompanying table, compiled from observa-
tions of the U/nited States Weather Bureau, gives the
annual and months mean temperatures and the
extremes for St. Michaels, which is on the southern
of Xorton Sound; it also may be utilized for as-
lining approximately the yearly temperature of
Cape Xome, which is one hundred and fifty miles
listant on the northern shore of X'orton Sound, at its
junction with Behring Sea. In the same table will
be found a statement of the mean number of rainy
and snowy days. As will be seen, the rainfall is
light, and is about fourteen inches annuallv. a
striking contrast to that of Southern Alaska.
One cannot be sure of reaching Xome by sea much
before the middle of June on account of the ice in
Behring Sea, or of getting away from there after the
latter_ part of September or 1st of October. The
prevailing winds are from the north, and severe
blizzards with strong northeast gales are frequent in
winter. In comparing the climate of Xome with
"f the Klondike region to be spoken of directly.
it may be said that in general the climate of the latter
i- rather more favorable than that of the former. The
most trying climatic element is the continual wind.
The Klondike. — Fifteen hundred miles in the in-
r, to the east of Xome City, is the Klondike
region, also famed and frequented for the gold dis-
Vol. I.— 12
extreme Siberian region." "Yet a beautiful vegeta-
tion smiles not only over the valleys, but on the hill-
tops, the birds gambol in the thickets, and the tiny
mosquito pipes out its daily sustenance to the wrath
of man." (Heilprin, "Alaska and the Klondike.")
The following observations of mean and extreme
temperatures of the United States Weather Bureau
made at the Yukon River at the international
boundary, about eighty miles north of Dawson, from
September, 1889, to June, 1891, will indicate approxi-
mately the temperature conditions of the Klondike.
From observations made on the Yukon, not far
from the site of the gold discoveries, by the l'nited
States Coast and Geodetic Survey for a series of six
months, the following temperatures are noted:
From October, 1889, to April, 1890, the mean tem-
perature was as follows: October, 33° (above zero);
November, 8° (above zero): December. 11° (below-
zero) ; January, 17° (below zero) ; February, 15° (below-
zero); March, 6° (above zero); April, 20° (above zero).
"The daily mean temperature fell and remained
below the freezing point (32° F.) from November 4.
18S9, to April 21, 1890, thus giving 16S days as the
length of the closed season. The lowest temperatures
registered during the winter were: 32° below zero in
X'ovember: 47° below zero in December; 59° below-
zero in January: 55° below zero in February: 45°
below zero in March; 26° below- zero in April. "The
greatest continued cold occurred in February, 1890,
when the daily mean for five consecutive days was
47° below zero. The weather moderated slight ly
about the 1st of March, but the temperature still
remained below the freezing-point. Generally cloudy
weather prevailed, there being but three consecutive
days, in any month, with clear w-eather, during the
whole winter. Snow fell upon one-third of the days
in winter, and a less number in the early spring and
late fall months. The change of temperature from
winter to summer is rapid, owing to the great increase
in the length of the day." (Bulletin of the United
States Weather Bureau," July 29, 1S97.)
177
Alaska
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Yukon River at International Boundary. Lat. 6o°, Long. 141°.
Jan.
Feb.
Mar.
Apr.
-May.
June. | July.
Aug.
Sept.
Oct.
Nov.
39.0°
31.0°
3 0°
66
52.
39.0
14.0
4.0
—35.0
Dec.
Year.
2:) 0°
87 (I
-60.0
.Mean temperature
(degs. Fahr. i
Extreme maximum.
■ rue minimum
-17.0° —10.0°
25 37.0
-60 . —.35 .
7.0°
3S.0
-45 II
24.0°
56.0
-26.0
45 . 0°
74
8.0
57.0°
S4.0
30.0
60.0° 52 0°
87.0 74
35.0 31.0
-16.0°
17.0
19 n
Harriman (Alaska expedition) says that the mean
temperature of the warmest month on the Yukon, in
latitude 64° 41', was 4° higher than at Sitka over five
hundred miles farther south; but while at Sitka the
extreme range of temperature is 90°, it will be seen
from the above table that on the Yukon it is 147°.
" With a claim to have seen many distant lands,"
says Professor Heilprin, "I can truthfully say that
never before had it been my fortune to experience
such a succession of wonderful summer days as during
my stay in t he region about Dawson. From August
6 to September 21), barring three days of partial rain,
and perhaps a fourth of cloudiness and mist, the
weather was simply perfection — a genial, steady,
mild summer, with a temperature rising at its highest
to about 80° or 82° F. in the shade."
The average annual rainfall is given as from ten to
twenty-five inches, and, according to the authority
just quoted, the weather is bright and sunny, and there
is practically no fog. "There is more sunshine," saj -
Harriman, "in a month (in the interior) than at Sitka
in a year."
Such a climate, although severe, is said to be a
healthy and invigorating one to most people, for the
cold is uniform and dry, and there is very little wind.
a contrast, in this respect, to Nome. In a report by
Capt. W. P. Richardson, Eighth Infantry, U. S. A.,
tin' fact is stated that when the thermometer rises to
zero, as it sometimes does in midwinter, it is too
warm for comfortable travel. The best temperature,
he states, is from 10° to 25° or 30° below zero. " With
this temperature the sleds run easily, dogs work with
spirit, and one can exercise with the warm clothing
necessary at all times in Alaska without discomfort."
The ground is frozen deeply, and in the wannest
season only thaws to the depth of a foot or two.
The vegetation in the Klondike region is, compara-
tively speaking, far more luxuriant than at Nome,
where it is of arctic character, chiefly mosses and
lichens, and the tundra or thick peat moss, or grass
which renders foot travelling wearisome and slow.
In the Klondike region the country is well wooded,
principally with the spruce, although the aspen, birch,
balsam, and poplar are found, and this region of forest
extends with breaks several hundred miles northward
of Dawson. In the summer the country is green and
variegated, with a rich flora. Grass grows abun-
dantly, and all the hardy vegetables are said to grow
without trouble. Grain, vegetables, and fruit have been
raised in small quantities. The native strawberry is
found in many parts of the Yukon valley, and so also
are various native berries, especially the blueberry.
In the Yukon valley, near Dawson, celery, lettuce,
potatoes, turnips, etc., have been successfully grown,
as well as oats and wheat, and this in a latitude which
runs through Greenland and Iceland! Of course
such results would be impossible were it not for the
fait that the summer days, though few, are very hot
and the sun is almost continually above the horizon.
Fish, furs, and gold are the principal industries
of Alaska. The discovery of gold has naturally
attracted the most attention, but the fisheries form
one of the most important industries, and next in
importance to the fur trade is the salmon industry.
Large bodies of coal have also been discovered in
S mi hern Alaska, but from lack of transportation and
the formulation of a definite plan of development by
the TJ. S. Government, whose property they are. they
have not yet been worked. There are also extensive
petroleum fields and copper mines. The population
was 64,356 at the census of 1910, about equally divided
as between whites and natives.
Nome City is the largest town, with a population of
over 12,000, and next comes Skagway, with a little
over 3,000. Dawson, the principal town of the Klon-
dike region, in Canadian Territory, had in 1899 16,000
inhabitants.
The testimony is somewhat conflicting regarding the
mosquitos, but they are apparently pretty abundant,
and at certain times and places constitute a veritable
scourge. The gnats are also ven* annoying.
The accommodations, especially in the mining
towns, are naturally not of the best, and are expensn i
still, any one possessed of robust health need mil be
deterred either by the climate or by the poor accom-
modations from a journey to, or a permanent abode
in, Alaska. The steamer accommodations from
San Francisco, Seattle, or Vancouver are by some lines
quite satisfactory. A summer excursion to the south-
eastern coast of Alaska — the iceberg region — is a
favorite one, and is in calm waters on account of the
protection of the outlying islands.
References. — Various government reports from the
Interior Department; Department of Commerce and
Labor; Department of Agriculture, and the Weather
Bureau; yearly reports of the governor of Alaska:
Harriman, "Alaska Expedition"; Heilprin's "Alaska
and the Klondike"; "The Land of Nome," by Laurie
McKee; "The Pacific Coast Pilot," Maj. Gen.Greely's
" Handbook of Alaska" and " Alaska Almanac," 1908,
and many other special works. Edward O. Otis.
Alassio. — A winter health resort on the Italian
Riviera, fifty-seven miles from Genoa, and about the
same distance from Nice. It is a small town of about
4,200 inhabitants, attractively situated at the head of
a curving bay about five miles in width. To the rear
is a circle of hills, the greatest elevation of which is on
the North (1,963 feet). Thus the town is protected
from the winds of the north, west, and southwest,
The Mistral (north wind), that bane of the Riviera,
is rarely felt here. From the east, however, a strong
wind is not infrequent, which, in mid-winter, may !"■
exceedingly uncomfortable.
Besides the town proper, there are suburbs at the
two promontories at each end of the baj r , in each of
which there is a hotel facing the sea. There are
hotels and villas on the beach, and on the hill
above the town are villas of the English residi
and one or more hotels. One can, therefore, obtain
comfortable accommodations at a somewhat cheaper
rate than at many other Riviera resorts.
No accurate information can be obtained as to the
sanitary condition of the town, but from its location tin 1
natural drainage ought to be efficient. Sparks ("The
Riviera," London, 1879) declared that, the drinking
water was good.
The scenery is very attractive, with a luxurious
vegetation and the picturesque olive groves. "It
would be difficult to imagine," said Dean AJford
(Ball's "Mediterranean Winter Resorts"), "any place
more lovely in spring than Alassio. The somber hoe
of the olive is broken by patches of bright green
178
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Albinism
here oak and acacia and chestnut lives are bursting
!,, leaf. Hoses everywhere with the lavish wealth
1 [taly a cascade of ruses over terrace, walls, balus-
ii, ilcs, and trees one glorious mass of bloom. Below,
[retching away to the horizon, is the bluest of seas
; hing and gleaming in the sunlight."
The following table gives the mean temperatures
in degrees Fahrenheit | for the months indicated,
uring a period of six years:
lotober i;1 '■' January 47.3 April 56.4
... r .... 54.3 February. ... 48.2 .May 64. 3
!, r . , . 40.7 March 52.3
:iu temperature of the three winter months is,
hen, IS. t° 1'.
The average rainfall for the above period was
ighty inches, and the average number of days per
nontfl on which rain fell was 6.6. The mean relative
imidity was 57.6, and of the three winter months
i 1.7. '' Fog has been recorded on fourteen days
[g the six winters."
It will be seen from the above that Alassio possesses
dry, bracing temperate climate; almost complete
of fog, and an abundance of sunshine; and,
ition, the characteristics peculiar to a seaside
I he cases for which such a climate is suitable are:
children suffering from malnutrition and sur-
real tuberculosis, particularly glanduar tuberculosis;
2) sufferers from various nervous diseases and ner-
ireakdowns, provided they sleep well; (3) cases
if heart diseases; (4) cases of gout and chronic rheu-
i are said to do well here; (5) convalescents
i nte disease; (6) in general, the valetudinarian
rom whatever cause, who desires a mild, sunny
ilimate where existence is easy, and outdoor life is
, issible under attractive surroundings. Patients suf-
imin hysteria and melancholia should not be
.at here, as the climate is said to aggravate those
■omplaints.
I d conclusion, the writer may be allowed to quote a
portion of a letter received from an intelligent
gentleman who resided at Alassio for some months:
The climate in December and January," he says,
" is somewhat severe indoors in the Italian houses,
but one can be perfectly warm and comfortable in the
hotels on the sea beach and in those villas which
have been rebuilt or remodelled by the English. But
the climate out of doors is delightful even in these
two months, when it does not rain, that is, for more
than half the time. Early in February acres of
riolets for the Paris and even the St. Petersburg
market perfume the open air, where they grow quite
unprotected, and we had an endless supply of open
air roses all through the winter."
Edward O. Otis.
Albargin. — Gelatose silver,, prepared by evaporat-
ing or precipitating a mixture of nitrate of silver
and aqueous solution of gelatose. It contains about
fifteen per cent, of silver. It occurs in the form of a
ciiarse, yellow, light crystalline pow'der, readily
soluble in water. It should be kept in the dark.
Ubargin is an astringent and antiseptic, employed
an intestinal antiseptic, and as a substitute for
silver nitrate as an injection in gonorrhea. For the
latter purpose solutions of 0.1 to 1 per cent, strength
are employed, the stronger solution only in inveterate
T. L. S.
Albarran, Joaquin. — Born in Sagua la Grande,
Cuba, on August 22, 1S60. His preparatory medical
studies were carried on partly in Havana and partly in
Barcelona, Spain. In 1S77 he removed to Paris and
devoted himself to the study of urology under Prof .
Guyon in the Necker Hospital; in 1S84 he was ap-
pointed an interne in this hospital; in 18S9 he was
awarded the faculty prize (a gold medal) for his
graduating thesis on " Les reins ih-^ urinaires";
in 1890 he was made Chiei of the Clinic for Diseases
of the Uropoietic System and in 1892 he was appointed
"Professeur agregeV' From 1901 to 1906 he was Chief
of Service in another hospital; and in l'.x iti he was called
to succeed Prof. Guyon. It was not long, however,
before he began to show signs of breaking down
under the heavy strain to which he was subjected.
He died in France on January L8, 1912, after a linger-
ing illness (t ubereulosis) .
Of his contributions to medical literature the follow-
ing two deserve special mention: "Anatomic et
physiologic pathologique de la retention de l'urine"
(in association with Prof. Guyon), 1890; and "Traits
des maladies ehirurgicales de la verge." 1896.
A. II. B.
Albert!, Solomon. — Born in Nuremberg, Germany,
in 1540; studied medicine at Wittenberg; and in 1575
was appointed professor of physics. Two years later
the chairs of physics and medicine were combined,
and Albert! filled the position acceptably for over
twenty years. Having been chosen by the Elector
of Saxony as his chief physician, he transferred his
residence to Dresden, and died in that city on March
29, 1600. His chief distinction rests upon the fact
that he was honorably esteemed as an anatomist.
According to Haller he was the first to publish an
actual picture of the valve of the colon; he had
drawings made of some venous valves; and he also
furnished more complete descriptions of the anatomy
of the tear duets. Portal is authority for the state-
ment that Alberti described very accurately the little
bones of the cranium, the discovery of which some
authors," insufficiently informed," have attributed
to Olaus Worm. Alberti also published interesting
researches in relation to the brain, the sinuses of the
dura mater, etc.; and he described the anatomy of
the ear in great detail. A. H. B.
Albinism. — Synonyms: Albinismus, congenital
achroma, leucasmus, leucoderma, leueopathia, leucism,
leucosis, leucynosis, kakerlakism.
The term albinism (Latin, albus, white), or con-
genital leueopathia (Greek, Xewcos, white, and TzdOos,
affection), is used to designate the peculiar condition
characterized by congenital absence of pigment in the
skin, hair, choroid, and iris, and which is classed under
the atrophies. Although albinism has been noted
from the earliest historical period, the Portuguese
are the first on record to have named this lusus naturce,
which they met now and then among the negroes on
the western coast of Africa. These abnormal indi-
viduals they called albinoes. In some of the African
courts, especially in Congo, they are venerated and
are known as " dondos." The term "leuca?thiopes",
i.e. white negroes, has been applied to them.
Extensive investigations have been made in regard
to the origin of pigment in the skin. Various workers
have reached the conclusion "that the pigment in the
epithelial cells is carried there by special connective
tissue cells (chromatophores) which wander up to or
actually in between the epithelial cells to supply the
pigment." However, still later work gives strong
evidence " that pigment can be produced without
the transfer by aid of chromatophores."
Concerning the etiology of albinism there have been
numerous theories many of which have been thor-
oughly unscientific.
Some investigators have attempted to attribute to
albinism a pathological origin. Indeed, in early
times, albinoes were considered a sort of leper, and
consequently were avoided and shunned in life,
while after death the bodies were throw-n on a
dunghill unburied. On account of their faulty
vision by day, and their custom of appearing most
179
Albinism
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
frequently at twilight, since their sight is most per-
fect at this time, they were contemptuously called
" cockroaches."
Consanguinity in marriage has been considered an
etiological factor, an example being noted by Darwin,
in which " two brothers married two sisters, their
first cousins, none of the four nor any relation being
an albino; but the seven children produced from this
double marriage were all perfect albinoes."
A theory has been advanced connecting inactivity
of the suprarenal bodies with deficiency in pigment
and so with albinism.
Also excessive function of the carbon-eliminating
organs has been suggested as a causative factor, as
well as constitutional insufficiency of iron.
Albinism has been ascribed to certain disturbances
of the nervous system.
The affection has been said to be endemic in some
tropical countries.
Maternal impression has also been suggested as the
cause.
Another theory considers that the formation of
pigment may be due to the action of a ferment. Con-
sequently albinism would result from the absence of
this ferment.
The theory of arrested development must be true
in a certain sense but nevertheless it does not account
for anything. " If the distinction between the nor-
mal and the albinotic be assumed to be an absence of
pigment, and if pigmentation normally begins to
appear during fetal life, then albinism is distinctly
an arrest of development." This theory merely asserts
" that albinism is a pre-natal defect, not excess, of
development. It is quite consistent with any modern
theory which asserts that albinism is due to the
absence of one or more development controlling
determinants in either one or both parents. It is
little more than the statement of an obvious fact, as
far as concerns pigmentation."
Heredity, as the chief etiological factor in albinism,
has been as vigorously upheld as it has been sharply
attacked. There are instances on record of families
of albinoes. These are very rare, however, and have
been said to be observed only in the tropics. It is
well known that the offspring of an albino and a black
is generally the pure type — either universal albino or
black; though some cases of partial albinoes have
been reported. However, the children of a normally
pigmented individual and an albino are usually not
lacking in pigment. Also healthy, normal parents
have had albino offspring. In several instances
families have been observed in which universally
pigmented children have alternated in birth with
albinoes.
A very recent hy-pothcsis advanced is " that albin-
ism is an hereditary defect of structure, and possibly
only of superficial tissue structure, which interferes
with the normal metabolic process by which pigment
is produced and stored. The absence of pigment is
a secondary result of the albinotic structure, and not
the primary source of the albinotic constitution.
The delicacy and thinness of the albinotic tissues,
their resulting increased vulnerability, and diminished
resistance to thermal, luminous, and mechanical in-
fluences are not solely due to the absence of pigment;
it is suggested that they mark a differentiated tissue
structure on which the absence of pigment itself
depends. There are many ways by which this
hypothesis can be tested, and such tests will be
fruitful even if the hypothesis has to be dis-
carded." (Draper's Company Research Memoirs,
Biometric Series vi.)
Casting aside first the theory that albinism is a
disease ami secondly the theory of arrest of develop-
ment, and accepting as the only or at least the chief
source of albinism "the inheritance of an abnormal
tissue 1 structure," we are then in a position to put
albinism in the category of "other forms of inheri-
tance of abnormal structure." In addition, we shall
be able to put the hypothesis to proof " by ascertaining
whether its inheritance follows the same laws'
All facts being considered, we may conclude that " the
essential pathological characteristic of albinism" j~
not the mere absence of pigment but the condition
of the tissues lacking pigment — in other words, tin-
texture of these structures.
As to the sex in which albinism most frequently
occurs, both male and female seem to be equally repre-
sented, different authors inclining toward one or the
other according to their individual observations.
Albinoes have been known in all climates and among
all races. Albinism is more common in colored than
in white races.
Albinism may be universal or partial. In univer-
sal albinism the appearance of the individual is very
striking. The skin is absolutely lacking in pigment,
though there is sometimes a slight reddish tinge from
the circulating blood underneath the translucent sur-
face, the characteristic complexion having a dull
waxen pallor. The skin is often roughened, scaly, or
scurfy, a condition which is easily- explained by it.
extreme delicacy of structure and the consequent
effects of its exposure. It is often covered with a
soft white down, though sometimes it is perfectly
smooth.
The whole hairy system is colorless. This may he
due to the absence of iron in its composition, as in
the chemical analyses of hair of various colors, made
by the French chemist Vauquelin, black hair has been
proved to contain iron, while white hair lacks this
element. The texture is peculiarly fine, glossy, and
silky. Although the hair is colorless, its appearance
is not that of hair whitened by age, but rather that of
flax or corn silk. There is one case on record of an
albino having red hair (Folker). In the albinoes of the
black race, the hair, though white, is as woolly and
the features as characteristic as those of their black
brothers.
Although the appearance of the eye in this condi-
tion differs so widely from the normal, "the patho-
logical significance of albinism lies solely in the fart
that the iris or diaphragm of the ocular camera is
transparent, or so nearly so that it does not act as a
true photographic or physiological diaphragm''
(Gould). This deficiency^ of ocular pigment brings in
its train much pain and discomfort. The usual color-
ing matter of the eye being absent, the pupil looks
bright red from the rich background of blood-vessel-,
and the iris light pink or a very delicate blue, tin
variations in tint depending upon the angle of observa-
tion and the nature of the illumination. Photople
is present in the highest degree, the characteristic
position of the albino in daylight showing him with
one arm held up as a shield for the eyes. There is
perpetual nictitation — rapid and repeated motion of
the transparent eyelids, which open and shut con-
tinually in the double effort to see, and at the same
time to exclude the overpowering amount of light
which has free access to the inner parts of the eye
The iris is constantly expanding and contracting.
Nystagmus, or oscillation of the eyeballs, which is
present, is due to the effort to obtain a clearer vv«
of the objects of vision. Amblyopia is a serious fea-
ture in albinism, various causes cooperating to pro-
duce it — viz., ametropia, which increases with the age
of the albino, and which is due to pressure on the i
ball in the effort to exclude light, retinal exhaust i
and nystagmus. Myopia is also common.
It has been generally supposed that albinoes are
weak both in bocty and. in mind, but this is by no
means always true. Often the albino member of :i
family has been intellectually the strongest, many el
these unfortunates being particularly shrewd.
Partial albinism, more common in negroes than in
white people, is observed as one or more patches,
colorless or pinkish, generally circumscribed and ir-
I.SII
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Albuminuria
regular, of any size or form. Instances have been
noted, however, in which these patches were sym-
trically disposed, corresponding to the course of
peripheral nerves, as similarly happens in the case
of certain pigmentary and verrucose nsevL They may
be in any pari of the body, being most c< non, how-
ever on the scalp, face, dorsal surface of the hands,
pies, and genital region. The hair on these spots
, nerally while. The eyes are usually normal,
bowing the ordinary amount of pigment, though
I may be bluish or pinkish. Negroes having this
affection are called pied or piebald. The hair is flaxen
,,l. These patches generally remain permanent
iugh life, or they may gradually extend (ill they
include a large surface; they have been known to
change to a normal appearance through a redepdsi-
tion of pigment, although this is rare.
Work by the most recent investigators calls atten-
iii "the relative rareness of complete albinism,
ie spotted or splashed condition, and of xanthisin,
and their relatively frequent coincidence in the same
L." Such conditions would seem to point to the
that these abnormalities of pigment conditions
arc not entirely independent. It may be accepted
reasonable working hypothesis that these various
conditions complete, partial, and incomplete albin-
and xanthism, "all static forms of leucosis, are
phases of tin' same process and are probably linked
« ith leucoderma and possibly other forms of dynamic
losis In albinism as in many other
defects, we find equivalence or interchangeability of
dity." These workers look forward to still further
-ligation of this subject from the various stand-
>f pathology, physiology, and genetics.
Albinism has been noted not only in man, but also
in the lower animals, and among plants, a very com-
mon example among animals being the pink-eyed
white rabbit. It is seen in elephants, otters, horses,
cows, hogs, dogs, cats, squirrels, rats, mice, raccoons,
ferrets, hooting owls, leather-wing bats, doves, chick-
ens, pigeons, parrots, blackbirds, robins, martins,
swallows, sparrows, and the silver variety of gold-
fish. Some animals become white physiologically in
winter. This is not an example of true albinism.
It lias been suggested that the etiolation of plants
kept in the dark may belong in the same category,
but this differs from persistent lack of pigment, since
color returns on exposure to light.
As to the therapeutics of albinism — there is abso-
lutely no remedy for the affection.
Emma E. Walker.
Albinus, Bernard Siegfried. — Born at Frankfort-on
-the-Oder, Germany, February 24, 1697. The fam-
ily name was Weiss, but at some period of the six-
teenth century it was latinized into Albinus. The
father of Bernard Siegfried and his two brothers
(Christian Bernard and Jakob) were all of them
physicians of considerable distinction. Bernard
Siegfried studied medicine at the University of Leyden,
Holland. From the very beginning he showed a
strong predilection for anatomy and botany, branches
of medical science which were then being taught at
Leyden by Boerhaave and Rail. In October, 1719,
he was chosen Instructor in Anatomy by the Faculty,
the degree of Doctor of Medicine having been given
to him only a short time previously. Two years
later he was made Professor of Anatomy and Surgery
in the same university. In 1726 he published his
treatise on osteology, and he was engaged, at about
the same period, in assisting Boerhaave in the prep-
aration of an edition of the works of Vesalius. In
1734 he published his History of the Muscles of the
Human Body, a work which was remarkable in at
least two respects: it was most beautifully illustrated,
and the individual figures were drawn with great
delicacy and with almost perfect correctness. In
L736 and 1 7: ;7 he published two other works of
importance — a treatise on the veins and arteries
of the intestines, and one on the seal of the color
of the skin in negroes and other dark-skinned raci
and on the causes of this coloration. In 17".s lii-
was chosen Boerhaave's successor as President of
the College of Surg is al Leyden, and he was also
(for the second time) made Rector of i he University.
In addition to all his other work Albinus, during
this very busy period of his life, never lost sight o£
the two undertakings which he considered of the
greatest importance — viz., the preparation and
publication of a commentary on the anatomical
plates of Eustachius, and the construction of his
ow n large plates.
As the health of Albums was beginning to be
affected injuriously by his spending such a large
proportion of his time in the atmosphere of the dis-
secting-room, the curators of the university made
him Professor of Medicine in 174"). His younger
brother was appointed his successor in the Chair of
Anatomy. Bernard Siegfried Albinus died Septem-
ber 9, 1770.
Of his fairly numerous contributions to medical
literature the following deserve to receive special
mention:" De ossibus corporis humani ad auditores
suos libellus," Leyden, 1726 (reprinted in 1762);
" Historia musculorum corporis humani," Leyden,
1734 (Frankfort, 1784); "Dissertatio de arteriis et
venis intestinorum hominis," Leyden, 1736 and 173S;
"Dissertatio secunda de sede et causa coloris jEthi-
opum et ca?terorum hominum," Leyden, 1737;
" Icones ossium foetus humani: aecedit osteogenic
brevis historia," Leyden, 1737; " Explicatio tabularum
anatomicarum Barthol. Eustachii," Leyden, 1744
and 1761; "Tabuke sceleti et musculorum corporis
humani," Leyden, 1747; "Tabulae ossium humah-
orum," Leyden, 1753; and " Academicarum annota-
tionum libri VIII," Leyden, 1754-1768.
A. H. B.
Albucasis (Abul-Casem-Khalaf-Ebn-Abbas.) — The
last one of the Arabian physicians whose writings have
been preserved up to the present time in the form of
Latin translations. He was born in Zahara, near
Cordova, Spain, reached the period of his greatest
celebrity at the beginning of the twelfth century, and
died in 1122. According to the opinion of Schenck,
stated in his " Biblia iatrica," Albucasis and Alsa-
haravius were one and the same person. The great
treatise on the theory and practice of medicine (en-
titled "al Tasrif"), which is commonly accredited to
Alsaharavius, is therefore the work of Albucasis.
While parts of the book have gone through numerous
editions (1471-1602), the work as a whole has been
printed only three times. Albucasis was the first to
describe the affection popularly termed "milk*tetter"
(crusta lactea), the symptom known as dysphagia,
and mercurial salivation; and he was also familiar
with tetanus, smallpox, the aphthous affections of
childhood, and a variety of mental disorders. " But
his three books on surgery constitute one of the most
precious monuments of the twelfth century." (Dic-
tionnaire historique de la medecine, etc.) A.H.B.
Albuminuria. — Albumin is a normal constituent of
human urine in the same sense as is glucose, that is,
neither can be demonstrated in the renal secretion
by ordinary clinical tests but both are found in traces
when the urine is subjected to refined methods of
examination. This normal albuminuria, clinically
of no interest whatsoever, is not analogous to that
which Senator, for instance, understands by "physi-
ological albuminuria" when he declares that_ the
increase of urinary albumin ensuing after consider-
able bodily exercise, a diet rich in proteins, cold
baths, and during menstruation is a physiological
181
Albuminuria
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
phenomenon. Senator evidently does not consider
the facts that physiological circumstances may give
rise to pathological effects, and that the frequency of a
pathological occurrence is not a criterion by which
its physiological character can be determined. En-
demic goiter for instance, so frequent in certain moun-
tainous districts and of probably pure physiological
causation, is nevertheless a disease, and it occurs to
nobody to describe it as a physiological manifestation.
The conception of Senator is shared by other
authors who assign to physiological albuminuria a
wider scope than can be conceded by him who rea-
sons by analogy. If, for instance, the output of
glucose by the urine be ever so small in a clinical
sense, the trained observer will never designate it
as a physiological occurrence. He may accept a
normal glycosuria in the same sense as I admit the
possibility of a normal albuminuria, for glucose will
invariably be detected in large amounts of artifi-
cially concentrated urine, but he will never speak
of a physiological glycosuria if he discovers sugar
in the native urine by his every-day reagents.
Withal, no evidence has as yet been brought forth
that the protein substance, excreted in tangible
amounts after bodily or psychical exertion, is iden-
tical with the protein which is present in every urine.
The true character of the latter is not only unknown,
but there is also sufficient proof that we do not always
have to deal with the same albumin body, and that
there may occur diverse kinds of protein, succes-
sively or together, in the manifold forms of so-called
physiological albuminuria.
Normal albuminuria is a fact, but it is and re-
mains an academic issue as far as the practitioner is
concerned. Whenever albumin can be demon-
strated in the native urine by the ordinary clinical
methods, we are confronted with an abnormal con-
dition. Normal albuminuria is the only feasible
physiological albuminuria, and every albuminuria
recognized by routine examination, and be it ever so
slight or evanescent, is an abnormal albuminuria.
Clinical Albuminuria. — Clinical albuminuria is
always a tangible fact. It is due to the appearance
in the urine of one or more proteins, in the vast ma-
jority of instances of dissolved serum albumin together
with serum globulin (paraglobulin). The native
serum proteins do not always occur in the urine in the
relative amounts in which they exist in the blood
serum wherein they are found on the average in the
proportion of two parts of globulin to three parts of
albumin. As a rule the serum albumin preponder-
ates in the general run of chronic cases of albumi-
nuria, but a genuine serinuria (the excretion of serum
albumin alone) is an exceedingly rare occurrence.
In maivy instances of acute nephritides, on the other
hand, globulin seems to be the prevailing urinary
protein. As a matter of course, we treat now and in
the following pages of genuine albuminuria only,
and not of the spurious variety which is the result
of the admixture of adventitious protein substances
like pus, lymph, blood, prostatic secretion, etc.,
with a urine that was free from protein material
when it had just traversed the renal parenchyma.
While clinical albuminuria in itself is an abnormal
incident, it is no! of necessity the result of a demon-
strable pathological state. True enough, at its foun-
dation, especially if it be of a chronic nature, stands
very frequently a permanent structural lesion, but
then it is invariably associated with a chain of more
or less pronounced pathological features which have
a definite significance in the majority of the cases.
However, when the albuminuria is the most prominent
or even the only abnormal phenomenon, the true
state of affairs underlying it, for the reason that it is
often of a functional and not an anatomical charac-
ter, is disclosed in a comparatively small number
of instances only. Albuminuria without ascertain-
able cause may be transitory, as is frequently the
182
case; it may, however, tend to recurrence or may
be persistent. Albuminurics of this class may enjoy
the best of health, and their metabolic equilibrium
is often perfectly maintained for long periods They
may attain a good old age, and they generally die
from other than renal diseases. The albuminuria,
and may it be ever so evanescent, is nevertheless an
abnormal occurrence, and even if its cause be not
determinable by the clinical means at our disposal
a cause there must be.
Medical writers generally differentiate between
"functional" and "pathological" albuminurias. How-
ever, the clinical albuminurias are of necessity abnor-
mal circumstances, for were it not so, why does not
every urine exhibit ascertainable amounts of albu-
min? All "functional albuminurias," the scope of
which has heretofore been too narrowly drawn, are
albuminurias of pathological function; they are just
as pathological as the "pathological albuminurias"
of former writers. The only difference between tin
albumin output of these two arbitrary forms of albu-
minuria is possibly that of degree; this, however, is
not invariably the fact.
The greater part of this encyclopedic statement
is devoted to a discourse of the group of albumi-
nurias at the foundation of which there apparently
stands one or the other perverted physiological
function. Albuminuria symptomatic of structural
disease, sufficiently understood by the practitioner
even if only on account of the accompanying clinical
features, is dealt with in a casual manner only.
Renal affections, as such, are not dwelt upon at ail,
neither are the other diseases during the course or in
the wake of which albuminuria may supervene.
Albuminuria Due to Patholoqical Function. — By
albuminuria due to pathological function is under-
stood the occurrence in the urine of clinically deter-
minable amounts of serum albumin and serum glob-
ulin in the absence of any demonstrable anatomical
disease of the kidneys. This group includes, however,
albuminurias which are the result of malposition of,
and undue traction or pressure upon an otherwise
normal kidney. In the latter instance the albumin-
ous urine is not infrequently excreted by one kidney
only. Besides the albumin, the urine of this group
of albuminurias generally exhibits no abnormal
features. The diurnal amount of the excreted
albumin varies greatly and may be considerable,
but does not exceed one or two grams in the majority
of cases. In the presence of a definite renal lesion, on
the other hand, the twenty-four hours' urinary albumin
output usually amounts to from five to ten grains and
may exceptionally attain a much higher figure.
A transient albuminuria may obtain in a healthy
individual without any recognizable cause. E
such cases must be considered as the result of a patlio-
logical function inasmuch as there is no physiological
albuminuria which is clinically demonstrable. No
matter how insignificant and fleeting the exciting
cause it must have been of sufficient impetus to give
rise to a disturbance of function somewhere in the
organism. A long-continued functional disturbanci
may develop into a state of pathological physiology in
which the abnormal phenomenon — in this instance the
albuminuria — bears less a frankly pathological than a
compensatory character. Many functional albumi-
nurias are compensatory manifestations of some non-
renal deficiency or disturbance. The "compensatory
albuminurias," as the writer 1 has termed them,
although not pointing to a kidney affection are, no
theless, of a decidedly clinical nature.
Compensatory Albuminuria. — The various transi-
tory types of albuminuria have been considered by
some to reflect a specific or latent form of nephritis
while others have viewed it as an expression of a tem-
porary disturbance of renal function. Langstein's
autopsy findings have finally done away with the first
assumption, at least so far as the orthotic type of
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Albuminuria
dbuminuria is concerned; the latter supposition
nerely substitutes a derangement of renal activity
or aii anatomical renal lesion — a conjecture which
loes not bring us one step nearer the solution of
ted question.
\n albuminuria cannot ensue if the cells of the
cidney are impermeable for the large albumin molecule.
We know, however, that the structurally sound renal
nembranes permit under certain circumstances the
lassage of albumin from the blood current into the
Is this transudation of the large albumin mole-
through the normal kidney membranes referable to
oerted function or to a compensatory response of the
i.e. is the o Hi ii miliaria due to deficiency or efficiency
, rial action; to a renal, exclusively local, functional
\\ eoiii/n li neij or to anterenal pathological influences .'
The kidneys regulate the composition of the blood.
When their work is not interfered with the amount of
- arii his urinary constituents ordinarily reflects the
omparative quantity in which the same substances
have existed in the blood. However, when the renal
activity is lowered, be it on account of functional or
rphological circumstances, there will be retention
ol the urine-making substances in the blood and a
lortional deficiency of them in the renal secretion.
lertony of the blood plasma in the presence of
idly functionating kidneys can be only a transi-
tory occurrence, and if there be a hypotony of the
ma tin' regulatory function of the kidneys will
ion correct it. Thus, the kidneys tend to maintain
a rather definite concentration and osmotic tension of
the blood for every period of life. Substances which
contained in excess or are foreign to the blood
invariably reach the kidneys whence they are elimi-
ited. (While water and the normal catabolic prod-
ucts do not alter the constitution of the sensitive
renal membranes, blood-foreign material is liable to
t the function of the renal cells and may cause
their structural damage if large amounts of it are
continuously brought in contact with them through
the medium of the circulation). This fact again
demonstrates the blood-regulative ability of the
kidneys, and also evinces that the appearance in the
urine of certain so-called pathological substances is
not of necessity due to diseased excretory organs, but
that it may be, on the contrary, a manifestation of
their healthy and vigorous condition.
The occurrence of albumin in the urine in the pres-
of structurally sound and functionally efficient
kidneys must be designated as a regulatory act of the
litter. By their regulatory capability the renal
organs tend to compensate for the insufficiency of
those organs which have permitted entrance into the
circulation of blood-foreign albumin, or to the incom-
petency of which is due a peculiar physicochemical
blood composition, demonstrating itself in the defi-
cient power i'f attaching the absorbed protein material.
In a limited sense, that is as far as the interchange
between blood and urine is concerned, we may speak
nf regulatory albuminuria; in so far, however, as the
blood-foreign protein or the abnormal blood compo-
sition is the outcome of perverse metabolic processes,
we are justified in describing the resulting albumi-
nuria as compensatory in character. While, as a
ter of course, a non-nephritic albuminuria cannot
ensue without renal regulatory activity, the causative
factors of compensatory albuminuria are anterenal
in time as well as location, and are entirely independ-
ent of the kidneys. The designation "compensatory
inintiria" is therefore much more comprehensive
mid expressive than either the terms "regulatory
albuminuria," chosen by Rosenbach, or "hematogenic
albuminuria," propounded by Bamberger. Although
regulatory albuminuria corresponds in many respects
with compensatory albuminuria, its most distinctive
factor is deemed to be the regulatory function of the
kidneys, while the conception of compensatory albumi-
nuria sees in the regulatory activity of the kidneys
not a selective-voluntary, but, more properly, a com-
pulsatory operation. On the other hand, the rather
indefinite so-called hematogenic albuminuria (l food products rich in albumoses. Artificial preparations
g :i^ albumin substitutes often exhibit a large proportion of
albumoses. Such artificial products are frequently prescribed in
gastrointestinal affections and during convalescence from acute
forth ing, the blow received by the unsuspecting
former proposer lor life insurance is in realitj a
great boon to him, for now he knows I hat a change in
his mode of life, con fnrin ing to I he decreased demands
and functional activity of bis organism, i^ imperative.
Febrile Albuminuria. In many of the acute diseases
there may ensue an albuminuria which endures with
or without intermissions during the febrile stage.
An albuminuria developing in l he course or in t he wake
of a febrile disease may, of course, be a manifestation of
a nephritic process; in the preponderating majority
of instances, however, there exists no .structural
disease of the kidney. The albuminuria usually
vanishes with the decline of the fever, and appears
never to be associated with any permanent disturb-
ance of the renal function. The amount of excreted
protein varies and depends entirely upon the intensity
of the toxic process. In rare instances the protein
output may be so abundant that it may be impossible
to differentiate between this type of albuminuria and
an actual nephritis. The temperature elevation as
such does not influence the protein output. The
albuminuria may be due to several factors working
synchronously or successively. At the onset of the
affection it may be deficient renal blood supply
(ischemia) and at a later stage, especially in grave
cases, renal hyperemia to which the advent of the
albuminuria can be attributed. In either eventuality
the albuminuria may be a compensatory phenomenon.
The albuminuria in typhoid fever complicated by
meningism is probably not alone dependent upon
the bacterial toxin circulating in the blood but also,
in some degree at least, to an irritation of a portion
of the central nervous system. In influenza there
may ensue an active renal hyperemia characterized by
an insignificant serumalbuminuria and globulinuria.
The moment the influenza poison is eliminated or
neutralized, the albuminuria ceases and the renal
incident of influenza closes there and then. 19 In
other infectious diseases, particularly in scarlet
fever and diphtheria, the bacterial poisons may
directly and permanently injure the renal parenchyma.
It is also possible that the excreted protein in some
of the minor febrile albuminurias is neither serum
albumin nor globulin but toxalbumin due to bacterial
activity. This, at least, is Krehl's suggestion who
n mmends differential testing for the urinary
proteins..
The albuminurias of this class are erroneously
termed febrile as it is not the thermic but bacterio-
toxic influences to which their origin must be assigned.
A more appropriate designation would therefore be
" bacteriotoxic albuminuria."
Toxic Albuminuria. — Besides febrile albuminuria
which is in some respects a toxic albuminuria there
occur albuminurias as the consequence of poisoning
with certain chemical substances. While there can
be no doubt that the ingestion of agents like oil of
turpentine, cantharides, mustard, and mineral acids,
when undiluted or insufficiently diluted, is liable to
be followed by renal irritation or even structural
disease, it is also true that the specific toxic albumin-
uria may arise in the absence of a kidney lesion. This
is particularly the case when an albuminuria
ensues after the introduction of chemicals like arsenic,
phosphorus, phenol, mercury, iodine, salicylic acid,
and potassium chlorate and nitrate. Such toxic
albuminurias are due to disturbances in the general
and renal circulation and to an altered blood com-
position. Here again the protein excretion is refer-
able to an effort on the part of the kidneys to com-
pensate for anterenal difficulties. The heretofore
sound kidneys remain sound if the toxic process
called forth by these agents declines within a short
time. Even the presence in the urine of hyaline
casts and some fresh blood after the introduction of
such chemicals does not indicate nephritis. In the
average case soon after the toxicosis has ceased,
1S7
Albuminuria
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
there is no longer any albuminuria, nor can casts or
blood be demonstrated.
Hematogenous Albuminuria. — There is no con-
sensus of opinion as regards the nature of hematog-
enous albuminuria. This type of albuminuria
accompanies affections like pernicious anemia, leu-
cemia, scurvy, diabetes, etc. Many clinicians believe
that the renal structures participating in urine pro-
duction have become deteriorated and pathologic-
ally altered in the course of these systemic diseases,
so as to be rendered permeable for the albumin mole-
cule. Though there can be little doubt that the
kidneys may in time become involved in the general
process of bodily decline, there is no evidence that
there commonly exists renal deterioration in the early
stages of these affections. The characteristic hema-
togenous albuminuria which prevails before neph-
ritic changes have taken place is virtually a toxic
albuminuria and is almost entirely due to qualitative
and quantitative changes in the circulating protein.
The abnormal excretory work of the kidneys in these in-
stances must be regarded in the light of a regula-
tory or compensatory process. (See Compensatory
Albuminuria.)
Postepileptic Albuminuria. — By the term postepi-
leptic albuminuria is understood the occurrence of
urinary protein after an epileptic attack. While
some observers have found the protein in the wake
of every seizure, others assert that it appears only
occasionally, and a few others have failed altogether
to detect it after the attacks. The truth of the mat-
ter seems to be that the urinary protein appears
quite irregularly; in the same individual even it
may occur after one seizure and may be absent
after another. Postepileptic albuminuria may be
due to a latent nephritis temporarily activated by an
epileptic paroxysm; to circulatory renal disturbances
concurring with the seizure and manifesting them-
selves mostly as passive congestion; or to toxins in
the circulation prior to and during the attack. The
first eventuality assumes an out and out nephritic
hcaracter of postepileptic albuminuria which, however,
is displayed in only a certain proportion of the cases.
We possess sufficient proof that eventual chronic
kidney changes may be of an entirely secondary
nature, and that the majority of instances of post-
epileptic albuminuria arise on a non-nephritic basis.
There is little doubt that circulating toxins, and
especially disturbances in the blood supply of the
kidneys stand at the foundation of this type of
albuminuria. The one eventuality would stamp it a
toxic, the other a recidivating albuminuria. Mun-
son 20 who has examined .'543 epileptics, 197 men and
146 women, for the albuminuria following epileptic
seizures, summarizes his observations, thus: (1)
postepileptic albuminuria is found in about twenty per
cent, of epileptics; men are much more frequently
affected than women, and severe seizures are more
likely to cause the condition than are mild attacks;
(2) the condition is not constant in the same individ-
ual; (3) the presence of albumin is almost invariably
associated with the finding of casts, sometimes in
great numbers and variety; they persist longer than
the albumin, but may also be found in the inter-
paroxysmal period in the absence of albumin; (4)
the first appearance of albumin may be at any time
within the first two hours after the attack and it
may not disappear till the fourth day; (5) physical
examinations are not fruitful of diagnostic results,
except that a few slight heart findings are noted; the
blood pressure is elevated in some of the cases; (6)
in a series of cases of death in or shortly after seizures,
congestion of the kidneys is almost constantly
found, with albumin in the lumen of the tubules;
there is also a good deal of chronic change which, it
may be assumed, is due to the congestion, so often
repeated.
Postepileptic albuminuria is not the only so-called
neurotic albuminuria, for a transient excretion of
urinary protein has been observed in hyperthy-
roidism, apoplexy, progressive paralysis, brain tumor
delirium tremens, etc. The cause of neurotic albu-
minuria has been ascribed to the stimulation of the
albuminuriogenic center of Bernard situated in the
floor of the fourth ventricle; however, it appears fco
be due to exactly the same factors which may occa-
sion the postepileptic albuminuria, i.e. circulatory
disturbances in the kidneys or a toxic state of the
blood. Thus the albuminuria of Graves' disease is
undoubtedly of hyperthyrotoxic origin.
Heinrich Stern.
1. Heinrich Stern: Compensatory Albuminuria, a Contribu-
tion to the Study of the Clinical Albuminurias, -Medical 1;,
June 26, 1909.
2. Langstein: Die AJbuminurien alterer Kinder, Leipzig. 1907.
3. Virchow: Verhandlungen d. Gesellsch. f . Geburtsnilfe, 1846.
4. Pavy: The Lancet, 18S5.
5. Edel: Munchener med. Wochenschr., Nov. 19, 1901.
6. Edel: Deutsche med. Wochenschr., Sept. 3, 1903.
7. Jacobsohn: Berliner klin. Wochenschr., Oct.. 5, 1903.
8. Sutherland: Am. Jour. Med. Sciences, Aug., 1903.
9. Beck: Am. Jour. Med. Sciences, Sept., 1903.
10. Jehle: Munchener med. Wochenschr., Jan. 7, 1908.
11. Nothmann: Archiv f. Kinderheilkunde, Vol. XLIX, Nos. 3
and 4.
12. Hamburger: Wiener klin. Wochenschr., 1912, No. 25.
13. Lury: Jahrbuch f. Kinderheilkunde, 1910, p. 705.
It. Uhlenhuth: Deutsche med. Wochenschr., 1900, p. 734.
15. Inouye: Deutsches Archiv f. klin. Med., March, 1903.
16. Oroftan: Archives of Diagnosis, Oct., 1908.
17. Ascoli: Zeitschr. f. physiolog. Chemie, 1903, p. 2S3.
IS. Wells: Jour. A. M. A., Sept. 11, 1909.
19. Heinrich Stern: Renal Complications and Sequela? of Influ-
enza. Medical Record, Jan. 11, 1908.
20. Munson: N. Y. Med. Jour., Nov. 27, 1909.
Alburgh Springs. — Grand Isle County, Vermont.
Post-office. — Alburgh Springs.
Access. — The Canada Atlantic Railroad runs
through the village. The Central Vermont Railroad
is within a mile of the village; thence one mile to
Springs hotels.
This is an old-time New England resort, which has
been in use since the year 1816. The springs are
located on the shores of Missisquoi Bay, and are sur-
rounded by picturesque lake and mountain scenery.
The situation is thirty feet above the level of Lake
Champlain and about eighty rods from the water's
edge. There are two springs, one of which was
analyzed by Dr. C. T. Jackson, in 1868, with the
following results:
One United States Gallon Contains:
Solids. Grains.
Sodium sulphate 7 11
Potassium sulphate with potassium sulphide 9.50
Sodium chloride 8 T ' .
Magnesium chloride 5.02
Calcium chloride with calcium sulphate 4.81
Insoluble matter Ml
Organic matter, acid, and loss 2.00
Total 38.00
The water gives off a large quantity of sulphureted 1
hydrogen, and may be placed in the saline sulphureted
class of mineral waters. We are informed that an
analysis by Professor Chandler, of New York, shows
also the bicarbonates of lithium and strontium. The
other spring in the neighborhood is of a ferruginous
character. Emma E. Walker.
Alcaptonuria. — A rare condition, first described
by Bodeker in 1857, in which the urine, clear and of
normal color when passed, becomes of a dark brown
and finally black color on exposure to the air. This
change in color is produced immediately upon the
addition of an alkali, such as a solution of caustic
188
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Alcohol
soda The addition of a few drops of ferric chloride
,,luti, PM "i\r., « ''I'"' l '" 1 '"' which soon fades, me
urine reduces Fehling's solution, a fact which might
cause a suspicion of diabetes, but the specific gravity
is normal, the fermentation test fails, and the plane
of polarization is not deviated. Trine presenting this
peculiarity always contains homogentisic, or hydro-
quinone-acetic, acid C s H 8 0„ which, though not itself
nitrogenous, is derived from the splitting up of the
aromatic nucleus of albumin, more especially from
tyrosine and phenylalanine. The cause of this con-
dition is unknown", but it is doubtless due to some
ormality of protein metabolism, analogous to
and diabetes. It is seen more frequently in
lis and may be intermittent or permanent in its
irrence. In some cases it appears to be a familial
affection, Osier having observed it in four members of
family. It is said to be observed more frequently
in cases of consanguinity of the parents.
AJcaptonuria is. so far as at present known, a con-
in of no pathological significance, being accom-
ied by no other symptoms of functional or organic
ise. It may. indeed, be present in cases of
ochronosis, but is not a necessary accompaniment
of this affection. Gouget (La Prcsse Olediccdi .
July 20, 1912) has found a number of references in
the" literature of the past, to cases of melanuria which
. probablv instances of alcaptonuria. Thus Scri-
ius (1584), Zacutus, and Lusitanus (1649) describe
- of young children in apparent health who passed
black urine, and Schenck (1609) reports the case of a
monk who presented the same urinary anomaly during
his whole life. T. L. S.
Alchemy was the immature chemistry of the
Middle Ages, characterized by the pursuit of the
transmutation of base metals into gold, and the
ch for the alkahest and the panacea. Adam,
states a medieval legend, was the first alchemist;
one cannot say absolutely that the last has not yet
heen born, but certain it is that the alchemist still
lives, and thrives, indeed, in this twentieth century.
This pseudoscience existed in Egypt and India; the
Us handed it on to Rome and Constantinople.
The rise of the Christian Church, and the fall of
paganism, contributed a belief in the warring spirits
of right and wrong, and in the constant presence of
unseen powers. What was true of humanity was to
the medieval thinker true also of non-sentient matter.
There was human demonology; and the half-under-
Stood chemical phenomena were considered demon-
iaoal struggles. Thus was alchemy part and parcel
with necromancy, witchcraft, and the black arts.
Many of the alchemists of the Middle Ages were also
true mystics and followers of the esoteric teachings
of ancient Egypt and Greece. Alchemy should
have died when Lavoisier in the eighteenth century
discovered oxygen and the laws of the conservation
of mass. Instead alchemy simply slipped out of
scientific society. And yet even to-day chemists
are not at all sure regarding the number of elements
in matter, or whether there are elements at all; nor
are they sure of the impossibility of changing one
kind of matter into another. It has oftentimes
happened that out of charlatanry comes good; cer-
tain it is that out of alchemy was born the modern
ile science of chemistry, by which medical science
has in turn so greatly benefited. Johx B. Huber.
Alcohol. — Ethyl Alcohol; Ethyl hydrate; Ethanol;
Methyl carbanol, Spiritus Vini. The term alcohol
formerly restricted to grain or ethyl alcohol, but
is now used as a generic name for a definite class of
bodies. Other alcohols resemble ethyl alcohol in
their properties; that is, they contain hydroxy! (OH)
in combination with a hydrocarbon radical. The
general formula for an alcohol can be expressed by
"ROH," where "R" is any aliphatic hydrocarbon
radical. When, however, "R" is an aromatic radi-
cal, the resulting compound closely resembles the
alcohols in its properties, but possess a I e acid
character, and is classified under the phenols, the
type member of \\ hich is carbolic acid.
The alcohols, while not alkaline in character,
resemble the inorganic bases in forming salts with
acids. The compounds so formed are called esters.
Under the influence of dehydrating agents, two mole-
cules of alcohol lose ft molecule of water and an ether
IS formed. The hydrogen atom of the alcoholic hy-
droxy! reacts with some metals, as sodium, and forms
alkoxides or alcoholates. With the fixed alkali' ,
no salts are formed, while the phenols, on the other
hand, form definite compounds. Ordinary alcohol,
grain or ethyl alcohol, is produced by (1) the fermen-
tation of a saccharine body; (2) synthesis in the
laboratory.
Preparation. — Alcohol is produced by a particular
ferment (Torula cerevi&ice) acting upon saccharine sub-
stances, causing them to split up into alcohol and
carbon dioxide, e.g.:
Glucose = Alcohol + Carbon dioxide.
C 5 H 12 O a = 2C,H,HO + 2CO,
Its preparation depends on the property of glucose
(dextrose) to decompose into carbon dioxide and alco-
hol in the presence of yeast. On account of the pro-
hibitive cost of dextrose, substances rich in starch,
as potatoes, grain, etc., are used. After the proper
treatment, by which the starting material is converted
into a fine pulp, the starch is converted into sugar by
an enzyme or acid. The saccharine solution is then
fermented by the aid of yeast. The resulting liquid,
containing the alcohol, contains also carbonic acid
gas, and is known as a fermented liquor. It may be
used in this, the carbonated or "sparkling" condition,
all t he effects of the alcohol exhibiting themselves, or
it may be left until the CO, has escaped; or the alcohol
may be distilled off in a more or less impure condition,
giving us a distilled alcoholic liquor or spirit.
Cane-sugar and milk-sugar undergo a conversion
first into glucose and then into alcohol. Minute quan-
tities of acetic and succinic acids, also traces of alde-
hyde, fusel oil (amyl alcohol), and glycerin are
produced at the same time. It is an interesting and
important fact that the fermentation gradually ceases
as the alcohol produced nears eighteen per cent,
strength, and when the latter is reached further action
ceases. This is due to the action, on the ferment, of
the alcohol itself; the strength named above being just
able to precipitate it. In the grape juice, when this
strength is reached, if there still be unfermented sugar,
a "sweet" wine results; if none, a "dry" wine.
When any of the fermented liquors are distilled, al-
cohol mixed with water passes over into the receiver.
Repeated distillations free it from the greater portion
of higher alcohols and water. Its degree of concentra-
tion can then be determined by taking its specific
gravity and comparing the result with a fixed and
official table in which the strength for each specific
gravity is worked out. The last amounts of water can
be gotten rid of only with the greatest difficulty; as,
for example, by distillation over quicklime out of
contact with air (from which it rapidly abstracts
moisture).
In a diluted condition, under the influence of
another ferment, alcohol is changed to acetic acid by a
process of oxidation; thus, e.g. white wine vinegar
is produced.
Alcohol
C,.H,HO +
O,
= Acetic acid
= CILO,
+ Water.
-f- H,0.
Alcohol occurs in commerce and pharmacy in vary-
ing degrees of concentration. When absolute alcohol
is required, it should be freshly prepared, that of the
shops being often only of 98 per cent, strength.
IS!)
Alcohol
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Absolutely pure alcohol is a colorless, limpid, pleas-
antly smelling liquid having a sharp, burning taste;
boiling at 7S.5° C. (173.3° F.), and, at 20° C, having a
specific gravity of 0.7895. Its affinity for water is
intense, even abstracting it from the air when the
bottle is not securely corked. If it be mixed directly
with water, heat will be produced, the volume of the
mixture being less than the sum of the volumes of
the components, thus showing that combination has
resulted. It is a solvent of great power, advantage
of which is taken both in the arts and in medicine,
e.g. in the solutions of the fixed active principles of
drugs, called tinctures, or the solutions of the volatile
active principles, called spirits. It dissolves the alka-
loids, essential oils, many resins, some fats, and C0 2
freely.
Its distinguishing chemical properties are: (1) its
affinity for water, (2) its coagulating power on albu-
minoids, and (3) its antifermentative power when
stronger than eighteen per cent. Advantage is taken
of the first, in the mounting of microscopical sections,
to abstract all the water before immersing them_ in
the oils and balsams; of the second, in the hardening
of the tissues for study and section; of the last, in the
preservation in bulk of anatomical specimens, and
those medicinal agents which undergo change in other
media.
Alcohol, U. S. P., is defined as "a liquid composed
of about 91 per cent., by weight, or 94 per cent, by
volume, of ethyl alcohol, and about 9 per cent., by
weight, of water." It has a specific gravity of 0.820
at 60° F. and boils at 7S° C. (172.4° F.).
Alcohol Absoluhim , U. S. P., is "ethyl alcohol, con-
taining not more than 1 per cent., by weight, of water."
Its specific gravity and boiling-point are stated above.
Alcohol Dilutum, U. S. P., is "a liquid composed of
about 41 per cent, by weight, or about 48.6 per cent.
by volume, of absolute ethyl alcohol, and about 59
per cent, by weight, of water." It has a specific
gravity of 0.938 at 60° F.
Alcohol Deodoratum, U. S. P., is "a liquid composed
of about 92.5 per cent, by weight, or 95.1 per cent, by
volume, of ethyl alcohol, and about 7.5 per cent., by
■weight, of water." It has a specific gravity of 0.S16
at 60° F.
Physiological Action. — The extraneous effects of
alcohol are of high importance. By the creation of a
partial vacuum upon the cooling of an enclosed space
previously heated by burning it, glasses are affixed in
cupping. It is a powerful disinfectant, especially
antizymotic, being thus one of the best and most
generally used preservatives.
Its local effects are even more important. Exter-
nally, it is cooling by its evaporation, although, if the
solutions have a strength of fifty per cent, or more, it
becomes a rubefacient, especially if rubbed into the
surface, or if its vapor be confined. It is slightly
locally anesthetic, especially in relieving itching, and,
through the contraction of the vessels by its cooling
effect, may locally check perspiration. Its solvent,
combined with its disinfectant and stimulant proper-
ties, render it a useful lotion for cleansing diseased
surfaces. If, however, the solution be strong, it acts
rather as an irritant, and, by the abstraction of water,
and the partial and temporary coagulation of the
albumen, as an astringent. It acts very promptly
upon mucous surfaces, being, as upon denuded tissues,
stimulant to irritant and more or less astringent. Its
presence in the mouth stimulates the secretions, not
only of the mouth, but of the stomach. Even a few
drops applied at the base of the tongue have been
seen to produce an almost immediate flow of gastric
juice. The intellectual functions are thus reflexly
stimulated also, though later, by direct contact with
the cells, the opposite effect is produced, upon both
the salivary glands and the brain. If held in the
mouth, it produces a numbing effect.
Small quantities of alcohol, properly diluted, taken
into the stomach, produce an agreeable sensation of
warmth. A turgescence of the capillary plexus of
the mucous membrane occurs, which is speedily
followed by a free secretion from the gastric follicles
due, in all probability, to (a) the increased supply of
blood, and (,3) the stimulation of their glandular
orifices. The movements of the stomach, as well as
its secretions, are increased, and absorption of the
products of digestion is greatly hastened. It is
therefore one of our most powerful stomachics and
digestive stimulants. These effects are not lost upon
the absorption of the alcohol, but appear, upon the
contrary, to be still further increased by its presence
in the circulation. Its presence, however, in any
considerable quantity in the food mass inhibits pro-
teolysis, while in concentrated form it acts rather as
an irritant, and its favorable action upon digestion is
wanting. The direct irritation may result even in
vomiting. Continued concentrated doses tend to
produce chronic gastritis and gastric catarrh. More-
over, the continued recourse to this artificial aid to
digestion tends to necessitate it, and in increasing
degree. Larger and larger amounts are apt to be
required, and the natural powers of digestion be-
come permanently and seriously impaired, and at
length may be almost completely lost. Aside from
the effects upon digestion already described, the
action of alcohol in the stomach is one of reflex stimu-
lation of the heart and of the respiration, provided
t hat the drug is not too much diluted. In the intes-
tine, peristalsis is directly stimulated, and an astrin-
gent effect produced.
Alcohol is very promptly absorbed, and circulates
as alcohol, in which form it comes into contact with
the tissues and exerts its peculiar activities.
The liver, being the first to receive the blood freshly
charged with alcohol, in a more concentrated con-
dition than after dilution by the general circulation,
is the first to feel its stimulating effect, and the first to
undergo pathological changes. The liver cells are
stimulated, and as a result we have an increased flow
ofbile. Later, the cellsenlarge and become infiltrated
with fat globules. The stronger drinks, particularly
if taken undiluted, and if the practice be persisted in
for any considerable period, cause an irritation of the
connective-tissue cells in the liver surrounding the
portal radicles. A proliferation of the same occurs,
and, as a final effect, contraction of this newly formed
tissue — as is the case with all newly formed connective
tissues— ensues, producing the so-called cirrhotic or
hob-nailed liver. With the primary new formation
there is naturally an increase in the size of the organ,
while the secondary contraction causes an atrophy of
the liver cells, (a) by direct pressure, and (,.)) by
diminishing their normal blood supply. In I
countries where the more dilute alcoholic drinks
(wines and beers) are the national beverage, cases of
cirrhosis are unusual; while the contrary is true whi n
the more concentrated drinks (brandy, whiskey, gin,
or rum) are largel} r consumed. Finally, the portal
radicles become so narrowed by the contraction of tlie
connective tissue in which they lie that the portal
circulation is interfered with, thus producing a
mechanical congestion of the intestinal, peritoneal,
and gastric capillaries, with ascites and watery stools.
Kidneys. — The alcohol being in a much less concen-
trated condition on reaching the kidneys than is the
ease with the liver, the effects, both physiological and
pathological, are less marked. The watery portion of
the urine is increased; the solid, at least so far as urea
is concerned, is diminished. The increased amount
of water excreted is a natural result of the increi
blood pressure; the diminution of urea is due to the
lessening of oxidation of the nitrogenous tissues. In
these organs, although, the irritating results manifest
themselves more slowly than in the liver, they occur
in an exactly similar manner. Bright's disease is
thus frequently induced.
190
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Ah nliiil
I ]„■ effect of alcohol upon the skin is moderately to
ncrease perspiration. 'I his is a natural result of the
•utaneous turgescence, but it is not known whether
here is also a direct stimulation of secretion.
I he temperature of the skin is temporarily raised I v
his turgescence, and the nerve endings are thus
vanned. There is thus a false impression of warmth
created, the general temperature actually falling
liiiekly, and the individual being especially exposed
o the evils of cold, tn chronic alcoholism there is apt
, be interstitial thickening of the integument.
Systemic Effects. — In spite of the great amount of
i which has been concentrated upon the investi-
gation of the systemic effects of alcohol, our con-
clusions arc doubtful to a greater extent than in the
ol almost any other drug. There seems to be
room for question as to the ultimate net results,
ml a great deal of it as to the modus operandi. The
ndications are those of a drug which for a very brief
id stimulates, then depresses the tissues upon
ii it acts. As to the depression, there is nowhere
question, but it is claimed by high authority that,
nit for the reflex stimulation already noticed, its effects
ipon the nervous system are wholly depressing, the
irent stimulation resulting from depression of the
bitory and controlling functions. Undoubtedly
his weakening of will power, and of the higher
unctions of coordination, plays a very important part
: i lie apparent manifestations of stimulation, and
nuts for the great lack of uniformity in them in
lifferent individuals; yet it does not seem possible to
nit so well in any other way for the symptoms
i^ by assuming the existence of a primary stimulation.
practical study like the present, it seems more
irofitable to discuss the conspicuous net results, and
■ id extended discussion of the mechanism.
Thi> peculiar interaction between the effects of
deohol upon the circulation and those upon the
ous system renders it difficult to consider either
without having first taken up the other.
As a result of the systemic effect of alcohol, the rate,
md to a greater extent the force, of the heart, are
eased, and this sufficiently to increase the blood
-lire, in spite of the fact that there is marked
ial dilatation. This period is followed by one of
lepression, and the first stage is shorter, even almost
altogether wanting, in proportion as the dose is
increased. How far this result is due to depression
of inhibition is one of the questions of greatest
dissension among physiologists.
The same observation of an increase in respiration,
and the same dispute as to its cause, are to be re-
corded. In any case, it seems clear that the result is
nut due to any direct central stimulation.
The chief nervous effects of alcohol are upon the
brain, especially upon the cerebrum. Its action is
delirifacient, there being a preliminary period of
stimulation running into excitement. Even this
stimulation is a narcotic one, being unequal, and
resulting from the first in an interference with
equilibrium. It is because this increased activity is
due largely to inhibition of the powers of self-control
and restraint that the claim has been advanced that
this is the sole cause, and that alcohol does not
directly stimulate at all. It is quite evident, however,
that such a result would necessarily follow the
increased cerebral circulation due to general circula-
stimulation, even if there were not, as there
appears to be, a direct primary stimulation of the
rebral cells. Only at the very beginning are the
mental processes quickened, but after they have
become slowed and blunted, the individual still be-
lieves them to be greatly improved. Despondency
and mental pain are thus decreased, but the subject
loses his judgment and becomes talkative and other-
wise demonstrative and self-asserting. Intellectual,
followed by sensory and motor paralysis then comes
on, and the coma stage follows that of delirium.
Paralysis of respiration and particularly of circulation
may become complete, resulting in death. During
the stage of depression, vomiting of central origin
usually appears.
Alcohol is itself Oxidized as a food, but decreases
tissue oxidation. This may to some extent account
for the reduced temperature, though this is chiefly
due to the increased heat radiation resulting from
engorgement of the superficial vessels. It is more
rapidly oxidized under the influence of exercise,
exposure to cold, and in fever, 'this is regarded as
the normal method of its elimination, only five or
ten per cent, ot it being excreted by the kidneys and
lungs as alcohol, it is believed that this nutrient
function does not at all relieve the demand for
nitrogenous nutriment, but may to a great extent
supply that for carbonaceous. The latter fact
explains the accumulation of fat in alcoholic subjei
though their obesity is also favored by the decreased
elimination of water which finally takes place.
The remote effects of alcohol may be good, but are
far more likely to be harmful, due to excessive use,
or to use continued beyond the period required. The
general rule should be to use alcohol only temporarily.
If used only to the extent of stimulating the digestion,
it can result in great improvement of nutrition. But
it may result in the complete destruction of digestion.
If properly proportioned as to dosage, it is an excellent
food in fever, but it may be used so as to exhaust the;
system. It can be used to benefit the excretory
processes of skin and kidneys, but it may destroy
cither or both, resulting in cutaneous hypertrophies,
or in nephritis. It is very apt to induce obesity,
partly by interfering with the elimination of water,
ami partly by checking the oxidation of fat. It has
a tendency to destroy fine cell structure everywhere.
This is specially seen in the destruction of the finer
moral and intellectual functions, in sensory and motor
paralysis, and in reducing the parenchymatous liver
tissue, with an increase of its fibrous portions. A
peculiar kind of mania is induced by it, known as
delirium tremens, chiefly characterized by hallucina-
tions and delusions of snakes, demons, and other
terrifying subjects. This appears to be connected
with some peculiar form of malnutrition, as it never
appears until after the loss of appetite has become
pronounced. The ability of the system to withstand
exposure, fatigue, or disease is slowly but most surely
destroyed by alcoholism. This is especially noticed
in pneumonia, which is almost certainly fatal to
drunkards, although alcohol is one of the surest
reliances in supporting pneumonic patients who have
not been addicted to its use. Fatal acute poisoning
by alcohol is not unknown, the effects pertaining espe-
cially to respiration in some cases, to circulation in
others.
Various accidents are frequently mistaken for
intoxication, especially apoplexy, coma from blows
upon the head, and opium poisoning, and many
scandals have originated from wrong diagnoses. The
greatest care should be taken in the differential
diagnosis of these cases.
Therapeutic Uses. — The therapeutic local uses of
alcohol are sufficiently indicated by our account of its
local effects. Its uses as a digestant are undoubtedly
its most important ones, if we regard the frequency of
employment. Here the method of administration is of
the utmost importance. It should not be used when
any inflammation or irritation of the stomach exists.
The smallest, possible dose consistent with effectiveness
should be employed. A teaspoonful to a tablespoon-
ful of brandy or whiskey should suffice. The strength
as imbibed should not be greater than five to fifteen
per cent. It should be taken quickly just at the
beginning or during the early part of the meal. If
taken too soon, the effect is lost, and the liver may
suffer. If taken too late, it interferes with digestion.
Diluted alcohol is preferable to liquors, if one regards
191
Alcohol
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
the danger of forming a habit. The administration
should be carefully watched and skilfully controlled,
and an effort made to decrease the dose almost from
the beginning, and abandon it just as soon as possible.
This is not only to avoid the formation of drinking
habits, but to avoid inducing the stomach to depend
upon the artificial stimulus.
Its next most important use is as a food. This may
be at such times as ordinary food is not desired or not
borne, but when food is imperatively required. It
may then be taken by the stomach or the rectum.
It will often aid in the digestion and assimilation of
milk, besides contributing its own portion of nutri-
ment. Therefore a milk punch is one of its most use-
ful forms, but one of the most dangerous as to habit.
In fever, it is useful in one, injurious in another class
of cases. In a typical case, it should not only
nourish the patient, but calm him, and reduce the
fever. If the opposite effects are induced, it should
not be used. Alcohol is a fairly good carminative,
and brandy is astringent in many cases of diarrhea;
it is very difficult to say why. Insomnia may be
relieved by alcohol, though there is a tendency to
require its continued and increasing use, and this
should under no circumstances be permitted. Gin is
an excellent diuretic, but the alcohol plays probably
a subordinate part.
Alcohol, if taken in full dose and very early, espe-
cially with an abundance of water, is most valuable
in breaking up an impending cold. It is readily
conceivable that the most disastrous results may be
thus avoided, when we consider the consequent trans-
fer of blood from the viscera to the skin. The effect
of the alcohol must in such cases be promptly sup-
plemented by warm external applications, or at
least protective coverings.
Alcoholic Liquors. — The various forms of alcohol
can profitably be here considered, rather than to take
them up in their regular alphabetical order in the
different parts of this work. The alcoholic liquids of
the different classes are as follows:
Kumyss is the weakest of all in alcohol. It is
simply fermented milk. Mare's milk was originally
used, but it is now very often substituted by cow's
milk variously modified. It was originally fermented
by the action of a special ferment, but yeast is now
generally employed. It should be used while fresh,
never more than four or five days old. It should con-
tain about one and a half or two per cent, of alcohol,
and be strongly carbonated. There are also traces of
unknown ethers developed in the fermentation. It is
estimated to contain about twelve per cent, of solid
nutriment. It is soothing to the stomach, without
in any degree retarding digestion. Its primary
stimulating effect is followed by a slight soporific
tendency.
Beer, Stout, Ale, and Porter are made from barley,
the starch being first converted into sugar by the
action of the diastase, under the influence of heat
and moisture. In this condition it is Malt. The
malt is subjected to a vinous fermentation. In
making beer, this is done slowly at a low temperature'.
in the others more quickly, at a high temperature.
The darker-colored stout and porter are made so by
a partial burning of the materials. The percentage
of alcohol ranges from two to nine, ordinarily about
four or five. These liquors are abundantly carbon-
ated and they contain more or less digestible nutri-
ment. They appear also to exercise a small amount
of digestive effect upon some foods. Hops or lupulin
are added to genuine beer, but a great variety of
bitter substances are in use, many of them selected
without the slightest regard to their injurious effects
upon the system, so that beer, if prescribed, should
be always of a brand of known composition.
Various other seeds, especially rice and peanuts, are
similarly used, as well as many other starchy sub-
stances. Some savage tribes are ahead of us, in that
they use substances which contain distinct medici-
nal constituents, together with the alcohol-yielding
portion.
Wine, Cider, Pulque. — These are fermented vege-
table juices, wine from the grape, cider from the
apple, and pulque from the century plant. If used
while still in the carbonated state, they are called
"sweet" or sparkling, otherwise they are "hard" or
" dry." In addition to the carbonic acid and alcohol,
there are considerable amounts of sugar. When
this amount is large, they are specially called "sweet."
There are also considerable amounts of tartaric and
acetic acids. When this is the case the wines are
called "sour." A variable amount of tannin is
present in red wines. Wines which have had the
percentage of alcohol artificiallj- increased, as port and
sherry, are called "heavy" or "fortified ".
Vinum Rubrum, or Red Wine, U. S. P., is made
from the entire grapes.
Vinum Album, or White Wine, U. S. P., is made
from grapes from which the skins, seeds, and stems
have been removed. Each contains from ten to
fourteen per cent, of alcohol.
A very large number of sugary fruits are utilized in
the manufacture of special wines.
Distilled Spirituous Liquors. — Any fermented alco-
holic liquor may have its alcohol distilled off. In
this process various other substances are certain to
come away with the alcohol, and their complete re-
moval is very difficult, so that each kind of spirit
will possess its characteristic color, odor, and taste.
For the most part, however, these associated matters
have not a high degree of physiological importance.
Medicinally, the liquors are used chiefly for their alco-
hol, and there is little choice among them. The physi-
cian's responsibility in prescribing brandy, whiskey,
and other pleasant forms of alcohol, and thus tending
to promote alcoholic habits, is very great. In most
cases, dilute alcohol or diluted deodorized alcohol,
variously admixed so as to obscure its character or to
make it less palatable, can frequently be employed
with equal advantage. Because this is now so gen-
erally done by the more cautious class of physicians,
and as there is so little genuine prescription demand
for brandy and whiskey, it is seriously proposed to
drop them from the Pharmacopoeia.
Spiritus Yini Gallici, or Brandy, is distilled from
wine, and contains thirty-nine to forty-seven percent.,
by weight, of alcohol. There must be no admixture
or modification of any kind, and it must be at least
four years old. With the ordinary properties of its
alcohol, it combines a distinctly astringent effect upon
the bowels.
Spiritus Frumenti, or Whiskey, U. S. P., is similarly
distilled from the fermented product, "mash," of
grain, either rye or corn (the latter " Bourbon Whis-
key"), or mixtures of them. It should be at least
two years old and contain from forty-four to fifty
per cent, of alcohol.
Gin is the equivalent of the compound spirit of
juniper, elsewhere considered.
Upon keeping spirituous liquors, various ethers de-
velop in them, which tend to make them pleasanter
to the taste, but which do not materially modify the
action of the alcohol.
The principal impurity of alcohol, especially
of whiskey, is fusel oil, or Amylic Alcohol, next
considered.
Amylic Alcohol. — Fusel Oil; Grain Oil; Potato
Spirit Oil. (C,H„HO.)
In speaking of the alcoholic liquors, reference v i
made to fusel oil as one of the commonest of impu-
rities. It can be obtained from all crude alcoholic
liquids, and is removed from them in purification.
It is chiefly obtained during the later portions of their
distillation, and is much more abundant in spirits
obtained from some sources than from others, notably
from potato spirit. It is considerably heavier than
192
REFERENCE BANDBOOK OF THE MEDICAL SCIENCES
Alcoholic and Drue
Intoxication
pure ethyl alcohol (specific gravity 0.818) and its
boiling-point (128 130 C.) is very much higher. It
has an oily consistency, is colorless, has :i powerful
odor and a burning, acrid taste, the inhalation caus-
ing headache. Although amylic alcohol has very
powerful physiological properties, it has never been
b utilized in medicine, and it is used chiefly
solvent in manufacturing operations. It is a very
, -rf ul poison, the symptoms being those of great
iression.
Mi:tiiylic Alcohol. — Methyl Alcohol; Wood Al-
Spirit; Wood Naphtha; Columbian Spirit;
Pyroiylic Spin!. ( (II .< > II.)
In the crude pyroligneous acid distilled from wood
'.c Acid) there is about one per cent, of methyl
ihol, which is obtained by light distillation, after
iddition of lime, and is then purified. It comes
first in the series of alcohols, that is, it is the simplest
of them. It has been found somewhat sedative, es-
pecially to the cough of consumptive patients, in
s of 1 to 3 c.c. (15 to -15 minims), yet it can
t-lv be regarded as a medicinal substance. As it
cannot" be used as a beverage, ten per cent, of it is
added to alcohol in England, to allow of the use of
the latter in the arts without danger of defrauding
the customs laws relating to spirituous beverages.
This mixture is known as Methylated Spirit. Methyl
alcohol is excellent for burning purposes, owing to its
large percentage of carbon, and isrelatively very
cheap.
Denatured Alcohol. — In 190f>, a Federal law was en-
acted, providing that domestic alcohol may be with-
drawn from bond without the payment of the internal
revenue tax. for use in the arts and.industries, and
for fuel, light, and power, provided it shall have been
mixed in the presence and under the direction of an
authorized Government officer, with methyl alcohol or
other denaturing material which is destructive of its
character as a beverage and which renders it unfit
for liquid medicinal purposes. By a subsequent
amendment, it was specified that such alcohol can be
used in the manufacture of definite chemical sub-
ices, when the alcohol is changed into some other
mical substance and does not appear as alcohol
in the finished product.
The denaturing material employed may be either
ten parts of methyl alcohol and one-half part of ben-
zene to one hundred parts of alcohol, or two parts of
methyl alcohol and one-half of pyridine basis. The
characters of the methyl alcohol and pyridine basis
to be employed are specified, as are all other condi-
tions and regulations, in a pamphlet of 169 pages issued
by the Internal Revenue Department.
Toxicology. — The internal use of wood alcohol is
most dangerous and even its application externally
should be discouraged. So small an amount as a
poonful has produced serious results, as has ab-
sorption through the skin, notwithstanding that it is
often applied in this way with impunity. Serious
results nave also followed its free inhalation. The
poisonous effects are much like those of formaldehyde.
There is great irritation of the mucous surface, fre-
quently with severe vomiting. There is headache,
mostly frontal, with a sense of pressure, pain and
soreness of the eyeballs; later, usually from the second
to the fourth day, there are disorders and then loss
of vision. Sometimes this first failure will be followed
by apparent recovery, but total blindness almost
certainly supervenes. Very large doses may result in
prompt and fatal depression following an initial
period of irritation. Most cases of poisoning by
wood alcohol have resulted from its fraudulent use
in liquors, medicinal preparations and flavoring ex-
tracts, and most of the States now have stringent
laws against its use. Very little can be done in the
way of antidotal treatment, though the early use of
pilocarpine has sometimes resulted favorably.
Henry H. Rusby.
Vol. I.— 13
Alcoholic and Drug Intoxication and Habituation.—
I he role that alcohol plays in the production of
psychoses, while admittedly an important one, is
not at all well understood. Recent statistics, con-
servatively interpreted, would indicate that about
twelve per cent, of the insane confined in public
institutions in the United States are there because
of its influence, direct or indirect. When, however,
the multitudinous ways in which alcohol may enter
as a factor in the production of mental disease and
the far-reaching effects it produces are considered,
it is readily seen that do statistical study can begin
to fathom the problem.
While the psychoses considered under this heading
clo.-ely associated with alcohol and in the
main present fairly constant and characteristic
pictures, it must not be forgotten that alcohol may
enter as an etiological factor in the production of
symptoms ordinarily considered to be quite distinct
from the alcoholic psychoses properly so called, such
as the manic-depressive and dementia precox psy-
choses, while it is considered by some to be a very
important causative agent in paresis. When attacks
of these psychoses are brought about by alcoholic
indulgence it is probable that they are considerably
modified and as a result present a somewhat atypical
picture.
That the psychoses produced as the result of
abuse of alcohol are dependent, in the last analysis,
upon something besides the alcohol, namely, upon
some peculiarity of make-up of the individual, is well
shown by the fact that while a history of abuse of
alcohol is frequent in cases admitted to hospitals for
the insane, it is rare to find at autopsy what in
general hospitals is considered so typical of alcoholism,
namely, cirrhosis of the liver. This means that the
locus minoris resistentiae in these cases is the brain
and that mental disease supervenes before the liver
becomes involved.
Psychology. — Alcohol has long been supposed to
be a stimulant. Such supposition, however, was
based largely upon false interpretations of subjective
experiences. For example, one feels rested from
fatigue by a small dose of alcohol. The rested
feeling was supposed to be due to stimulation. On
the contrary, it is due to inhibition in the sensory
channels conveying the sense impressions that make
up the feeling of fatigue.
It has also long been supposed that small doses of
alcohol produced an increase in the power of muscular
work and an increase in efficiency in the performing
of simple mental tasks. This stimulation was sup-
posed to continue for twenty minutes to one-half hour.
The recent work of Rivers and Webber indicates that
such small doses produce no effect whatever. If they
are correct alcohol then remains a depressant and
paralyzant from the first without any effects of
stimulation whatever.
The types of persons who drink and the reasons for
drinking are many and varied. While there are
certain social factors involved, the more important of
the conditions lie in the make-up of the individual.
First, we have the cases in which the drinking is the
expression of a psychosis and in no wise its cause.
Here we find especially the early cases of paresis and
the mild cases of manic-depressive psychosis. The
alcoholic symptoms may completely cloud the picture
for some time.
Second, there is a considerable group, to which
belong those who drink "to drown their troubles,"
who attempt to escape from reality by introducing a
veil between it and them, by making themselves less
accessible to the world of reality by dulling their
sensorium. This class is composed of hysterics and
members of that large group of psychasthenics. It
should be remembered that the expressions of their
difficulties are often periodic and that it is generally
upon such a groundwork that dipsomania is founded.
193
Alcoholic and Drug
Intoxication
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Third, there is a considerable group who are
especially susceptible to alcohol and although not
consuming large quantities manifest an exaggerated
reaction to small doses. Here we have especially the
post-traumatic constitution — cases following head in-
jury and sunstroke — and arteriosclerotic and senile
cases. These are the unresistive types and alcohol,
like fever, proves to be a measure of their resistance
and stability.
Fourth, we have alcoholism entering into, compli-
cating, and modifying the picture of other psychoses,
particularly dementia pracox. Not infrequently
praecox cases are supposed to be alcoholic in their
early stages because of the prominence of the alcoholic
features.
Finally, there appears to be a certain number of
purely alcoholic psychoses — that is, psychoses de-
pendent upon alcohol per se. Of these psychoses
those clearly dependent upon the effects of alcohol are
the states of acute intoxication, including patholog-
ical drunkenness, while delirium tremens, alcoholic
hallucinosis, Korsakoff's psychosis, and the chronic
alcoholic psychoses are dependent upon long indul-
gence, and whether they are directly thefurt her ex-
pression of chronic alcoholism or are in some way
dependent upon the secondary elaboration of toxins
the result of disordered nutrition, they certainly
need something besides the simple ingestion of a toxic
dose of alcohol. Kraepelin proposes to call them,
after the manner of the psychoses due to syphilis, the
meta-alcoholic psychoses.
Drunkenness. — The phenomena of drunkenness
are, from the first, phenomena of paralysis. In the
early stages it is only the higher psychic functions,
which are largely inhibitive, that are affected, so we
get apparent stimulation in the excitement produced
with flight of ideas, pressure of activity, loss of the
sense of propriety, degradation of the moral tone, and
loss of power of voluntary attention. The lower
centers then become paralyzed and then appears
muscular incoordination, manifesting itself first in the
hands and facial muscles and the muscles controlling
articulation, the speech becomes thick and the gait
unsteady. Sensory disturbances appear, such as diplo-
pia, tinnitus aurium, and the senses of touch and
pain are blunted. If the paralyzing action of the
alcohol continues, coma results which may be fatal.
The mood during intoxication may be a pleasant one,
and frequently is one of boisterous exaltation, consti-
tuting the exalted type; on the other hand, a sad,
depressive, lacrymose mood may prevail, constituting
the depressed type.
Pathological Drunkenness. — Among certain predis-
posed individuals alcohol produces unusual and much
more severe symptoms. In this condition we may find
hallucinations and delusions dominating the field of
consciousness, the delusions being usually of a per-
secutory character. In other cases the excitement
may issue in a wild, maniacal frenzy or the depres-ion
may be so profound as to result in attempts at suicide,
In some persons the paralyzing effects of alcohol are
unusually pronounced and coma appears early on the
scene. Those who have latent hysterical tendencies
may have hysterical attacks during intoxication,
while alcohol frequently produces convulsions in
epileptics. Aside from this latter action, however,
the convulsive properties of alcohol alone are capable
of producing convulsions in persons who have long in-
dulged and are profoundly degenerated, though this is
disputed by others who claim that such individuals
must have been of epileptogenic make-up.
In these cases of pathological drunkenness in which
the reaction to alcohol is so pronounced, it is quite
common to find amnesia for periods of profound
intoxication.
Delirium Tremens. — This disorder usually occurs
as the result of a prolonged drunken debauch in a
chronic alcoholic, during which the patient has had
insufficient food and rest. According to some authors
it may result directly from the withdrawal of alcohol'.
It may, however, appear in the moderate but continu-
ous drinker as the result of a single excess, following a
traumatism, or as the initial symptom of an acute
illness.
The whole question of the occurrence of an absti-
nence delirium is a mooted one. The recent researches
of Holitscher on this point are illuminating. The
conclusion appears to indicate that abstinence
delirium if it occurs at all is extremely rare. Care
must be taken in reaching a conclusion to eliminate
as possible causes, wounds, infectious diseases, psychic
shocks, operations, etc. We must remember also
that in many cases the delirium has had a prodromal
period of a number of days, and that one of the symp-
toms of this period is a disgust for liquor. The
delirium, therefore, occurs in spite of, not because of
abstinence. The disease may appear suddenly, but
there is generally a prodromal period during which
the patient is nervous, with coated tongue, suffering
from anorexia, restlessness, tremulousness, disturbed
sleep and insomnia. This condition rapidly advances
with the onset of the attack, the characteristic
symptoms of which are rapidly developed. They are
tremor, delirium, and albuminuria.
The tremor involves more particularly the small
muscles of the hand, face, and tongue, but may also
affect the entire musculature. It is increased by
muscular tension, such as forcibly spreading the
fingers apart.
The delirium is an acute hallucinatory confusion.
Disorientation is often quite complete, the patient,
although perhaps fastened in bed, believing himself in
his office or home, surrounded by familiar faces. The
predominating hallucinations are visual and charac-
teristically take on the form of animals. The patient
sees all sorts of horrible creatures, snakes, rats, mice,
alligators, etc., which are uniformly in motion.
Surrounded by the loathsome creatures and by hor-
ribly grimacing faces, terrified by screams and shrieks
(auditory hallucinations), he presents a picture of
abject terror. In addition to these symptoms, the
patient may complain that insects or worms are crawl-
ing under his skin (paresthesia) and mistake spots
upon the bed or walls for bugs, mice, etc. (illusions).
At the height of his excitement the patient is in con-
stant motion, picking insects from his night-die--,
repelling the approach of terrible animals; in the
extreme frenzy of his fright, he may make murderous
assaults on those about him, believing them to be his
enemies, or perhaps attempt his own life to escape
from his horrible surroundings. During all this time
the patient is constantly talking, shrieking in fear at I
times, at others carrying on an incoherent discourse
with imaginary persons, fragments of which often
relate to his former occupation and friends.
The character of the delirious experiences varies
greatly. One patient left the house in his m
clothes and went a distance of several miles attired
thus to the house of his sister. On reaching there lie
told them that his father and some Chinamen \
going to kill him. Another patient came to the
hospital with the history that he suddenly became
disturbed one night and told his wife that he saw a
troop of darkies dancing in his bedroom; they appeared
to be rehearsing a play; he saw a strange man of giant
stature jump off his bookcase into his wife's bed. He
tried to chase these strangers from the room, and as
they vanished he could see the skirts of the women
and the heels of the men flitting past the doors; they
would invariably return; their faces mocked him.
Some patients do not present this picture of ex-
treme restlessness and the pressure of activity is not
communicated to such a degree to the function of
speech. Such patients may present an alert appear-
ance, be fairly calm, and can often be taken in the
lecture room before the class.
194
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Alcoholic and l>niu
Intoxication
The mood, ton. may be quite different ; instead of be-
ing in a condition of constant apprehension and tear of
an overwhelming and terrifying environment, they
may be calm, interested, and amused by their delirious
experiences. The patient quoted above on his second
day i" the hospital was highly entertained by the
iearance in the ward of a man with a monkey's
\ walking aliing the floor in a barrel, the bottom
hich had been knocked out. Then there was the
"human ironing board." This was a man's head
I to an ironing board on wheels; the man spit
icco juice a fiout the floor and water squirted from
eyes. The patient was much amused by these
riences ami told the doctor how he loved to lie
ed anil watch it come and go. He thought these
two monstrosities the property of the government
that they were intended for the amusement of the
nts.
Another patient saw flocks of partridges about his
D ami a turkey an inch high on his window sill.
spiders and thousand-legged bugs came crawling on
bed. These hallucinations produced no surprise
lisgust. He merely cited them as of passing
■rest while talking. His aunt's face was lying
• to him on the bed, and he tried to kiss it. An-
er patient in the hospital saw about him numerous
of Lilliputian dimensions anil displayed the
liveliest interest in these strange little people.
Often dreamy hallucinations and delusions relate
igether to his occupation and the patient busies
himself with his usual pursuits — occupation delirium.
Physically he is in a condition of acute exhaustion.
The pulse is rapid and of low tension, the temperature
normal or only slightly elevated (occasionally high,
the febrile delirium tremens of Magnan), the body
id in a profuse perspiration and constantly
agitated by muscular shocks and tremors. Occa-
ally one sees cases ushered in by all the typical
prodromal symptoms, sweating, atonic dyspepsia,
restlessness, tremor, precordial distress, anxiety, and
disturbed sleep, which do not proceed to the typical
lition of mental confusion with multiform halluci-
nations. This is the so-called abortive type, the
: in sine delirio of Dollken.
During the course of the disease almost any cxperi-
ee the patient may have, any impression made upon
his sensorium is woven into the warp and woof of his
d ilirious experiences — sensory flight of ideas. Hallu-
cinations seem to arise spontaneously or are easily
produced by pressure on the eyeball or merely by
L r ning the patient to look at a blank piece of paper.
Paraphasia and paralexia are commonly present.
Albuminuria is found in a considerable proportion
uf cases, probably considerably over fifty per cent.,
.luring the early stages. At the height of the delir-
ium leucocytosis has been found. It must not be for-
gotten, too, that here, as in acute toxic states gener-
ally, a sluggish reaction of the pupil to light and even
complete Argyll-Robertson pupil may be found.
This sign disappears, however, on recovery. This is
an important fact to be borne in mind in the matter
of diagnosis.
Acute cardiac dilatation may develop at the height
of the disease.
Course and Duration. — The psychosis runs an
acute course of about three days and terminates in
recovery in the majority of cases.* The delirium
usually ends in a long sleep. About ten to fifteen
per cent. die.
Potliology. — Degenerative conditions are found in
the central nervous system — acute degenerations of
the ganglion cells, and recent hemorrhages. The
ganglion cells are found shrunken and there is increase
in the glia and some vascular proliferation with slight
round-celled infiltration. There may be a chronic
leptomeningitis and some narrowing of the cell layers
of the convolutions. Changes are also found in the
cerebellum. The alterations in the Purkinje cells
are supposed to be correllated with the motor symp-
tom — tremor and ataxia (Kraepelin, Allers).
Wassermeyer is of the opinion that the pathology
indicates that the delirium results from an increase in
the chronic alcohol poisoning rather than a metabo-
lism poison.
Chronic Alcoholism. — The effects of chronic
alcohol poisoning arc exhibited in every organ of the
body) mure particularly the central nervous organs,
stomach, pancreas, liver, kidneys, and blond-vessels,
and give rise to characteristic symptoms as a result,
the most prominent of which are tremor, gastric
catarrh, arteriosclerosis, albuminuria, and progres-
sive mental cnfeebleinent.
The effects on the nervous system are shown in
disturbances of sensation, motion, and the intellect.
The sensory disturbances arc paresthesia (prickling,
tingling, formication), hyperesthesia, and hyperal-
gesia. The sensory disorders of the special senses
involve principally the eye and ear, producing illu-
sions and hallucinations, muscie volitantes, photopsia,
amblyopia and amaurosis, diminution of the acute-
ness of hearing with the production of subjective
noises (hissing, ringing, roaring, etc.), due to
middle or internal ear disease.
The motor disturbances are tremor, spasms and
cramps, epileptiform attacks, and general motor en-
feeblement.
The mental changes are gradual and progressive,
the intellect is obtunded, the judgment overthrown, the
moral sense blunted, and mendacity appears in its
most bizarre forms; delusions may develop, the most
characteristic of which is of marital infidelity and jeal-
ousy, and the patient sinks gradually into a condition
of permanent mental enfeeblement.
Diagnosis. — Alcoholic dementia is to be differen-
tiated from other dementias largely by the history.
Alcoholic dementia will have a history of progressive
mental enfeeblement closely associated with alcoholic
indulgence.
Graeter has recently called particular attention to
the association of alcoholism and dementia precox.
Many of the cases of mental deterioration associated
with over-indulgence in alcohol will be found to be
true cases of precox in which the alcohol is only an
incidental and associated feature.
Alcoholic Psbudoparesis. — On a groundwork of
mental enfeeblement the alcoholic may develop a true
expansive delirium which, combined with the signs
of alcoholism (ataxia, speech defects, tremor, pupil-
lary anomalies, and muscular weakness), may make
the distinction from paresis difficult — alcoholic pseu-
doparesis. This similarity to paresis is noticeable
even when the expansive delirium is absent in cases
in which the mental reduction is marked, but be-
comes greatest when the symptom complex above
outlined is ushered in by epileptiform attacks.
Diagnosis. — The distinction from true paresis can
usually be made. Pupillary inequality is more com-
mon and the permanent results of apoplectic insults
(hemiplegia, aphasia) are more often found in the alco-
holic form than in the true. The results of polyneu-
ritis should be looked for and if found suggest alcohol-
ism. The most reliable differential sign is found in
the course of the two maladies. True paresis is pro-
gressive, tending toward ever-increasing degradation,
while in the alcoholic form removal of the poison re-
sults very shortly in a remission of all the symptoms,
even, in some cases, amounting to a recovery. The
symptoms, however, reappear subsequently if drink-
ing habits are returned to.
It must not be forgotten that an Argyll-Robertson
pupil may be transiently present. It is an open
question whether both this sign and the whole pseudo-
paresis picture may not be dependent upon the pres-
ence of syphilis.
Alcoholic Epilepsy. — As a result of chronic alco-
holic toxemia, the symptoms of which are marked
195
Alcoholic and Drug
Intoxication
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
throughout by their explosive character, it is not
strange that actual convulsions, alcoholic epilepsy,
should complicate the morbid picture. These con-
vulsions, so far as their individual characteristics are
concerned, are indistinguishable from true epilepsy.
Occurring, however, in a person beyond the period of
adolescence who is addicted to the immoderate use
of alcohol, their origin should be suspected. The
diagnosis is made clear if they cease upon the with-
drawal of alcohol. As this sometimes does not occur
the diagnosis can be made only by excluding the
causes both of true and of symptomatic epilepsy other
than from alcohol.
Alcoholic Hallucinosis. — This psychosis may
come on suddenly in a chronic alcoholic, as the result
of an unusual excess, or it may be of gradual evolution.
It is sometimes preceded by one or more attacks of de-
lirium tremens. It is characterized by hallucina-
tions, auditory predominating, thus contrasting
strongly with the predominance of the visual hallu-
cinations in delirium tremens.
The delusions are of a persecutory nature, in which
the sexual element is frequently prominent, and show
a tendency to systematization. The system, how-
ever, is of rapid growth and loosely organized.
Whether of sudden or gradual onset, the first symp-
toms are hallucinations, with which persecutory
delusions are intimately bound up. The patient
hears voices making all sorts of inimical remarks, tell-
ing him that his children are not his own, calling him
an onanist, reviling or threatening him. In every
way his persecutors annoy him by their malign com-
ments. Visual hallucinations are rare. Hallucina-
tions of smell and taste are not infrequent. The au-
ditory hallucinations, quite characteristically, tend to
fall into rhythm with outside sounds, as, for example,
in one of my cases, the humming of a dynamo.
The delusions of this state harmonize well with the
hallucinations. The patient is persecuted by invisible
enemies who inject noxious vapors in his room at
night, poison his food, draw off his semen, and pro-
duce nocturnal pollutions.
One patient heard voices of enemies whispering
at the windows; they were going to kill him, called
him a variety of unpleasant names and accused him
of all sorts of crimes. The patient attempted suicide.
He gave a history of being troubled with noises in his
cars for a considerable time, resembling the click of a
telegraph machine. When he was drinking these noises
became voices. Another patient thought he heard
different people talking about him, cursing him, and
calling him vile names. Then later he thought he
heard his thoughts repeated. While on a drinking
bout he wandered about aimlessly, felt that he was
being pursued, and heard threats made against him.
He bought a knife and walked into the water. In the
hospital he heard his old friends accusing him of
sexual perversions, pederasty, etc. He told of having
heard his associates say, " He is no good; we will get
him out of the army," and " He is a sucker for fixing
a horse instead of allowing the veterinary to do it,"
etc. Another patient, a sailor, had been drinking
heavily while on shore. When three days out at sea
he began to hear threats against him. He heard the
men say that they would kill him, they would cut
his heart out, and cut him into 50,000 pieces. On
the evening of the third day he could stand it no
longer and thinking that he saw land ahead he jumped
overboard.
Grandiose delusions do, however, occasionally occur
though they are not sufficiently controlling to modify
the picture in any essential way. A case cited by
Mitchell shows how they usually manifest themselves.
In this ease, in the midst of an active hallucinosis,
during which the patient was constantly hearing
voices coming from the air and out of the floor, and
the passing trains were whist ling his name, and while he
saw faces staring at him from the walls, he had an
episode during which he assumed chaTge of affairs
gave orders, and threatened with death the doctors
who refused to obey. Bonhoeffer reports only one
case with grandiose ideas, which, however, were only
of temporary duration, during the course of an hallu-
cinosis with auditory hallucinations of a distinctly
threatening character, and one case in which the
patient heard music, but otherwise had disagreeable
hallucinations.
In this state the patient is depressed, apprehensive,
often fearful of impending danger, may have anxious
and angry states, and often reacts by attacking his
supposed persecutors. Throughout this condition the
patient is well oriented and consciousness is clear.
Some of these cases run a long course and become
chronic.
Diagnosis. — The diagnosis from delirium tremens
is made by the absence of disorientation and by the
marked prevalence of auditory hallucinations in the
form of threatening voices. It must not be forgotten
that there exist cases that are intermediate in their
symptomatology between delirium tremens and acute
hallucinosis. From paranoia the distinction is made
by the very rapid systematization of the delusional
system, as opposed to the slow evolution in that
disease.
Alcoholic Psetjdoparanoia. — In some cases of
chronic alcoholism a paranoid state is developed, in
which psychosensory disturbances (hallucinations)
may be of secondary importance or not present at
all. The characteristic delusion in these cases is that
of marital infidelity.
While some of these cases develop primarily upon
a background of chronic alcoholism, others may fol-
low directly upon an attack of hallucinosis or de-
lirium tremens.
These cases have a long course, a poor prognosis,
and may terminate in considerable impairment.
Diagnosis. — This delusion of marital infidelity and
jealousy may not be accompanied by any noticeable
degree of impairment of judgment or mental cti-
feeblement, and in these cases it may be extremely
difficult to make a differential diagnosis between this
form of alcoholic psychosis and true paranoia.
Particularly is it difficult to recognize paranoia with
subsequent or coincident alcoholic indulgence.
Certain other paranoid conditions, especially of
the involution period, may present this picture with
the characteristic delusions of jealousy.
Differentiation is made by excluding alcohol in the
anamnesis.
Korsakoff's Psychosis. — The mental state of this
psychosis accompanies polyneuritis and is usually of
alcoholic origin, but may be caused by other poi
as those of typhus, tuberculosis, influenza, diabetes,
the metallic poisons, etc., and the Korsakoff syn-
drome is seen not infrequently in general paresis and
in senility. The signs of polyneuritis may be very
slight.
Symptoms. — The patient is usually a chro
alcoholic and may enter the hospital suffering from
delirium tremens. The delirium instead of clearing
completely, as is usual, merges into Korsakoff's
psychosis, which has often been called chronic alcoholic
delirium in contradistinction from delirium tremens,
which is an acute alcoholic delirium.
The mental symptoms are the result of a charac-
teristic combination of disorders of attention and
memory, together with a serious defect in the sense of
time. The result is a peculiar type of amnesia
There is a defect in the recording of present evi
resulting in an anterograde amnesia. In more severe
cases this amnesia may reach back a considerable
distance — retrograde amnesia — but the events of
early life and long distant occurrences are well
remembered.
This defect of memory is associated with a com-
posed bearing and apparent lucidity on casual
196
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Alcoholic and Drug
Intoxication
questioning. A more careful examination, however,
will show not only this memory defect, but probably
also that the patient is disoriented as to time and
place.
The characteristic symptom is associated with the
, i ;l and consists of a peculiar falsification of
nory. The gaps in memory are filled by all sorts
of fabrications which are narrated in great detail and
with a perfeel appearance of lucidity — opportune
ibulation.
A patient who had been confined to his bed for days
ith font- and wrist-drop told inc. when asked where
he was the day before, about having gone to the races
and detailed his conversation with different person-,
described the events, told what horses won, and the
like.
One such patient says to the physician on approach-
ing the bed: "I am pretty sleepy. I have just had a
over home and I came over here to lie down
in." Asked if his wife had been to see him lately
had 'idled the day before), said that he saw her
two days ago and added: " I was just out there at the
front window a few moments ago to see if she was
ing." Being questioned as to what he had for
dinner yesterday (he was on a milk diet), said he had
ie delicious New York plums, the usual vege-
and cocoa."
Often delirious experiences seem to be related to
the neuritic pain. This same patient told once how a
big, black, burly, ugly negro grabbed his sore legs
lays before and how it made him angry.
Another patient tells how two years ago he was
chloroformed by unknown parties. He awoke just
hey had escaped from the room and saw a machine
.in his right foot. (He suffers from pain and weak-
ness in this foot and ankle.) This was crushing the
tendons of the instep. He immediately dropped off
leep again. When he awoke the next morning
the instrument of torture had been removed, but he
suffered from pain and weakness in that right foot
and also to some extent in the left foot.
In many cases the fabrications can be suggested by
leading questions and the patient may be led to make
almost any statements, no matter how contradictory
gestion confabulation.
One patient, confined to bed, -when asked what he did
the day before, replied: "I took the horse and buggy
out and took a drive, my father being in Baltimore;
I don't know whereabouts I had him fed; I went
down Pennsylvania Ave. and Fourteenth Street."
Another patient, when asked what she had for
breakfast, proceeded to give a bill of fare, none of the
articles of which she really had had.
These pseudo-remin iscences are usually unstable and
fleeting, or at least seldom told twice alike. Such for
instance is the following: " A few weeks ago I was out
walking on the Washington Heights, you know, just
beyond the Treasury, with a friend. It was during
lunch hour at the office. We saw some cattle grazing
on the hillside and we thought we would have a little
shooting match. I went down to the man and he
gave me a gun and I fired away and hit a steer right
behind the ear. It, of course, killed him. They all
laughed and considered me a crack shot. They sent
me a check for it the next day. It was for a pretty
large amount, but I do not remember just how much.
I suppose by looking up the records I could find just
uuch they did give me."
Sometimes, however, some of them become fixed.
It is fairly common, for example, for women to
ive and act as though they had a baby in bed
with them.
With this state of mind the patient is usually very
poorly oriented if not completely disoriented. His
time sense i< particularly affected.
Physically the patient typically has all the signs of
a polyneuritis, which of course differs in its distribution
according to the etiological factor. In the alcoholic
type, which is the mo t common, wrist-drop and
foot-drop are characteristic symptoms. Of com e
various unusual and anomalous involvements may
occur, for example, of the cranial nerves. Bulbar
and vagUS involvement are naturally most serious.
Inasmuch as the pathology of the disease shows that
it is not confined to the peripheral nerves but is
general, involving the whole of the nervous system,
cord, basal ganglia, and cortex, and inasmuch also as
there seems to be some tendency to the localization
of the pathological process, we might expect to find,
and as a matter of fact do find in certain cases, focal
symptoms. These an- the various types of aphasia,
apraxia, reading and writing disturbances, homonym-
ous hemianopsia, etc.
Pupillary disturbances are not infrequent. In-
equality of the pupils, sluggishness to lighl and
accommodation reflexes, and transitory Argyll-
Robertson pupil may be present. .More rarely
various kinds of ocular palsies or muscular weaknesses
occur.
Clinical Forms. — Various clinical types of the
disease have been described according to the promi-
nence of special symptoms. Thus Dupre describes
five as follows: (1) amnesic, (2) confusional, (3)
delusional, (4) anxious, and (5) demented. Knapp
describes eleven forms: (1) delirious, (2) stuporous,
(3) demented, (4) hallucinatory without systematiza-
tion of false ideas, (5) hallucinatory with systematiza-
tion of false ideas, (6) paranoic!, (7) anxious, (8)
expansive, (9) manic and melancholic, (10) poly-
neuritic motility psychosis (of Wernicke), and (11)
anomalous. Of course it will be understood that this
separation of forms of the disease is nothing more than
giving the name of the most prominent symptom.
Thus in the stuporous type stupor is especially in
evidence, etc.
Diagnosis. — The association of the peculiar falsi-
fication of memory, with confabulation and usually
disorientation, with foot- and wrist-drop is charac-
teristic. Paresis is to be distinguished by the absence
of evidences of polyneuritis.
Dream States. — Less common and more unusual
effects of alcohol are the conditions of so-called trance,
automatism, double consciousness, spontaneous som-
nambulism, which are followed by amnesia. In these
conditions the subject of alcoholism may do almost
anything imaginable, make contracts, transfer prop-
erty, commit criminal acts, take long journeys, enter
into complicated business or professional transac-
tions, and later have absolutely no knowledge of what
he has done. During a protracted debauch the sub-
ject may suddenly start off on a journey and travel
under an assumed name, meanwhile conducting him-
self in such a manner as not to lead to any comment
on the part of those whom he meets. Suddenly,
without warning or after a night's sleep, he "wakes
up'' to a realization of his true situation with abso-
lutely no memory of how he got where he is or what
he has been doing since he started away from home.
As the name indicates, this condition has been de-
scribed as one of automatism, but a moment's con-
sideration will serve to show that acts of such a com-
plex character cannot be automatic acts. The fact
that no recollection remains of what was done has
been used to argue unconsciousness, but that is
equally inconceivable. Hundreds of miles could not
be travelled by an unconscious man without attract-
ing attention. The mere fact that the patient has
forgotten what occurred is no reason why he must
necessarily have been unconscious. I have been
fully able to demonstrate that consciousness actually
did exist in certain cases that I have studied which
were followed by amnesia, and as a result I am con-
vinced that the same condition might be found to
exist in others. Some persons are especially liable
to this form of mental disturbance, and it may re-
peat itself on the occasion of renewed intoxication.
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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Its psychopathological basis is probably a dissocia-
tion of consciousness.
Course. — Chronic alcoholism, whether interrupted
or not by any of the forms of mental disturbance de-
scribed in this chapter, tends to an ever-increasing
dementia, alcoholic dementia. Mental enfeeblement
is a symptom from the outset and is noticeable at
first in the esthetic and moral sphere. The previously
proud, well-dressed man becomes slovenly in his
habits and unkempt in his appearance. Incapable
of the close and continuous mental application of
former years it becomes impossible for him to meet
the requirements of his business or professional life
and lying is resorted to in finding excuses. This is
followed by moral obliquities of a more serious nature
in which the sexual element is apt to predominate
and result in medicolegal complications. Memory
is early and noticeably affected. The every-day
affairs of life are forgotten, so that the subject of alco-
holism neglects to keep appointments, forgets impor-
tant business engagements, etc. Judgment and the
reasoning faculties are similarly enfeebled, until finally
the most profound degree of dementia is reached,
hastened perhaps by apoplectic insults which are not
uncommon.
Pathology. — The gross pathology of alcoholism has
already been indicated. Cirrhotic liver, chronic ne-
phritis, fatty heart, chronic gastritis, arteriocapil-
lary fibrosis, cerebral arteriosclerosis, and cerebral
hemorrhage.
The principal lesions found in the brain are pachy-
meningitis, edema, congestion, thickening and opacity
of the piarachnoid, atrophy of the convolutions,
sclerosis of the vessels, degeneration of the cells, and
increase of neuroglia.
Treatment. — The treatment of delirium tremens
and the other acute alcoholic psychoses should be sup-
porting; liquid concentrated food, predigested if
necessary. The bowels should be kept free and the
kidneys kept flushed by a goodly supply of fluid.
Heart stimulants are often necessary, digitalis,
caffeine, strychnine, to combat cardiac failure, and
hypnotics to induce sleep and give rest. The latter
should be carefully selected with reference to the pa-
tient's condition, depressing agents, such as chlo-
ral, giving place to safer ones as trional if there is
much heart embarrassment. The after-treatment con-
sists of abstinence from alcohol, tonics, nourishing
food, and regulation of the emunctories.
For the excitement especially hydrotherapy in the
form of the continuous bath is valuable. The thing
to be kept constantly in mind in these eases is the
matter of nourishment. If the patient does not take
sufficient food, tube feeding should be begun at once
without any delay in temporizing. Food alone will
often ameliorate in a remarkable manner the excite-
ment and the insomnia.
The medicinal treatment of chronic alcoholism
should be tonic and supporting. Strychnine for a
general nervous and cardiac stimulant, ergot if there
be symptoms of "wet brain," capsicum and bitter
tonics for the gastric condition and anorexia; atten-
tion to the emunctories, moderate exercise, baths,
massage and electricity for their general tonic effects;
sedatives and hypnotics with caution; a modified
"rest treatment" if there is marked neurasthenia,
and later a sufficient amount of mental and bodily
exercise to keep the patient healthfully occupied.
The matter of isolation is an important one. I
feel convinced that in all cases in which the habit is
firmly fixed isolation is highly desirable, if not im-
perative, as in these cases the patient is unable to
resist temptation and, as soon as opportunity presents
itself, will lapse. After confinement for a few months,
during which the patient is restored as far as possible
to physical health, he is in condition to abstain if he
wants to and is able; if he does not wish to or if he
suffers from too great weakness of will, he will return
to his old practices and his case is hopeless. If he
does wish to stop drinking, however, he has been given
the best possible opportunity, an opportunity which
should be early extended in all cases and not offered
when by long-continued indulgence the case is of
necessity hopeless.
Opiumism. — Causes. — As in other varieties of nar-
comania the most important cause is the neuropathic
diathesis. In this class of patients the habit is often
initiated by the use of morphine to relieve the periodic
pains of neuralgia, tabes, dysmenorrhea, rheumatism
etc., or the mental depression incident to worry, loss
of position, grief, and the like. A great many ca
are unfortunately traced to the carelessness of p)
cians in prescribing the drug, and as if in retribution
medical men furnish the largest quota of sufferers (fif-
teen per cent.).
Symptoms and Diagnosis. — The symptoms of a sin-
gle dose are at first those of mild stimulation of the
mental faculties, followed by a period of quiet, half-
waking, half-sleeping, interrupted by multiform pleas-
ant hallucinations (predominantly visual) which show
no tendency to delusive elaboration in the waking
slate. This condition is followed by malaise, head-
ache, dry mouth, constipation, and nausea.
The physical symptoms of prolonged use of opium
in any of its forms are anorexia, irregular action of
bowels, constipation alternating with diarrhea, car-
diac weakness, general muscular weakness and tremor,
miosis and sluggish pupils, impotence, amenori
diminished sensibility, paresthesias, sensation of
coldness.
Mentally there is a gradual degradation. The
memory and power of attention become impaired
and the capacity for initiation is lost. Then
marked impairment in the ethical feelings and pre-
viously honest persons will begin by lying out "f
business engagements and about the taking of the
drug and end by associating with the most degraded
persons and resorting to any means whatever, even
criminal, to obtain the drug.
Some persons who have taken opium in some form
for a considerable time and in large doses develop an
hallucinated state that may be of paranoid coloring or
may be distinctly delirioid. Thus one patient (laud-
anum and whiskey) on admission to the hospital said
that her food was poisoned. Another patient (mor-
phine) is restless and excited, has hallucinations of
hearing, and carries on conversation with imaginary
persons. Sometimes her language is violent and
abusive, she threatens her imaginary persecu
and will jump out of bed and run through the
hall-way looking for the people she thinks are
after her.
The diagnosis can often not be made without the
anamnestic data. The patients frequently deny their
habit — mendacity is a prominent symptom, and they
are often cute enough to find means of indulgence
even though carefully watched. The moral deg-
radation is pronounced and they will go any length
to obtain their drug. Symptoms which should ex-
cite suspicion are periods of torpor and languor in
marked contrast to the activity of alcoholism, amount-
ing at times to an inability even to sit up, occasio
signs of stimulation, small pin-point pupils, yellowish-
brown cachectic complexion, and, above all, the numer-
ous scars of hypodermic injections. In conditions in
which a diagnosis is necessary it is to be remembered
that morphine can be recovered from the urine and
stomach.
The least serious method of taking the drug is by
smoking, the next more serious by mouth, and the
most serious method is the hypodermic. Morphine
is distinctly more dangerous, more dominating after
habituation, than the other forms. It is, too, more
serious in its effects upon the general health.
Prognosis. — The prognosis is not good and except
in such cases as are not complicated by neurotic or
I '.IS
REFEREXCK HANDBOOK < >F THE MEDICAL SCIEN( I 3
Alcoholic anil Drue
Intox Icatlon
psychopathic taint or disorders relieved by opium,
recovery is hardly to be expected.
>logy. Opium has less tendency to produce
[issue degeneration than alcohol and many persons
continue for years to take small doses With no ap-
parent harm.
Trent i',: "i. The treatment of morphinism has to do
with the removal of the drug and the symptoms of
abstinence. Isolation is more necessary than in
alcoholism, as these patients make more effort to
tin their accustomed stimulant surreptitiously. It
II, in accordance with Dercum's suggestion, not to
n stopping the drug until thepatienthasbeenunder
itment fur a time, confidence being established, and
t he general health raised to the best standard. The
luxe can then be rapidly withdrawn, in ac-
vrith the method of Erlenmeyer, leaving
patient on about 0.15 to 0.20 gram morphine per
i, below which amount serious symptoms are apt
present themselves. From this point on tfie
withdrawal should be gradual. Symptoms of ab-
if they appear, are referable to the heart,
aach, bowels, and nervous system: the}' are circu-
latory failure, respiratory disturbance, pyrosis,
vomiting, diarrhea, tremor, general debility, and
hallucinatory delirium and sometimes profound
ipse. Ball has called attention to pollutions and
erotomania which may result from abstinence. For
the cardiac weakness digitalis or sparteine hypoder-
illy should be used; for the pyrosis, bicarbonate of
nin; vomiting and diarrhea should be treated in
ce with general principles (bismuth, etc
opium being avoided. If the mental and physical
symptoms become grave morphine should be given
and will usually relieve them. The evening dose
should be omitted last, to combat any tendency to in-
somnia, and full feeding, massage, and hydrotherapj'
aluable adjuncts.
Meconarceine (Duquesnel's solution) has been used
Jennings a- a substitute for morphine for a few days
after entire discontinuance. It is necessary to
■ ■all attention to the danger of cocaine for this purp< ise.
ine has also sunk into disuse and the synthetized
derivatives of morphine, heroin, dionin, and peronin,
aot be said to be any better. Their use is founded
on a wrong theory and is fraught witli danger. Cases
i ious addiction to codeine and heroin have been
reported.
unism. — Causes. — Addiction to this drug has in
a great many cases come about by attempting to
substitute it for morphine, and as a result pure cases
of cocainism were formerly more rare than at present,
line has been used so much of late in dentistry,
minor surgery, and especially nose and throat work,
that a knowledge of it has become more or less general.
The victims are often those who have commenced
its use for its analgesic effects and are frequently
< ians.
ptoms. — The symptoms resulting from the use
of cocaine are those of marked stimulation. The pulse
is increased, pupils are dilated. The patients are
active and extremely talkative, often repeating re-
marks a number of times; they are constantly busy.
~ome of them writing endless letters, and their whole
tearance indicates an acute intoxication. The ef-
- are, however, very fleeting and the dose has to be
frequently renewed. Chronic addictions result in
marked emaciation, cachectic anemia, insomnia,
times epileptiform attacks and various paresthe-
tic most marked of which is a sensation of crawl-
inder the skin ("cocaine bug")- In the psychic
re occur incapacity for mental application,
aed moral sense, mendacity, irritability, im-
paired judgment, and sometimes the delusion of
marital infidelity. These symptoms may be followed
by mental confusion with hallucinations, or by a
paranoid state. From true paranoia this is differen-
■'1 by the greater variety of delusions, those of
paranoia being less Variable, rather noticeable for
their QOtony. In the paranoid -tale of alcohol-
ism, on tin- o'tner hand, the hallucinations are more
stereotyped.
The absl inence symptoms are ncit so severe as with
morphine and may not appear for several days.
Erlenmeyer has called attention to a profoundly
depressed, lacrymose, demoralized condition, with
moaning and sighing, which may supervene. The
persecutory delirium may persist for a long time and
constitute the patient a dangerous individual.
Morphine and cocaine addictions may also bring
out a neuropsychopathic state, with symptoms of
psychasthenia — morbid impulses, insistent ideas, etc.
line such r:i-i sutleied fn.ni a convulsive tic with
mental depression and suicidal impulse. Recovery
followed prolonged abstinence.
Treatment. — Isolation should be insisted upon.
The drug may be withdrawn rapidly a- the symptoms
of abstinence are not as marked as in morphine. The
prognosis of deprivation is good, but relapses are
pretty a] it to occur.
Miscellaneous Intoxicants. — V a r i o us other
drugs may produce marked mental disturbances as a
result of acute or chronic poisoning or habituation.
Ihe limits of this article permit only of their mention.
They are chloral, cannabis indica, somnal, sulfonal,
paraldehyde, ether, chloroform, aspirin, antipyrine,
phenacetin, trional, chloralamid, iodoform, belladonna,
hyoscyamus, salicylic acid, quinine, the preparations
of lead, arsenic, and mercury, and the bromides.
It should be realized that many of these drugs are
drugs in common use and that unless the possibilities
of their producing a psychosis are borne in mind such
an accident may arise as the result of large doses or
even of moderate doses in especially susceptible
persons. It is just such cases as these together with the
■ ases that arise as the result of taking several drugs,
analgesics and hypnotics, that one meets and finds
that no suspicion has arisen as to the true cause of the
trouble. Attention has recently been called to the
frequency of bromide delirium (O'Malley and Franz,
I asamajor). Casamajor has called particular at-
tention to the frequency with which bromide de-
lirium is produced in the treatment of alcoholism.
The character of the delirium in these cases may 1 it-
described as dream-like. The content of the delirious
experiences reminds one of delirium tremens, while the
tendency to confabulation reminds one of Korsakoff's
ps3'chosis. The patients are not usually apprehen-
sive and restless as in delirium tremens, but more
composed and may be dull and stupid, though there
are not infrequently outbreaks of violence dependent
upon paranoid experiences. The following extracts
from cases will illustrate these points:
The patient, a woman, fft. thirty-six, had been tak-
ing morphine hypodcrmically and bromides, chloral,
anil hyoscine hydrobromate. On admission she sees
men in rubber garb who stay in the water and look
at her constantly. She also sees the king and queen,
bugs and snakes, and bull-dogs with huge open
mouths. Says the king and queen congratulated
her when she picked up the broken glass at F — 's
on Ninth Street. She hears bull-dogs scream and
answers imaginary voices. Electricity is played on
her by Dr. B — and she feels snakes which crawl about
her neck. Says there are men who throw green pow-
der about the room.
Another patient, woman, a?t. thirty-eight, had been
taking antirheumatic treatment with aspirin to
relieve pain and later morphine and hyoscin. She
related the following delirious experience that oc-
curred just before admission:
" I believed that a party of us were going down in
the country on a picnic and that a cavalry regiment
had been ordered out. When we got started, we
found that a whole regiment of Indians and negroes
were following us. We went to the place in the coun-
109
Alcoholic and Drug
Intoxication
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
try where I was born and brought up, and there we
found a hospital which was to be used for earing for
us until the negroes and Indians were allowed to kill
us. The patients in the hospital were all in little
beds just like at Providence, but were all sitting up.
The doors were looked so that we could not get out,
but I could hear the negroes and Indians talking
about killing us. They decided to divide the party
up and take us to their different camps. They also
talked of blowing the hospital up with dynamite.
They talked of setting fire to a haystack that was
situated near my mother's home. I heard them pre-
paring fuse which was to be used in exploding the
dynamite. I was dreadfully afraid all the time I
was at Providence Hospital and felt that I was among
enemies. I thought the nurses were trying to do the
best they could for me, but that they were in the
employ of the Indians and negroes."
Another patient, female, let. thirty-seven, took
"bromo-quinine" for two weeks when she developed
a delirium. The following is the substance of a
letter she wrote while suffering from the delirioid
experiences. "Just go there, I cannot talk, I am
under a terrible spell, I do not know what it is, but it
is the most wonderful experience I ever had. I am
hypo, I am hypnotized. I ma}' be in a trance for
three months. Do not for God's sake, bury me alive
— Molly. Keep me out of the grave four or five
months. It will be all right. You will hear some
things that will surprise you. Ben, go in that room
for God's sake, there is a man in there, he scares
everybody dumb, I cannot talk, but for God's sake,
break down that door. Take Jack, he has got a good
strong arm, break that door down. That poor man
is suffering, I saw him do something terrible, and it
awed me so I am half paralyzed. For God's sake,
break that door down, hurry up."
In a case of bromide delirium (reported by O'Malley
and Franz) the patient had taken on an average
300 grains of bromide daily for fifteen days. Her
case illustrates well the dream-like character of the
hallucinatory and delusional experiences. She was
disoriented on admission. Three days later said she
had spent the night in the city, was with a large crowd
of men and women, that her husband was dead and
that she had seen his body buried. The next day,
asked where she had been the night before, said, "I
was over to the gipsy camp; I went over in northeast
Washington and saw them kill my husband — smash
his head; his brother, who is a sculptor, made a form
of his head; I saw it; he will be buried to-morrow."
A few minutes later her husband visited her. She
told him she thought he was dead, took him to task
severely for putting her in the hospital and being
unkind to her, but throughout the visit insisted that
he had been killed. Six days after admission she
still had visual hallucinations — saw cats and rabbits;
thought some of the women patients were men,
thought she had to walk on cats' heads when she
left her bed and that the physicians were watching
her from the register plate in her room. Later she
complained that she was "spirited away every night
by some influence."
In the treatment of these cases the principal thing is,
of course, the removal of the drug, though often the
underlying condition, for which the drug was taken —
pain, insomnia, must then be treated. It must lie
borne in mind that it may take several weeks for the
patient to clear up after all drugs are discontinued.
William A. White.
Aldehyde. — The aldehydes form a class of chem-
ical compounds. Of this class, acetic aldehyde is
the commonest example, and accordingly the" word
aldehyde, when used singly, is understood always
to mean that substance. ' Acetic aldehyde, CTL.-
COH, is, from the point of view of chemical com-
position, the first outcome of the oxidation of com-
mon — ethylic — alcohol. It resembles alcohol very
closely in physical and physiological properties,
being a thin, colorless fluid of pungent smell and
taste; inflammable, miscible in all proportions with
water, alcohol, and ether; antiseptic, irritant, and
narcotic. It is not used in medicine.
R. J. E. Scott.
Alder. — Abuts; Brook or Tag alder. Alnus Tournef.
is a genus of a dozen or more species in the family
Betulaccw, distributed through the north temperate
zone, and extending along the mountains into the
tropics. The bark and leaves are rich in tannin, and
therefore strong astringents, without special char-
acter. They are used in tanning, and have numerous
domestic medicinal uses, all depending upon the
action of the tannin. Finely powdered, they have
been found very useful by travellers for applying to
chafed surfaces. The wood, deprived of the bark,
makes a favorite charcoal for powder manufacture.
H. H. Rusby.
Alder, Black. — Prinos; Wititerberry. The bark of
Ilex verticillata Gray (fam. Aquifoliacece). (For the
properties of other species of this large and interesting
genus, the reader should consult Mate, Holly, and
Cassine.) The plant under consideration is a lars;r.
shrub, growing in hedges and borders of forests in the
Northeastern United States, and displaying in fall and
early winter slender branches densely covered with
shining, scarlet berries.
The bark is smooth, grayish or whitish ash-colored,
and when dried for medicinal use is in " thin, slender
fragments, about one millimeter (■,'- inch) thick,
fragile, the outer surface brownish ash-colored, with
whitish patches, and blackish dots and lines, the corky
layer easily separating from the green tissue; inner
surface pale greenish or yellowish; fracture short,
tangentially striate; nearly inodorous, bitter, slightly
astringent."
It contains tannin, resin, and an amaroid. No
special physiological properties are known, but it
has been used as a tonic and mild astringent. The
dose is two to four grams (5 ss. to i.).
H. H. Rusbt.
Alectrobius. — A genus of ticks which contains some
species that are parasitic on man. See Arachnida.
Aleppo Evil. — See Oriental Sore.
Aletris. — I'nieorn root; Star grass; Mealy starwort;
Colic root. Sometimes erroneously called Blazing-
star. The rhizome of Aletris farinosa L. (fain.
Liliaceai). This plant is a low, slender, erect, per-
ennial herb, common in swamps and low land- cast of
the Mississippi River. It has been much used in
domestic practice as an abdominal stimulant. It
contains an unknown bitter principle, soluble in
alcohol and somewhat in water. The use of !li»
drug is purely empirical — in colic and rheumatism.
The fluid extract is the best form of administration,
and is given in doses of 0.5 to 1 c.c. (ni viij.-xv.).
Seven other species of Aletris are known, one in tin'
Southern States and six in Fastern Asia, but their
properties have not been investigated.
H. H. Rt/sby.
Aleurobius. — A genus of the cheese mites. Tiirn-
glyphince, which is found in flour, fruit, tobacco,
cl se, and other organic materials. A. farina has
been observed to be the cause of a cutaneous eruption
on men unloading wheat. See Arachnida. A. S. !'■
200
REFERENCE HANDBOOK OF THE .MEDICAL SCIENCES
AlKlers
Alexander of Tralles. — Alexander was born in
fralles, a small city (if Lydia, during the reign of the
■mperor Justinian, about the middle of the sixth
entury. After travelling for some time in Italy.
Spain, and Egypt, he finally settled in Rome, in
\ hich city he published several treatises I hat summed
m i lie results of his long experience in the observation
mil treatment of disease. Here are the titles of
iome of these works, several editions of which (both
•k and Latin) were printed during the period
,, 1498 to 1772: "Libellus de febribus," "De arte
lica," "De corporis partium segritudinibus," " De
mbricis," and "Problematum medicorum et nat-
tralium libri duo." These books display an extra-
ordinary degree of independent thinking on the pari
if the author, for it must be remembered that he
1 at a time when the science of medicine had sunk
lo a very low level; indeed, they are worthy in many
ects of being read by physicians of the present
time. A. H. B.
Alexin. — This is the term originally used by
Buchner to designate that substance in immune
scrum which caused bacteriolysis. It was later
overed that this substance really consisted of
two bodies, one specific, the amboceptor, the other
-essiug little or no specificity now called the
complement or alexin. The alexin, also called end-
body or cytase, probably consists largely of a pro-
ftic ferment which acts upon cells causing 1yds.
It is present in all sera to a greater or lesser extent
and is unable to attack cells unless joined to them
by means of the amboceptor. Alexin is destroyed by
heating to 56° C. for half an hour and gradually
becomes inert on standing even though in the cold.
\ scrum thus "inactivated," that is robbed of its
alexin, may be reactivated by the addition of fresh
scrum from the same or some other animal. As
alexin from one animal can be used to activate the
scrum of another or to cause lysis of a number of
different cells it evidently has but little specificity.
[he complement does differ to a certain extent for
different cells but this difference is slight and may
usually be disregarded. The phagocytes are believed
chiefly to be concerned in its production but it is
probable that there are other sources for it. For a
.1 tailed discussion of this subject and the place
which the alexin holds in immunity reactions see the
article on Immu nity. Ralph G. Stillman.
Algiers.— Algiers (latitude 36°, 37' N.; longitude
3°, 2' E.) is the capital and seaport of the French
Colony of Algeria. It is almost directly south from
Marseilles, upon the Mediterranean coast of Africa,
and has a population of 154,000, composed of a
variety of races. The town has a most attractive
situation on the slope of a hill facing the east, and as
seen from the sea, it is exceedingly picturesque and
striking, its white houses rising in a succession of
terraces from the water's edge to the hills in the rear.
The luxuriant vegetation also adds to the beauty of
the scene.
The city consists of the modern French town near
the seashore, composed of public buildings, residences,
■i handsome boulevard, and a well-built quay; and
the old city of the Turkish period on the slope of the
hill back of the French quarter, culminating in the
Kasba, or former palace of the deys, about 500 feet
above the level of the sea. This old city is compose. 1
of a crowded "mass of low, flat-roofed, whitewashed
houses intersected by the narrow, crooked, dark, and
dirty streets characteristic of an Oriental town."
< * 1 1 the slope of the hills above the lower town,
facing the east, is the picturesque suburb of Mustapha
Superieur, about two miles from the center of the city.
This is the resort of choice for invalids and others who
spend the winter in Algiers. Here are excellent
hotels and villas with fine gardens, and the summer
palace of the Governor General. Many English and
Americans reside here; there are :m English club,
English physicians, English churches, golf links, and
all the attractions and luxuries of a first-class winter
health resort. It is well supplied with water, and
the sanitary condition is good. The hills about are
covered with vegetation and flowers, and there are
very attractive walks and drives.
The winter climate of Algiers is characterized by
mildness, moderate humidity, and an abundance of
sunshine. With the exception of the humidity, it
resembles that of Egypt and the Riviera. In summer
it is hot and dry. In many respects it resembles the
climate of those portions of Southern California near
the coast.
The mean annual rainfall is about thirty-six inches,
the most of which falls in the winter. The rain comes
in heavy downpours and suddenly ceases. It is
quickly absorbed by the sandy soil.
The following tables, given by Dr. Bennet, indi-
cate the distribution of the rainfall and the number
of rainy days.
Mean Rainfall at Algiers. 1839-1845.
5 inches. May 1 J inches.
November
December S inches.
January 6 inches.
February 5 inches.
March 3 inches.
A] iri] 4 inches.
June . . . $ inch.
July inch.
August i inch.
September 1 inch
October 21 inches.
Number of Days and Nights in t 1S43 on Which Rain Fell.
Days. Nights.
November 10
December 5
January 10
February 9
March 9
April 1
Total 44
10
34
Days
May 3
June 2
July
August
September 2
October 3
Total 10
Nichts
1
1
The relative humidity is fairly high, as shown by
the following table from Hann:
Nov. Dec. Jan. Feb. Mar. Winter Mean, Dec. -Feb.
68 % 73 %
Jan.
73%
Feb.
72%
Mar.
69%
Winter Mean,
73^
The average number of fair days in the course of the
year is 233. The mean winter temperature from
December to February is 54.38° F., and the mean
annual temperature is 67.22° F.
The duration of the season for invalids, according
to Weber, is from November to the end of April, and
for this period the average temperature is 50.99° F.
There are not infrequent sudden falls of tempera-
ture during the days, such changes occurring most
commonly between four and five in the afternoon.
The daily variations of temperature, according to
Weber, are from 10.8° F. to 14.4° F.; while the differ-
ence between the day and the night temperature is
given by Rochard as from 5.4° to 9° F.
The prevailing wind for the year is the northwest
from the Mediterranean, which often blows with
great violence. The west wind brings rain, and is the
one which is most frequent in the winter season. The
Sirocco, which blows from the desert, is a dry, dusty,
hot wind, and is most prevalent in the summer,
although it occurs also during the winter season. It
i~ always oppressive and exceedingly disagreeable on
account of the clouds of dust which it brings with it
from the Great Desert. Dust is one of the very annoy-
ing features of the climate of Algiers. The wind is
not regular, and, although its prevalent direction is
from the northwest, it also comes from the north and
east during the winter months, and the sudden
alterations of temperature mentioned above are said
by Huggard (Handbook of Climatic Treatment,
London, 1906) to be due to this irregularity. The
north and northeast winds blow most frequently
during the spring and summer months.
The rate of mortality is said by Huggard to be
201
Algiers
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
high, probably due to the unhygienic mode of life
of the native inhabitants.
Such a resort as Algiers is favorable for those per-
sons who thrive best in a warm, sunny winter climate
where the}- can spend a greater part of the day com-
fortably out of doors with attractive surroundings,
such as the aged and delicate and those convali -
from acute diseases. Cases of emphysema and chronic
bronchitis are said to derive benefit from this cli-
mate, although opinions differ with regard to this.
For instance, Huggard (loc. cit.) says that Algiers " is
hardly the place of resort for those who catch cold
easily. Such persons," he says, "are very apt to be
troubled with rheumatic affections or with recurrent
bronchial troubles," and one would readily think this
might be true when he remembers the sudden changes
of temperature and the dust. For tuberculosis, for
which this resort formerly had a reputation, one would
now hardly recommend it. A moderately moist,
warm marine climate, with frequent high winds and
dust and sudden variations of temperature, is far
from the best one for this disease, although certain
cases may do well there when for any reason the high
altitudes are not applicable or the dry inland resorts
are badly borne. However, Dr. Charles Theodore
Williams (Aero-Therapeutics, 1894) speaks thus
favorably from his own personal experience:
" Of the dozen consumptive patients of whom I
have notes who have wintered once or oftener at
Algiers the large majority improved greatly and num-
ber at least two cases of arrest; but I note that the
greatest improvement took place where patients re-
sided in villas with gardens and not in hotels. In
one case where a young lady, a member of a very
consumptive family, developed the disease and a very
considerable cavity had formed in one lung, complete
contraction of the cavity took place with arrest of
the disease in two winters, and the lady has since
married and has resided for the last nineteen years
in England without any signs or symptoms of relapse.
Another lady, with well marked tuberculosis of one
lung, spent two winters in a villa at Mustapha Su-
perieur with the result that the disease became ar-
rested, and since that date she has been able to pass
twelve winters in Scotland with impunity."
Two arrested cases out of twelve, or sixteen per
cent., would be considered a very poor result in the
light of present experience, and from this showing.
Algiers could not be recommended as a favorable
resort for the successful treatment of tuberculosis.
Edward 0. Otis.
Alhambra Springs. — Jefferson County, Montana.
Post-office. — Alhambra.
Access. — Via Northern Pacific or Great Northern
Railroad. The hotel is within 600 feet of the Great
Northern Depot, and is equipped with every modern
convenience.
These springs are located seventeen miles from
Helena, at a level of 4,200 feet above the sea, the sur-
rounding country being broken and mountainous. A
dry and salubrious climate, with varied and pictur-
esque scenery, characterizes this region. The hills
and mountains are covered by different varieties of
pine, fir, and cypress, while the bottoms are dotted
with groves of alder, willow, mountain ash, poplar,
and other trees. Many varieties of plants have been
found in the neighborhood, which, it is said, have
never yet been classified. The ideal location has
earned for Alhambra its title of "The Garden Spot
of Montana." In the Government Forest Reserve
four miles back of the hotel, game is still abundant,
consisting of grouse, pheasant, deer, elk. mountain
sheep, and numerous other varieties. The springs
are situated in an angle formed by the junction of
two creeks, in which mountain trout abound. They
are twenty-two in number, and vary in temperature
from 90° to 129° F. The water has 1 n analyzed
202
by the chemist, Emil Starz, Ph. G., Helena, Montana
who has given the following report :
Solids.. Parts per Gallon-.
Calcium bicarbonate 10.06
Magnesium bicarbonate 4 40
Potassium carbonate 4.16
Potassium chloride 6 .00
Calcium sulphate 1 .75
Alumina 272
Sodium sulphate 24 76
Silica 6 46
Toul 60.31
"The Thermal Springs, located at Alhambra, Mon-
tana, possess great medicinal virtues and rank among
the best medicinal thermal waters in the United States.
They are eminently effective in all cases of rheumat-
ism, especially in chronic rheumatism, renal calculus,
kidney, liver, and bladder diseases. Their curative
properties are due not only to the temperature of the
water, 129° F., but also to the mineral constituents
contained in it. The drinking of this water is in-
dicated and most beneficial in all kinds of stomach
troubles, especially when such are due to a hyper-
acidity of the stomach. At least one or two quarts
should be drunk during the day and one or two baths
a day used."
Abundant facilities for hot and cold bathing, with
a plunge and swimming bath, vapor and mud baths,
are provided. Hospital accommodations are fur-
nished for invalids. Emma E. Walker.
Alicante. — This Spanish city of 30,000 inhabitants
lies upon the shore of the bay bearing the same name,
on the eastern or Mediterranean coast of Spain, and
about fortv miles south of the middle point of that
coast (lat. 38° 20' N.. long. 0° 30' W.). Extending
in the form of a crescent along the northern shore or
head of the bay, and dominated by a rocky hill,
some 400 feet high, the town is tolerably well
sheltered from the north and northwest winds, the
bay being open only to the westerly winds. " The
landward environs are dreary," says Baedeker; "but
the distant mountains, the castle, the harbor, and
the sea combine to form a memorable picture.''
'The view from the east mole of the harbor," con-
tinues the same authority. " with its white, flat-roofed
houses, its palms, and the bare and tawny cliffs of
the castle hill, has probably no parallel in Europe."
The climate is a mild and dry one, drier than the
Riviera, the annual rainfall being only 16.93 inches, of
which (according to Lorenz and Rothe, quoted by
Dr. Weber, in Ziemssen's " Handbook of General
Therapeutics") 20.7 per cent., or the extremely
small quantity of 3.5 inches, falls during the winter
months. The percentage of clouds prevailing in the
sky of that portion of Spain in which Alicante is situ-
ated is much lower than is found in any other part
of Europe, Italy and Greece included. The relative
humidity of Alicante the writer has not been able to
ascertain; but at Valencia, some eighty-five miles
north of Alicante, the mean yearly relative humidity
is 66 per cent., and it is probably somewhat les- at
Alicante. The mean annual temperature is 64.4° F.;
that of winter being 53.5° F. Another authority B
the mean winter temperature as 60° F. There is no
mistral or dust.
The present condition of the water supply is not
known to the writer; it is probably the same as when
Dr. Bennet wrote of it in 1S75, which consisted then
of a large spring and rain water tank. The accom-
modations are said by Dr. Weber to be good. The
wine of Alicante is famous, and. besides a large com-
merce, the town possesses an extensive tobacco fac-
tors', which employs 400 Spanish girls.
When a mild, dry, and sunny climate is con
desirable for various conditions of debility, anemia,
convalescence from acute diseases, and the like, Ali-
REFERENCE HANDBOOK OF TDK MEDICAL SCIENCES
Mini, lit
ante would seem admirably to fulfil these conditions
ases of latent scrofula, asthma, bronchorrhea, albu-
ninuria, and rheumatism are also said to do well here.
Edwaud O. Otis.
Aliment. — Food or aliment is matter which, in con-
unction with the air, supplies the elements necessary
( ir the maintenance, growth, and development of the
irganism, and is thus the source of the power on which
vitality of the organism is dependent — i.e. the
-mine of the heat, mechanical work, and other forms
if energy liberated in the body. Hence, in the
tdest sense, true aliment is a mixture of food-
- and water, together with the air, from which
- the uxyni'ii necessary for the oxidation of the
ormer and by which energy is liberated. Again,
siologically considered, true aliment, especially
in the animal kingdom, is to be distinguished fromso-
d "food" as being only that portion of the food
which is either directly available for absorption, or
convertible by the digestive juices of the body into
ible and more or less diffusible products, appro-
ite for absorption by the blood and lymph.
The food of vegetable organisms is quite different
from that of animal organisms. Moreover, the nature
of the processes involved is likewise quite different,
vegetable organism, by a synthetical process — a
building up of more complex bodies from simpler ones
— derives its nourishment from the inorganic world;
ells appropriate such of the inorganic principle- as
are needed for its growth, and convert them under
the influence of the sun's rays into organic compounds
which enter into its own structure.
The animal organism, on the other hand, does not
possess this power to a great extent and thus we look
to the creative power of the vegetable kingdom as the
source, either directly or indirectly, of the aliment of
animals. Moreover, the vegetable matter which
thus serves as food not only furnishes the material
necessary for the growth and life of the organism, but
it contains, in addition, stored up within its molecules,
a certain amount of latent force derived from the
solar energy originally used in its construction.
Animal organisms, by a process of transformation
quite the reverse of synthetical, convert the pre-
formed animal or vegetable organic matter into allied
or simpler forms, which are absorbed into their own
tissues. Animal food possesses stimulating proper-
tics, due, without doubt, to the crystalline nitrogenous
bodies contained in it. Organic matter once entered
as a part of an animal organism and applied to the
purposes of life is decomposed or broken apart, and
its decomposition products are ultimately reconverted
into inorganic principles. There is thus a comple-
mental relationship between vegetable and animal
life and the inorganic world. The plant, by a se-
lective action, appropriates as an element of nutrition
certain kinds of mineral matter, together with nitrogen
in the form of ammonia and nitrates, from the soil in
which it grows, at the same time drawing from the air
carbon in the shape of carbonic acid, while hydrogen
and oxygen are supplied to an unlimited extent in the
form of water. The vegetable products thus formed
serve in turn as the food of animals, while the latter
at every breath pour forth carbonic acid and water,
which utimately find their way again, more or less
modified, into the tissues of plants. These, together
with the nitrogenous excreta, products of the meta-
bolism of life, and the postmortem decompositions
which follow, continually serve in their variously
modified forms as agents by which the conservation
and transference of energy are accomplished.
Now, since food is the source from which the
various elements of the body are supplied, it is evident
that to fulfil its purposes food must contain all of the
elements present in the body. These are, of course'
not free, but in a state of organic combination, for it is
only in the latter case that they are of service as food.
Aside from the elements which appear as inorganic
sails, there are in the body at the mo I bul seven
elements, three of which are present only in small
quantity. These seven elements are en lion, hydro-
gen, nitrogen, oxygen, sulphur, phosphorus, and iron.
Any substance which as food is to satisfy the re-
quirements of life, should contain all of these ele-
. in addition to inorganic salts and water.
Food as it OCCUI in nature: -d of mixtures
of chemically distinct substances which may be
eparated into four great divisions, termed food
stuffs. Food stuffs are classified as (a) proteins,
(6) carbohydrates, (c) fats, and (d) inorganic salts
and water. .Many of the comp i included in
these groups are to be found in both the animal and
vegetable kingdoms, as for example, the fat.- and pro-
teins, although minor points of difference in chemical
composition and structure may be observed. On the
other hand, certain of these substances are present
only in the vegetable kingdom, for example, starch,
and others such as the gelatin-forming substances are
characteristic of the animal kingdom only.
Viewed from the standpoint of origin food-stuffs
may be classified under two heads, viz., organic and
inorganic. In the first division may be placed those
compounds which have been produced by the agency
of living cells; bodies which contain carbon and are
capable of combustion and of furnishing energy.
Ihe second group contains substances belonging to
the mineral kingdom that have become mixed with
the organic materials. Proteins, carbohydrates, and
fats are organic compounds. Various salines and
water make up the division termed inorganic. Fur-
thermore, the organic food-stuffs are divisible into
two groups, dependent upon whether the element
nitrogen is present in their structure. Fats and
carbohydrates are non-nitrogenous whereas proteins
contain nitrogen. Following is a partial classification
of foods:
Organic.
Nitrogenous
Non-nit rogenous. .
T f Water.
Inorganic ^ g^
[ Proteins.
1
I Carbohydrates.
Proteivs may be defined as complex compounds of
high molecular weight made up of carbon, hydrogen,
oxygen, nitrogen, sulphur, and sometimes containing
phosphorus and iron. The distinctive feature which
differentiates protein from the other food stuffs is
that nitrogen is present and is contained in the molecule
in a form that is available for the physiological needs
of the organism. The term protein is derived from
-pcurevui (I am the first) and refers to the fact that it
forms the chief mass of the organic constituents of
animal tissues. The average composition of the
best known proteins is, approximately, carbon, fifty-
three per cent.; hydrogen, seven per cent.; nitrogen,
sixteen per cent.; oxygen, twenty-three per cent.;
sulphur, one per cent. Considered from the stand-
point of chemical structure our knowledge concerning
the proteins is very incomplete although as a result of
the recent investigations of Emil Fischer 1 proteins
may be regarded as essentially complex anhydrides
of amino acids. Glycocoll, or glycine, chemically
known as amino-acetic acid, may be taken as an ex-
ample of a simple amino acid. The structure of this
substance is CH,.NH 2 .COOH. If two molecules of
glycocoll are combined in such a manner that one
molecule of water is eliminated, a new compound re-
sults. Thus:
CH,.NH,.CO
CH„. NH,. CO OH
CH,
|H!
N.COOH
CH 2 .NH.COOH
Glycyl-glycine
203
Aliment
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Glycyl-glycine is the simplest of an enormous group
of anhydrides of amino acids, and these compounds
are called "peptids." A combination of more
than two amino acids is designated "polypeptid."
Through synthetic processes Fischer has succeeded
in fastening together various of these amino acids
until products have been obtained finally which
would respond to some of the chemical reactions
most characteristic of the proteins. Previous to
this type of investigation our knowledge of the struc-
ture of protein was derived mainly from studies
of the products resulting from the hydrolytic cleavage
of these substances. The products of protein
hydrolysis include a long series of amino acids of
varying chemical complexity and significance. 2
It is the presence or absence of one or more of these
amino acids or the quantitative variation in the
content of their antecedents that undoubtedly
is t lie reason why some protein substances are not as
well adapted to serve the nitrogenous needs of the
body as others. The most striking examples illustra-
tive of this point are found in gelatin and zein, the
latter a protein contained in corn. A clearer con-
ception of the varied composition of the proteins may
!»■ gained perhaps from the following table 3 in which
tin 1 content of amino acids of several proteins is
given.
Table I
Glycocoll
Alanine
Ammo-valeric acid
Leucine
a Proline.
Phenylalanine
Glutamic acid
Aspartic acid
Serine
Tyrosine
Tryptophane
Lysine
Arginine
Histidine
Cystine
Ammonia
( rliadin
from
wheat
flour.
0.9
2.7
0.33
6.0
2.4
2.6
43.0
1.3
0.12
2 4
1.0
3.4
1.7
5.1
Albu-
min
from
egg.
7.1
2 2.3
4.4
8.0
1.5
1 1
l'rrs.-nl
0.2
1.6
Casein
from
cow's
milk.
0.9
1.0
10.5
3.1
3.2
16.0
1 2
0.23
4.5
1.5
5.S
-I M
2 59
(I 085
1.9
Zein
from
corn.
0.5
Present
11.2
1.5
7.0
26.0
1.0
10.1
1.82
0.S1
3.6
Gela
tin.
4
II ss
0.56
0.4
2.75
7.62
0.4
These variations in amino acid content are obvi-
ously responsible for differences of chemical structure
and may account in large measure for the varying
physical properties upon which our present classifica-
tion is based.
Until very recently the classification of proteins
was in a state of confusion owing to the fact that
several classifications were recognized by various
groups of English-speaking scientists. At present in
the English-speaking world the British and American
classifications only are of value. These are quite
similar in a general way, the points of difference being
a question of nomenclature and of minor importance.
The following is the outline of the American classifica-
tion and it will be noted that the term "protein" has
been substituted for the older designation " proteid."
I. Simple Proteins.
(a I Albumins
ib) Globulins
(c) Glutelins
(d) Alcohol-soluble proteins
(e) Albuminoids
(fl Histories
(g) Protamines
204
II. Conjugated Proteins.
(a) Nucleoproteins
(b) Glycoproteins
(c) Phosphoproteins
(d) Hemoglobins
(e) Lecithoproteins
III. Derived Proteins.
A. Primary protein derivatives.
(a) Proteans
(b) Metaproteins
(c) Coagulated proteins
B. Secondary protein derivatives.
(a) Proteoses
(b) Peptones
(c) Peptids
Simple proteins are protein substances which yield
only a amino acids or their derivatives on hydrolysis.
The albumins are simple proteins that are soluble in
pure water and are coagulable by heat. The globu-
lins, on the other hand, are insoluble in pure water
but are soluble in neutral solutions of salts of strong
bases with strong acids, for example, sodium chloride.
Albumins and globulins are very often associated, as
for example, in blood serum, and in the substance <>f
cells. In a general way albumins are more abundant
in animal fluids (blood, etc.), while globulins pre-
dominate in animal tissues and in plants. Glutelins
are simple proteins insoluble in all neutral solvents
but readily soluble in very dilute acids and alkalies.
Alcohol-soluble proteins are simple proteins soluble
in relatively strong alcohol (seventy to eighty per
cent.) but are insoluble in water, absolute alcohol, and
other neutral solvents. These last two mentioned
groups, the glutelins and the alcohol-soluble proteins,
occur as constituents of the cereal grains. The best
known examples of these two groups are glutinin and
gliadin respectively. They make up what is known
as the gluten of flour. The elasticity and strength of
the gluten and therefore the baking qualities of the
flour are influenced by the proportions of glutinin
and gliadin, about twice as much gliadin as glutinin
being usually considered desirable in bread flour.
Albuminoids may be defined as simple proteins which
possess essentially the same chemical structure as the
other proteins, but are characterized by great in-
solubility in all neutral solvents. Examples of this
group may be found as the organic basis of bone
(ossein), of tendon (collagen and its hydration pro-
duct gelatin), of ligament (elastin), and of nails, hair,
horns, hoofs, feathers (keratins). The histones arc
soluble in water and insoluble in ammonia. They
are precipitated by other proteins and yield a coas;u-
lum on heating which is readily soluble in very
dilute acids. Histones may be regarded as basic
proteins which stand between protamines and true
proteins. Histones have been isolated from varied
sources, as globin from hemoglobin, scombron from
spermatozoa of the mackerel, gaduhiston from the
codfish and arbacin from the sea-urchin. The
protamines are relatively simple polypeptids. They
are the simplest natural proteins. On decomposition
l lev yield comparatively few amino acids among
which the basic ones predominate. Thus far they
have been isolated only from fish spermatozoa, and
according to origin have been designated salmine,
st urine, clupeine, etc.
The conjugated proteins are substances which
contain the protein molecule united to some other
molecule or molecules otherwise than as a salt.
Nucleoproteins are compounds of one or more protein
molecules with nucleic acid. These substances are
the characteristic proteins of the nuclei and hence
are found in largest quantity wherever cells are most
abundant, for example, in the glandular organs and
tissues. By artificial means or during digestion a
nucleoprotein is first decomposed into protein and a
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
\ linn til
substance called nuclein; the latter on further decom-
position yields more protein ami nucleic arid.
1 Nucleic acid, of which then- may be several types,
,,, ;IV be resolved into a series of peculiar compounds,
purine bases (xanthine, hypoxanthine, adenine,
,,„! quanine), the pyrimidine bases (uracil, cytosine,
and thymine), a carbohydrate group (pentose), and
phosphoric acid. Glycoproteins are compounds < >f
protein molecule with a substance <>r substances
aining a carbohydrate group other than a nucleic
,i.l The mucus-yielding portions of tissues are
particularly rich in the glycoproteins which serve as
ibstance to hold together the fibers in tendon
ligament, etc. Glucosamine has been isolated
, some nf the glycoproteins and is recognized as
carbohydrate constituent. Phosphoproteins are
compounds of the protein molecule^ with some, as
undefined, phosphorus-containing substances
i than a nucleic acid or lecithin. Milk, with its
and tl gg, with vitellin of the yolk
arc conspicuous foods containing phosphoproteins.
compounds yield a trace of iron on analysis
I although this has been regarded as an impurity it
is not at all improbable that it actually exists in the
ein in combination. Hemoglobins are corn-
els of the protein molecule with hematin or
ome similar substance. Hematin is the coloring
matter of the blood which acts as oxygen carrier for
tissues and is characterized by containing iron in
an organic combination. The protein portion of
II glob in consists of globin, a histone. Leeitho-
firoteins are compounds of the protein molecule with
bins. Lecithins are complex substances charac-
terized by containing nitrogen and phosphorus
together with fatty acid radicles and choline. They
■are found in nearly all plant and animal cells, but are
especially abundant in the nervous tissues. They
are essential cell constituents.
As their name implies the derived proteins are sub-
stances that have been formed from the naturally oc-
curring proteins. Of these compounds the proteoses
and peptones and the metaproteins are of particular
importance since they represent stages of protein diges-
tion. With a few exceptions proteoses and peptones
are not found preformed in nature. These two groups
of derived proteins are characterized by their great
solubility. The peptones are sometimes looked
upon as simple mixtures of rather complex poly-
peptids.
Carbohydrates 1 are especially abundant in the
plant kingdom forming the chief mass of the dry
tance of the plant structure. In the animal
tissues they are found only in small quantities either
in a free condition or in combination with proteins
forming conjugated proteins. The carbohydrates
serve as food for both man and animals and hence are
of great importance from the standpoint of aliment.
They contain the elements carbon, hydrogen, and
oxygen, and the last two elements are usually in the
same proportion that occurs in a molecule of water,
namely 2 : 1, hence the term carbohydrates. All
carbohydrates, however, do not have the hydrogen
ami oxygen in this proportion, for a sugar, rhamnose,
C,H 12 5 , has these elements in a different relation.
Moreover, various organic acids have the elements
hydrogen and oxygen in the proportion of 2 : 1 and yet
are not carbohydrates. It is exceedingly difficult to
give an exact definition of carbohydrates since they do
not differ from main - other substances in many respects.
Chemically the carbohydrates may be defined as
aldehyde or ketone derivatives of polyhydric alcohols.
The simplest carbohydrates are aldehyde or ketone
derivatives of such alcohols, and the more complex
members of this group of compounds may be regarded
as anhydrides of the simple carbohydrates. The
carbohydrates are generally divided into three chief
groups namely, monosaccharides, disaccharides, and
polysaccharides. Viewed from another standpoint
they may be classified into sugars, starches, dextrins,
gums and vegetable mucilages, and celluloses. The
sugars are mono- and disaccharides and t he remaining
groups belong under the division <>f polysaccharides.
The mono- and di-nccharides are fairly soluble sub-
stances possessing varying degrees of sweetness. In
general the polysaccharides are more or less insoluble
in the ordinary solvents. Mono- and disaccharides
are given the ending "use" in accordance with the
number of carbon atoms contained in the molecule.
Thus, one speaks of a pentose, < . 1 1 , , , < > , , of a hexose,
( ',, 1 1 ,_,( >„, or of a heXobin i , ( II ._,»_>,,.
(if tlie monosaccharides only the pentoses and
hex oses are of practical significance in their relation to
the food of man. The pentoses do not occur as such
in nature but are formed by the cleavage of more
complex molecules, the pentosanes, which are of a
gum-like nature. The pentosanes are widely dis-
tributed in the plant kingdom and are of great impor-
tance as food for the herbivora. In man pentoses are
absorbed and partially utilized but even when ingested
in small quantities traces promptly reappear in the
urine. The pentoses are of significance in human
metabolism since they were first discovered in the
animal kingdom by Salkowski and Jastrowitz in the
urine of a morphine habitue\ They may also occur
in traces in normal urine and in the urine of diabetics.
A pentose is furthermore an integral part of certain of
the nucleoproteins, and, therefore, may be isolated
from organs rich in nuclear material, as for example,
the pancreas, thymus, thyroid, spleen, and liver.
This pentose is xylose and is the only one thus far
separated from animal tissues. It is identical with
the xylose obtained by boiling wood gum with dilute
acids. Arabinose is a pentose that has been isolated
from human urine by Neuberg.
The hexoses are sugars and most of them occur in
nature. They readily undergo fermentation with
yeast, leading to the production of alcohol. They are
either aldehydes or ketones and hence are termed
aldoses or ketoses. Dextrose, an aldose, and levulose,
a ketose, are found either free in nature or else may
be formed by the hydrolytic cleavage of more com-
plex carbohydrates or of glucosides. Such hexoses
as mannose and galactose result only from hydrolysis
of naturally occurring products C a ), for example,
galactose is formed by the hydrolytic splitting of
lactose, or milk sugar, or from hydrolysis of certain
glucoside-like complexes, the cerebrosides, found
in nervous tissue. Of the hexoses, dextrose and levu-
lose are the most important. Dextrose ( = grape sugar
= glucose) is found particularly abundant in the grape
and also in company with levulose in various fruits,
seeds, roots, honey, etc.
Perhaps the most interesting feature in connection
with dextrose from the standpoint of metabolism is
that it is the sugar of the blood and lymph. It is
present in minute traces in normal urine but may be
found in large quantities in that voided by diabetics.
Dextrose, and levulose, are capable of ready assimi-
lation by the body without previous alimentary
treatment, a statement wdiich in general does not
apply to most of the other carbohydrates. Levulose
( = fruit sugar = fructose) is found especially distrib-
uted in fruits and honey. It may be formed also in
the hydrolysis of cane sugar and other more complex
carbohydrates. In certain types of diabetes mellitus
levulose may be eliminated in the urine. Dextrose
and levulose have been so designated because of their
influence upon the plane of polarized light, dextrose
solutions causing a rotation to the right, levulose to
the left. Glucosamine (chitosamine) is an amino
derivative of dextrose. It was first prepared by Led-
derhose from chitin by the action of strong hydro-
chloric acid. It is also a cleavage product of several
mucin substances and of proteins and may be re-
garded as the connecting link between the proteins
and the carbohydrates. All of the hexoses, because
205
Aliment
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
of their aldehyde or ketone structure, possess the
property of reducing metallic oxides, of copper, bis-
muth, etc. This behavior of the hexoses has been
made use of for the identification and quantitative
estimation of these substances.
The disaccharides are divisible into two groups,
those occurring preformed in nature, saccharose (= cane
sugar = sucrose) and lactose ( = milk sugar), and those
produced by hydrolysis of more complicated carbo-
hydrates, maltose and isomaltose. The disaccharides
are to be regarded as anhydrides, formed from two
monosaccharides by the expulsion of one molecule of
water. By the addition of one molecule of water,
that is by hydrolysis, the disaccharides may be re-
solved into two molecules of hexoses, thus:
C 12 H 22 Il +H 2 0=C 6 H 12 6 -rC, ) H 12 O e
Since the disaccharides all possess the same elemen-
tary composition, C l2 H 22 O u , and the hexoses have the
composition C„H i: ,O r , in common, the above reaction
will apply to the hydrolysis of all the disaccharides.
The hexoses yielded by the various disaccharides may
vary, however, as may be seen from the following
scheme. On hydrolysis
Saccharose yields dextrose plus levulose.
Maltose yields dextrose plus dextrose.
Lactose yields dextrose plus galactose.
This process of hydrolysis takes place along the en-
teric tract so that all disaccharides ingested as food
eventually are absorbed in the blood stream as mono-
saccharides. Unlike the hexoses, saccharose does not
reduce metallic oxides, whereas maltose, isomaltose,
and lactose possess this power. All of the disaccharides
exert a specific influence upon the plane of polarized
light in common with the hexoses. Saccharose or cane
sugar occurs widely distributed in the vegetable king-
dom. It is found in the stalk of the sugar cane, in
the roots of the sugar beet, in carrots and other vege-
tables, etc. It is of exceedingly great importance as a
food since the ordinary table sugar is pure saccharose.
The mixture of dextrose and levulose produced by
hydrolysis of cane sugar is termed "invert sugar"and
the' process is called "inversion." Cane sugar is not
directly fermentable by yeast. Ordinary yeast, how-
ever, contains an inverting enzyme which transforms
the saccharose into invert sugar. This readily under-
goes fermentation resulting in the formation of alco-
hol. Lactose is found only in milk where it occurs to
the extent of three to eight per cent., varying with the
type of animal. In the pregnant woman and animals
lactose is sometimes found in the urine. It may also
be eliminated through the kidneys during a stagnation
of milk. Milk sugar is not fermentable with ordinary
yeast but may undergo fermentation resulting in the
formation of alcohol by the action of certain schizo-
mycetes and the production of "kumyss" from mare's
milk, or "kephir" from cow's milk. Maltose is ob-
tained by the hydrolysis of starch induced by the
action of diastase, saliva, or pancreatic juice, or from
glycogen under certain conditions. It forms the fer-
mentable sugar of the potato or grain mash, and also
of the beer wort. In general, isomaltose occurs when-
ever maltose is formed.
Unlike the mono- and disaccharides the polysac-
charides as a class are not possessed of a sweet taste.
While a few are soluble in water most of them are
not, although the latter may swell in hot water with-
out visible change. The polysaccharides are all con-
vertible into monosaccharides by hydrolytic cleavage.
The chief groups of the polysaccharides are the starch
group, gum and vegetable mucilage group, and the
cellulose group. The polysaccharides all have the
formula (C 6 H 10 O s )a;. Starch occurs as a white taste-
less powder stored in various portions of the plant
structure as reserve food. It is found chiefly in seeds,
roots, tubers, and trunks. Starch may be quanti-
tatively transformed into dextrose by hydrolysis with
acids. Under the influence of amylolytic enzymes
206
starch yields a variety of dextrins, maltose, and a
small quantity of dextrose. The various types of
starch vary considerably in the character, that is, the
shape and size, of the starch granules. Starch is
incapable of utilization by the human organism unless
it has been boiled. The starch grains are enclosed in
a cellulose covering which is not dissolved by the
enzymes of the alimentary canal. When starch is
boiled with water, however, this cellulose membrane is
ruptured and the starch grains are transformed into
a paste which is readily attacked by the enteric en-
zymes. Upon these facts as a basis rests the ordinary
procedure of cooking vegetables containing consider-
able quantities of starch. The herbivora, however,
possess cellulose-dissolving ferments, hence raw starch
can be well utilized by this class of animals. Inulin
is a polysaccharide, in many respects similar to starch,
which is found in many underground parts of plants,
especially in roots and tubers. Enzymes have little
or no action upon inulin, but levulose may be pro-
duced from it by the influence of acids. Glycogen
stands in a position between starch and dextrose and
is an essential constituent of all animal cells, the
largest quantities being found in the liver and mus-
cles. The former organ is looked upon as the prin-
cipal store-house for this material. The quantity of
glycogen in the body at any time depends upon the
food and the amount of muscular work performed.
While it is conceded that protein and various other
types of compounds may lead to a storage of glycogen
it is well established that glycogen is most readily
stored in the liver after large intakes of carbohydra
The amount thus stored may reach twelve to sixteen
per cent, of the weight of the liver. The degree of ac-
tivity of the body also bears a direct relation to glyco-
gen storage, since by hard muscular work, or by the en-
ergy expended in shivering, 5 glycogen in the liver may
be reduced to a minimum in a few hours. Starvation
may bring about a similar result although less rapidly.
L T pon hydrolysis with acid, glycogen yields dextrose,
and maltose or dextrose may result from the action
of diastatic enzymes in accordance with the type of
enzyme employed. The dextrins stand in a close
relationship to the starches and are formed as inter-
mediate products from the latter in their transforma-
tion into sugar by the influence of acids and enzymes.
On the other hand the gums and mucilages occur ;ts
natural products in the vegetable kingdom. The cel-
lulose group comprises the mixture of carbohydrates
constituting the cell wall of plants. The celluloses are
characterized by their great insolubility in all ordinary
solvents. It is probable that these substances are
utilized by man to only an exceedingly limited extent.
The fats constitute the third group of the organic
food-stuffs. These substances are widely distributed
in both the animal and vegetable kingdoms. In the
latter the fats occur in the seeds, fruits, and in certain
instances, in the roots. All animal tissues and organs
contain fat, although the quantity present in th(
different structures may vary greatly. There are
three principal deposits of fat in the animal body.
namely, in the intermuscular connective tissue, tie
fatty tissue in the abdominal cavity, and the sub-
cutaneous connective tissues.
Chemically the so-called neutral fats are esters of
fatty acids and an alcohol, usually glycerol. Those
esters are triglycerides, that is, the hydrogen atoms of
the three hydroxyl groups of glycerol are replaced by
the fatty acid radicles. The chief animal fats are
mixtures of the esters of stearic, palmitic, and oleic
acids. In addition glycerides of such fatty acids as
butyric, caproic, caprylic, and capric acids occur in
considerable amounts in the fat contained in milk.
Less well known are the esters of lauric, myristic, and
arachidic acids which are usually present in small
quantities in animal fats. The triglycerides of
lauric, myristie, linoleic, erucic acids, etc., sometimes
are found in great abundance in the plant kingdom.
REFERENCE HANDBOOK OF TIIK MEDICAL SCIENCES
Allmrnt
i,. three most common animal fats present varying
erees of hardness, tristearin being the hardest,
olein a liquid at ordinary temperatures, and tri-
Imitin occupying a position between the two. The
riable hardness of animal fats depends upon the
iantitative relationships of these three triglycerides.
impaled with the carbohydrates fats are poor in
;ygen. The fats are soluble in ether, carbon bisul-
ilde, chloroform, benzene, etc., but are insoluble in
1 1 ei ■. The color, taste, and odor of fal from different
iinvs are due to contaminating substances, since
ire fats are colorless, tasteless, and odorless. The
ts give a temporary emulsion when shaken with
iter, but when shaken with an alkali or a soap the
nulsion is permanent. The fats may be split into
,-ir component parts, glycerol and fatty acids, by
e addition of the components of water in accordance
ith the following reaction, where R represents any
i iv acid radicle:
C 3 H s (OR) 3 + 3H : 0=C 3 H 5 (OH) 3 + 3HOR
'lis process is called saponification and may be
i niially induced by pancreatic lipase and other
uiilar enzymes of the plant and animal kingdoms.
may also be brought about by the action of steam
iilcr pressure; by long continued contact with air
id lignt; and finally by treatment with an alkali,
i the last instance soaps result and this reaction is
ie underlying principle in soap making on a com-
ercial scale.
In addition to the naturally occurring fats advan-
ige has been taken of the varying melting-points of
ie principal fats to make artificial mixtures on a
immercial scale as substitutes for butter. Thus
eomargarine is the name given by law to these
liter substitutes in the United States. By heating
ief suet to its melting-point, cooling slowly and
tbjecting the warm mass to pressure in a filter press,
ie softer portions consisting mainly of triolein and
ipalmitin, may be separated. The soft portion is
nown as oleo oil, the hard part as beef stearin. The
loo oil is the material most often employed under the
;itne oleomargarine. A similar mixture is made by
imbining cotton seed oil with beef stearin. Some-
mes the fats are churned with a certain amount of
al butter to furnish a product with a flavor sugges-
ve of butter. The name butterine is given to such
lixtures and from the standpoint of food they are
illy as wholesome and nutritious as butter. 7
Closely related to the fats stands a group of sub-
lances known as lipoids. They are similar to the
.is in physical properties, but differ from them in
lictnical structure. Cholesterol, a monatomic aleo-
• il, C 26 H. 5 OH, is undoubtedly, of importance in the
utritional rhythm, although its exact significance is
ot definitely known. Its wide distribution in
nimal fluids and tissues and the occurrence of closely
lied compounds, the phytosteroles, in the plant
ingdom is indicative of the significance of this group
l substances in life processes. Of special importance
- another group of compounds included under the
P =
CH-O/
I
N
'CH,
"CH.
CH,
I mm the st rue t urn I 1 01 inula given abo\ e it is evident
that there may be various types of lecithins in
correspondence with the fatty acid radicle or radicles
contained in the molecule. '| he phosphatides are
widely distributed, being especially abundant in the
brain and other nervous structures, in the yolk of the
egg, and in the muscles. The phosphatids, and
especially the lecithins, are of the greatest importance
in the development and growth of living organisms
for they serve to build up the complex pnosphorized
nuclein substances of the cell and cell nucleus.
Wood, as eaten by man and animals, is a natural
mixture of the various food stuffs described. Seldom
are the isolated principles eaten by themselves, other
than in the case of sugar and salt, or pure fat. It
is the function of digestion to separate the individual
principles from this natural mixture, by which means
they are separately absorbed. The behavior of
animal and vegetable' food is quite different in the
alimentary canal, which difference is dependent more
upon the quality of dry substance contained in the
latter food than upon its quantity. Vegetable food
yields a much larger percentage of indigestible residue,
and is in itself much less easily digestible, owing to the
fact that it is more or less enclosed in the difficultly
soluble cellulose, while animal food is free. More-
over, vegetable food, as a rule, is less easily absorbed,
and, as it contains usually a less percentage of
nitrogen, a much larger quantity is needed to furnish
a certain amount of this element than in the case of
animal food. Again, the large quantities of starch
contained in a vegetable diet tend to produce an acid
fermentation in the small intestines, with formation
of butyric acid, together with marsh gas and hydro-
gen, which causes the frequent intestinal excretions
of herbivorous animals.
Nearly all foods contain appreciable amounts of
water and inorganic salts. That these are essential
to the well being of the organism has been demon-
si rated repeatedly. For the present it will be suffi-
cient to note that the chief mineral substances needed
by the organism are the four elements calcium, so-
dium, potassium, and magnesium, which exist in com-
bination with four acids, namely, phosphoric, hydro-
chloric, sulphuric, and carbonic. The different nu-
trients are found in nature in a variety of combina-
tions or admixtures. Milk contains all the types of
food stuffs, whereas in lean beef the carbohydrates and
fats may be present only in small quantity, although
the protein content is large. On the other hand, cer-
tain types of vegetables, as the potato, contain only
small amounts of protein and little or no fat, but the
carbohydrates are present in large quantity. In gen-
eral, foods of animal origin are particularly rich in
protein and fat. Usually carbohydrates are abun-
dant in vegetable foods.
In the Table II., p. 208, is given the relative distribu-
tion of the various food stuffs as they occur in the
edible portion of the natural products.
In a determination of the food value of a given food
stuff, or of a given diet composed of a mixture of food
stuffs, it is necessary to ascertain its chemical compo-
sition with special reference to the content of protein,
fat, carbohydrate, and inorganic salts; its caloric or
heat value; and lastly its digestibility or availability.
In an ordinary mixed diet, protein matter is usually
present in the proportion of one part to about five
parts of non-protein matter — i.e. fats and carbohy-
drates. The proportion of fat to carbohydrate is
usually exceedingly variable, ranging anywhere from
one part of fat to from five to twelve parts of carbo-
hydrate. While these statements are to be accepted
as a general expression of the ordinary proportion of
the three primary varieties of food stuffs contained
in an average diet, it is to be remembered that the
element of cost or the ease of procuring frequently
determines the relative amount of the three classes of
food stuffs in the daily diet. Thus, in countries where
207
Ailment
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
meat is plentiful, as in South America, protein food
is consumed in much larger proportion than above,
whereas, in some Asiatic countries, the prevalence of
rice, cereals, and fruits leads to a daily diet in which
non-protein foods are especially conspicuous, and the
proportion of protein is reduced to the minimum nec-
essary for life. Further, for similar reasons, the ratio
of fat to carbohydrate undergoes wide variation among
different races or in different countries. Thus, in the
far north, fat (animal) constitutes the greater pro-
portion of the non-protein part of the diet, while
in countries where cereals abound, carbohydrates,
mainly in the form of starch, make up the greater
portion of the non-nitrogenous food.
Regarded from a broad viewpoint the human body
needs food for three purposes, namely, for growth
and development, to replace wornout cellular mate-
rial, and finally to furnish energy for vital activities.
Nitrogen is particularly necessary for the purpose of
cell repair, and food should be of such a nature that
it will readily yield its potential energy. Proteins
are the only food stuffs capable of supplying the nitrog-
enous need, whereas all types of food stuffs will yield
energy in varying degree. The older view that the
proteins were to be regarded as tissue formers and
the carbohydrates and fats as energy yielders has
been discarded. The prevalent view at present is that
the body is not restricted to the use of any one food
stuff for a particular purpose, but it may make use
of all types in order to employ the energy of all nu-
trients in an economical manner. "Thus, the carbo-
hydrates, fats, and proteins stand in such close mutual
relations in their service to the body that for many
purposes we may properly consider the food as a whole
with reference to the total nutritive requirements,
provided a common measure of values and require-
ments can be found. Since the most conspicuous
nutritive requirement is that of energy for work of the
body, and since these organic nutrients all serve as
fuel to yield this energy, the best basis of comparison
is that of fuel value." 9 Energy may be measured
in terms either of heat or of mechanical work. The
energy available in the food stuffs is expressed by its
heat or fuel value, that is, in units of heat, or calories.
In accordance with this unit it has been demonstrated
that one gram of protein has a heat value of 4.1
large calories; one gram of fat will yield 9.3 large calor-
ies, and the heat, or fuel value of one gram of carbohy-
drate amounts to 4.1 large calories. The total fu'ei
value of a few of the common food stuffs is given in
Table II.
The conditions which most obviously influence the
food requirement with respect to fuel value are age
size of body, and muscular activity. 'When a man
is at rest, that is, with all external muscular work
excluded, it has been estimated that approximately
2.UU0 calories per day are necessary for proper nutri-
tional rhythm. Such an energy requirement lias
been called the maintenance requirement. Of this
about eight to twelve per cent, is expended upon the
work of digestion and assimilation, five to ten per
cent, upon the circulation, ten to twenty per cent,
upon the respiration and thirty to fifty percent, upon
the maintenance of muscular tension or "tone."
Muscular work is the most important factor in raising
the energy requirement above the maintenance Deed.
Thus a man who works at manual labor may inn
his metabolism by 1,000 to 2,000 calories per day
above what is needed for maintenance at rest, making
his total food requirement 3,000 to 4,000 calories per
day, although with severe labor this may rise to 6,000
calories or even higher. Voit estimated the food re-
quirement of a moderate worker at 3,050 calories, and
Atwater in the United States believed that the
American needs 3,400 to 3,500 calories per day. By
moderate worker was meant a man engaged in manual
labor for nine to ten hours a day, such as a carpenter
or a mason. It is well recognized that the calorific
need varies directly with the severity of the muscular
exercise, and in accordance with this idea Tigerstedl
has estimated the energy requirements sufficient for
individuals engaged in a variety of occupations.
Thus,
2,001 to 2,400 calories suffice for a shoemaker.
2,401 to 2,700 calorics suffice for a weaver.
2,701 to 3,200 calories suffice for a carpenter or mason.
3,201 to 4,100 calories suffice for a farm laborer.
4,101 to 5,000 calories suffice for an excavator.
Over 5,000 calories suffice for a lumberman.
In a general way the total food requirement varies
with the body weight. This is not strictly true, for the
food requirement though greater in absolute amount
in the larger individual is less per unit of body weight
Table II.
Composition of Edible Portion- of Some Common Food Materials. 8
Food materials.
Water.
Protein.
Carbohydrate.
Fat.
Mineral
matter.
Fui 1 value
per pound.
Per cent.
73 8
54.6
67.1
S3 . 6
74.8
55.5
SS.3
73 7
11.0
79 2
53 , 5
58.5
Per cent.
22. 1
15 8
19.4
15 3
2 1 . 5
21.1
6.0
13 4
1.0
17 6
25 I
11.1
Per rent.
Per cent.
2.9
28.5
12.7
26.2
22 9
1 .3
10.5
S5.0
1.8
3
2
100
4.0
33.7
Per cent.
1 .2
0.9
0.8
4.9
1.1
1.0
1.1
1.0
3.0
1.7
24 7
0.8
i 'alories.
;30
1 495
91)11
1395
505
Turkey
Fresh oysters, s ilid
1360
3 .;
720
Butter
360.5
■in:,
411)
215
Milk
87 l)
34.2
3.3
25 . 9
5.0
2 4
100.0
56 7
73 1
22
65 . 9
19 7
16 9
IS 4
17.3
6.9
(1 7
3.S
325
1950
29 _'
5.9
68.5
10 I
75 1
74.6
78.3
4.S
6.4
8.9
9.8
7 1
18 1
3 1
7.7
2.2
21.0
33.9
4.1
9.1
7
1.5
1 1
0.5
0.1
54.9
49.4
1 1
2 1
1 7
4.1
0.7
1.0
1.0
2.0
3.4
1925
Fresh lima beans
:,7I)
1625
-179
165
385
3030
2845
208
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Ailment
than in the smaller. The energy metabolism increases
in proportion to the surface rather than with the
weight. However, in the human species the variation
in size is relatively not very great and for all practical
purposes the statement is essentially correct that the
greater the weight the greater is the energy require-
ment, cither tilings being equal. Fur the young the
,1 requirement is relatively greater than in the
adult even when calculated according to the unit
surface of body. It is probable that the period of
growth has a distinct influence on the extent of
metabolism and for this reason the food of children
should furnish ample fuel value to compensate for the
more active general metabolism. In old age metab-
olism is much reduced, being lower than in an in-
dividual of medium age, hence the food requirement
is correspondingly diminished. The question as to
what extent sex especially influences the food require-
ment cannot be said to be definitely established.
During life cellular material is constantly undergoing
disintegration as a result of life processes, thereby
creating a constant demand for the elements that
titute the cellular structures. In a large measure
the underlying basis of these structures is nitrogenous
rial, or protein. Hence, the need for food pro-
tein is in direct proportion to the destruction of the
nitrogenous structural elements of the organism.
Under ordinary conditions of life, work is not done at
tin 1 expense of the nitrogenous constituents. Ex-
pressed in other words, muscular activity is not per-
formed as a result of the combustion of protein ma-
terial composing the muscles. Work is done by the
organism preferably by the energy liberated during
the combustion of the non-nitrogenous substances,
the fats and carbohydrates. In the absence of a
sufficient supply of the last-mentioned compounds
protein material, for example, that of muscle, may
e as the source of energy and, therefore, under
these circumstances work may be done as a result of
protein disintegration. There are only a few condi-
tions under which a storage of protein occurs in the
body, and even under these circumstances storage
be merely transitory. Nitrogen may be stored
(a) in the growing body (or in pregnancy) where
tissue is being constructed; (/<) in cases where
ased muscular exercise calls for enlargement of
muscles; (r) in cases where, owing to insufficient food
intake, or to wasting disease, the protein content of
the body has been more or less diminished and conse-
quently any surplus available is utilized to make good
the loss. It follows from these facts, therefore, that
any huge excess of protein over the actual daily need
for tissue reconstruction is probably uneconomical
physiologically. Although protein may furnish gram
for gram as much energy as carbohydrates its
utilization as a source of energy is attended by a great
more difficulty than is true for the carbohydrates.
The latter are usually easily digested and are entirely
assimilated whereas protein disintegration, which
isential in order to make available potential
energy contained therein, is a much more protracted
process, finally resulting in the necessity for increased
activity on the part of the kidneys so that the non-
available nitrogenous products may be eliminated.
The exact amount of nitrogenous food necessary
for man per day is difficult of determination and is
a matter upon which has been based a great deal of
i Dntroversy 10 . An idea of the normal dietary need is
probably best obtained by an experimental determina-
tion of how much protein must be contained in the
food in order to keep the body in protein or
nitrogenous equilibrium. This is done by striking a
balance between the nitrogen of the food ingested
and the nitrogen eliminated in the excreta. A plus
balance indicates a storage of nitrogen in the body; a
minus balance shows a loss of body protein. When
the balance is approximately zero the body is said to
be in protein or nitrogenous equilibrium. From a
Vol. I.— 14
long series of investigations it has been concluded
that the body may so adjust itself in a short period
of time that nitrogenous equilibrium may be estab-
li bed on widely varying quantities of protein.
Thus the same individual may exhibit nitrogenous
equilibrium on -even grams of nitrogen in the form of
protein or on thirty grams or even more. The fuel
value of the food lias a great influence upon the- ex-
tent of protein metabolism by determining whether
the body must draw' upon its own tissues for fuel.
Under these circumstances it is readily conceivable
that non-nitrogenous food -luffs play an important
role in the establishment of nitrogenous equilibrium.
other things being equal it is much easier to get an
individual into a condition of nitrogen equilibrium
when the fuel value of the food is ample than when
the energy yield is small. That tissue protein
catabolism may be greatly diminished by intake of
carbohydrates and fats has long been known and this
action has been designated as their "protein sparing''
effect. Thus the loss of protein from the tissues
which occurs with an insufficient diet may be de-
creased or even entirely stopped by adding carbo-
hydrates and fats to the food. If these substances are
added to the diet of an individual in nitrogen equili-
brium a temporary storage of protein may occur. Up
to a certain point the fats and carbohydrates are inter-
changeable m isody nan lie quantities, that is, one gram
of fat is isodynamic with 2.2 grams of carbohydrate,
beyond this point, which may show marked variation
for different individuals, fat is not well utilized.
Carbohydrates tin- easily utilizable, fats with more
difficulty. The gastroenteric tract rebels at large
quantities of fat. This statement is especially true
for most civilized peoples though exceptions may be
found, as in the Esquimaux and certain savage
tribes.
On the assumption that energy is supplied suffi-
cient to meet all the ordinary demands, how much pro-
tein or nitrogen must the daily food contain in order
to maintain the organism in nitrogenous equilibrium
and in a general condition of well being? Among
other investigators Siven has attempted to answer
this query. Siven with a body weight of sixty kilos
experimenting upon himself found that with sufficient
fuel value he was able to maintain nitrogen equilib-
rium upon thirty-nine grains of protein per day.
The most extended and thorough series of investiga-
tions upon this point were those carried through by
Chittenden. 11 Professional men, athletes, and soldiers
of the United States Army acted as subjects. In the
following table are given a few examples of the results
obtained.
Table III.
TmtalFcel Valce, Protein- Intake and N'itrogex
Balance per Day.
Subject.
Body
weight.
Fuel
value.
Protein.
Nitrogen
balance.
C
Kilos.
.",7
70
01
61
04
64
60
02
7."»
Calories. Grams.
1,613 40 n
Gram.
+ 165
VI. .
2,448
2.00.S
2,152
2,509
2.S40
2.S40
2.4.-.0
2,809
53 2
55 2
63.1
59 4
53.9
54 . 2
55 2
71 7
4-0 38
u
4-0 158
Bo...
+ 34
O(I)
0(11)
Br
+ . S09
-0 2' 12
+ 1 5 !
P
4-0.089
S
4 339
It is apparent from these data that nitrogenous
equilibrium may be established and maintained by
men weighing between fifty-seven and seventy-five
kilos upon an ingestion of protein per day varying
209
Aliment
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
from forty to seventy-two grains without appreciably
increasing the fuel value of the food ingested. The
figures, however, probably represent the minimum
quantity of protein compatible with nutritional
rhythm and continued vigor,.
On the other hand, custom and habit have played a
role in the establishment of so-called dietary stand-
ards. 11 '! Thus Voit in Germany, by estimation of
the food eaten by the ordinary individual, set up a
standard whereby the organic food requirement
should approximate:
IIS grams protein.
5G grams fat.
500 grams carbohydrates.
These quantities of food-stuffs would furnish about
3,000 calories.
Playfair in England promulgated the following
standard:
119 grams protein.
51 grains fat.
531 grains carbohydrates,
which would yield a fuel value of 3,000 calories.
In France Gautier proposed a standard for men
with little muscular work as follows:
107 grams protein.
65 grams fat.
407 grains carbohydrates.
The fuel value of this dietary would furnish 2,630
calories.
Langworthy has collected the data of large numbers
of dietaries of families under diverse conditions both
in the United States and abroad, and stating them in
terms of protein and calories per man per day has
compiled the following table.
Table IV.
Langworthy's Compilation of Results of Dietary
Studies. 12
Food per man
Occupation of head of family.
per
day.
Protein
Fuel value
grams.
cal< tries.
United States:
Man at very hard work (average 19
177
6,000
studies).
Farmers, mechanics, etc. (average 162
100
3,425
studies).
Business men, students, etc. (average
106
3,285
51 studies).
Inmates of institutions, little or no mus-
S6
2,600
cular work (:iv<-ruge of 49 studies).
Very poor people, usually out of work
69
2,100
(average 15 studies).
Canada: Factory hands (average 13
10S
3,480
studies).
89
2,685
108
3 228
9S
3,107
German v:
134
3,061
Professional men
111
2,511
110
2,750
Japan:
118
S7
4,415
2,190
At
3,-100
112
2,825
108
2,812
In addition to the foregoing functions of the non-
nitrogenous food stuffs these substances may be of
service to the body in other ways. Thus although
fats are especially important for the fuel value they
furnish, they form the basis of adipose tissue and are
essential for tissue development generally. The
great importance of fat in food and of that deposited
in the body is to be found in the aid which it furnishes
to the hungry organism in developing its wasted
tissue. A purely protein diet for a person poor in
fat necessitates a large amount of the former to
sustain the weight of the body, indeed more than the
intestines are capable of absorbing. But a mixture
of fat and protein diminishes protein metabolism.
It is not possible to convert a poor body into a body
rich in fat and protein material by an exclusive
protein diet; fats or carbohydrates are needed,
admixture of which diminishes the work of the
organism. Carbohydrates, without doubt are in a
large measure the source of fat in the body. Sugar
or starch is always present in fattening foods and
although there is little evidence of a positive nature
that fat is formed directly from carbohydrate there
is a close relationship between carbohydrate intake
and fat deposition in the organism. It has been
suggested that carbohydrate functions by protecting
the fat already deposited. It does this by under-
going combustion instead of the fat.
Collagenous tissue, comprising the gelatinous
principles (organic basis of bone, cartilage, tendons,
and connective tissue), cannot supply the place of
the true proteins; still, Voit has found that nitrogen-
ous equilibrium is established at a lower level of
protein food when gelatin is added. The value of
gelatin has been found by Murlin 13 to be dependent
to a high degree upon the protein condition of the
body, on the calorific value of the food and the quan-
tity of carbohydrates in the latter. When two-thirds
of t lie total calories partaken of were in the form of
carbohydrates, gelatin could supply sixty-three per
cent, of the total nitrogen. Gelatin may also some-
what decrease the consumption of fat, although it is
of less value in this respect than the carbohydrates,
Water is of exceeding great importance for the well
being of the organism. According to Voit, the body
of a fully developed man contains sixty-three per
cent, of water, while the body of a growing child
contains nearly 66.5 per cent. Any great alteration
in the content of water in the animal body is always
attended with disastrous results; thus, in diarrhea,
cholera, etc., such large quantities of water are lost
as tn render the blood quite thick, and even the
muscles may lose as much as six per cent, of water.
Such loss, if long continued, soon results in loss of
vitality and consequent death. It is noticeable,
moreover, that a certain proportion of the water
contained in the tissues of the body can be removed
without difficulty, while a smaller, residual portion,
apparently more closely united to the organic matter,
can be separated only with great difficulty; this is
well illustrated in the simple drying of dead muscle
tissue. Removal of the water from low forms of
animal life, by drying them at the ordinary tempera-
ture, or at a temperature below the coagulating
point of their body protoplasm, causes them to lose
all appearance of life; but in such condition they will
again absorb the water lost, and return to their
former appearance and vitality. Increase of water
in the organism beyond the normal amount is usually
associated with an unhealthy condition of the body.
Various investigators have likewise demonstrated
t hat there is a close connection between the percen
of water in the body and the diet, irrespective of tin'
water taken as drink. Thus Voit has shown that a
bread diet, continued for some time, renders the body
more watery than normal. In one experiment with
a cat, the amount of water in the brain and muscles
was increased three to four per cent. Increase of
fat in the body is usually attended with a diminished
percentage of water. A vigorous, well-nourished
man possesses organs much poorer in water than a
badly fed person. Forster 14 nas figured that under
210
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Aliment
normal conditions a person living on an average diet
alces daily from 2,215 to 3, 538 grams (about 6.5 pounds
ivoirdupois) of water. It is easy to see, however,
i a great variety of circumstances, as variations
,i diet, exercise, temperature, etc. may have a
modifying influence on the amount of water taken
i to the system during the twenty-four hours. The
just given do not, however, represent all of
the water, since a variable amount is formed within
[he body by oxidation of tin- hydrogen contained in
organic food -stuffs. Tims, according to Voit in
case of a hungry man. thirty-two grams of hydro-
in the form of organic matter were oxidized to 288
us of water during twenty-four hours.
It is thus plainly evident from tin' Ion going that
er is a necessary constituent of the body, and as
. of the food-stuffs is a decidedly important one;
are need to understand its true significance. It
- not itself undergo any chemical change, and is
it source of energy, though it aids chemical
ige in supplying by its presence a condition
Mutely necessary for its occurrence in other
bodies.
The mineral matters are more closely concerned in
the structure of the organism than in the liberation
of energy, and this is true both of animal and vege-
table organisms. Further, inorganic salts appear to
. > an important part in regulating and controlling
line measure the various metabolic processes oi
the body although they themselves contain little or
no potential energy. They maintain a normal com-
ii. m and osmotic pressure in the liquids and
ues of the body, and by virtue of their osmotic
~ure they play an important part in controlling
low of water to and from the tissues. Moreover,
• salts constitute an essential part of the com-
position of living matter. They are bound up in the
re of the molecule in an intimate manner and
are necessary to its normal irritability. The proteins
of the body fluids contain definite amounts of ash
if this is removed the properties of these sub-
ire greatly changed. They are particularly
ssary in the developing animal body. Mineral
ter is needed not only for the growth and nutrition
of the skeletal port ions of the body, but it is also needed
in the structure of the softer tissues, as well as in
formation of secretions; thus, the acid of the
lie juice has its origin in the chlorine of sodium
i!e, or common salt, while the alkalinity of
the pancreatic secretion, as well as that of some of the
er fluids of the body, is due mainly to inorganic
salts, as the alkali phosphates and perhaps bicarbon-
ates. In many juices of the body, inorganic elements
arc held not only in solution, but quite firmly united
i the more characteristic matter, as in the sodium
salts of the bile acids, and in some instances they can
be removed only by decomposition of the compound.
The excess of salts taken into the body, by the food
or other means, and that which becomes free by
imposition within the body, is easily removed
througn the urine and feces.
There is still other evidence that the various
inorganic salts of food serve definite purposes in the
body." The two alkalies, potash and soda, so widely
distributed (for distribution of sodium and potassium
in some common foods see Table V.) and so closely
allied in their chemical properties, cannot be made
to replace each other in the living organism, while
the same is likewise true, to a certain extent, of the
alkali earths, lime and magnesium. Thus a qualita-
tive, and also a quantitative, selection of inorganic
matter is noticeable in the body, particularly in the
blood, where the corpuscles contain the greater por-
tion of the potassium salts and phosphates, while in
the serum, sodium salts and chlorides are in excess.
Again, it is quite noticeable that potassium salts
predominate in the formed tissues of the body, while
sodium salts are characteristic of the fluids.
I orster's experiments on pigeons with food poor in
salts, and on dogs u jth powdered meat from which
the greater portion of inorganic matter had been
ii moved by extraction with hot water, fat and carbo-
hydrates being afterward added, showed that these
animals could not bear the loss longer than four to
live weeks without great suffering, and, finally, death.
In fact, it is evident, from physiological experiment,
that an organism supplied with all organic food -tell
and water can live only for a limited time without
mineral matter. For a time the body draws upon
tin' inorganic matter stored up in it- own tissue: but
this failing, and that naturally present in the organic
f Is being removed, death soon results from lack of
inorganic aliment. In the ordinary diet of men and
animals, sufficient salts are generally contained in the
non-nitrogenous and proteid foods to furnish the
required amount of mineral matter. As to the
actual quantity of inorganic mat ter needed to counter-
balance that withdrawn from the hotly in twenty-
four hours, we can hardly say.
The eight elements, iron, calcium, magnesium, po-
tassium, sodium, chlorine, sulphur, and phosphorus,
constitute the so-called ash of our foods, in other
words, the inorganic food-stuffs.
Iron may be looked upon as the link connecting the
organic and inorganic food stuffs to the body com-
pounds. This element is an integral part of hemo-
globin and other compounds associated with the proc-
esses involved in oxidation, secretion, reproduction,
and development. The iron contained in these sub-
stances is in a firm organic combination with proteins.
These organic compounds of iron are probably in
turn constructed from somewhat similar iron-con-
taining groupings in the food-stuffs. Numerous in-
vestigations have been carried through to determine
the influence of various preparations of iron upon
the storage of this element within the organism, with
the general conclusion that the iron of naturally
occurring food-stuffs best serves the purpose of recon-
struction of hemoglobin within the body. It has
been estimated that approximately ten to fifteen
milligrams of food iron are sufficient to maintain an
average man under normal conditions in iron equilib-
rium. In the typical food-materials iron exists in
varying quantities (see Table V.). In meat iron occurs
largely in hemoglobin retained in the muscle tissue.
The iron present in milk, eggs and the vegetable
foods is perhaps better absorbed and assimilated to
greater advantage than the iron of meat. In the
grains a great portion of the iron exists in the germ
and outer layers. Hence, in the process of milling
this iron is rejected so that fine flours are less rich
in this element than the natural cereals. Vegetables
and fruits contain appreciable quantities of iron which
man undoubtedly utilizes to the best possible advan-
tage. Foods containing little iron are fat pork, bacon,
lard, butter, salad oils, sugars, starches, and confec-
tionery. Iron is eliminated from the body chiefly
through the intestine.
Of the calcium salts ingested only about one-tenth
is excreted through the kidney. Like iron this ele-
ment is eliminated from the body through the intes-
tinal wall and so passes out with the feces. If ani-
mals are kept for long periods of time upon diets poor
in calcium, marked wasting of lime salts from the
bones may occur. This is especially true for the
young growing individual in whom the symptoms of
an inadequate supply of calcium salts are chiefly mani-
fested by abnormal weakness and flexibility of the
bones. Herter 10 ascribes to insufficient assimilation
of calcium in the food many cases of arrested develop-
ment in infancy. The calcium requirement has not
been definitely established, although it is probable
that the ordinary healthy man needs about 0.7 gram
calcium oxide per day to maintain calcium equilibrium.
Calcium occurs chiefly in the skeleton as calcium phos-
phate and carbonate. It is these salts that give
211
Aliment
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
rigidity to the bones. Of the calcium in the body
about ninty-nine per cent, is found in the bones and
the remainder is distributed, partly in organic com-
bination with the proteins, and partly in solution in
the blood and other body fluids. Calcium salts are
especially necessary for the coagulation of the blood
and are of prime significance for the normal action
of the heart muscle. Moreover, calcium plays an
important role in regulating disturbances in inorganic
equilibrium. "Calcium is capable of correcting the
disturbances of the inorganic equilibrium in the animal
body, whatever the directions of the deviations from
the normal may be. An abnormal effect which
sodium, potassium, or magnesium may produce,
whether abnormality be in the direction of increased
irritability or of decreased irritability, calcium is
capable of reestablishing the normal equilibrium." 17
The occurrence of calcium in some of the common
foods may be seen from an inspection of Table V. It
will be noted that milk is particularly rich in this
element. Beef and flour are much poorer in calcium.
Other cereals which have undergone the milling
process contain less calcium than the whole grain-.
ample, phenol, cresol, indol, skatol, in a form which
is known as an "ethereal or conjugated sulphate."
Table V. shows the distribution of sulphur in a few
common foods.
Phosphorus is an essential cell constituent and as
such is found distributed throughout every tissue and
fluid of the body. Phosphorus occurs in foods chiefly,
in four forms; (a) in the proteins, as nucleoprotein of
cell nuclei, lecithoproteins, and phosphoproteins as
exemplified by casein and vitellin; (b) in the phos-
phatides, as the lecithins; (c) as organic derivatives
of phosphoric acid (inosite phosphoric acid ester) of
which the salts occurring naturally in wheat are called
"phytin"; and (d) inorganic phosphates which are
found in abundance in most foods. Phosphorus is
absolutely necessary for normal nutritional processes
and to maintain phosphorus equilibrium approx-
imately one gram of phosphorus is required per day.
For the reconstruction of nuclear material of cells
phosphorus is essential, and the problem has ari-cn
whether for this purpose organic or inorganic phos-
phorus is demanded. It is probable from recent ex-
periments' 9 that the organic phosphorus constituents
Table V.
Ash Constituents of Foods in Percentage op the Edible Portion. ls
Food.
CaO.
MgO.
K-O.
Najtl.
r ii
ci.
Fe.
Almonds
Apples
Asparagus
Bananas
Lima beans, fresh . .
Beets
Cab] >age
Carrots
Celery
Corn, fresh
Eggs
Codfish
Lean beef
Milk
Oatmeal
Wheat flour
Peas, fresh
Potatoes
Rice
Squash
Turnips
Walnuts
Wheat, entire grain
30
.35
014
.014
04
.02
01
.04
04
.11
03
.033
068
.026
077
.034
10
.04
nils
ii.-,.',
09S
.01.-)
(II. - )
.03
nil
.04
16S
.019
13
.212
025
.1127
04
.07
016
.036
012
.045
02
.01
089
.028
108
. 237
061
.213
20
.03
15
.02
20
.01
50
.02
70
.12
45
.10
45
.05
35
.13
37
.11
137
.05
165
.20
40
.13
12
.09
171
.038
158
.109
146
.04
30
.04
53
.025
084
.028
05
.05
40
.08
44
.03
519
.mis
.87
.03
.09
1 1.-,;,
.27
.09
.09
.10
.10
22
.37
.40
.50
.215
.872
.20
.26
.140
. 203
.OS
.117
.902
005
.135
.002
004
.005
.0003
04
.04
.0010
20
.013
.0006
009
.06
.0025
04
.015
.0006
03
.07
0011
036
(122
.0008
17
1125
;>
014
.044
.0008
10
.19
.003
24
0004
05
.20
0038
12
.033
. 00024
035
.215
.0036
07
.17
.01115
01
.06
.0016
03
.03
.0013
05
.105
.0009
01
.026
in ins
04
.07
. 000.5
01
.195
.0021
OS
.17
.0053
In general fruits and vegetables contain fairly large
amounts of this element. This is particularly true
of the fresh vegetables. It is apparent, however,
that in order to insure to the body an abundance of
available calcium the dietary should include an ample
supply of milk.
Our knowledge concerning the functions of mag-
nesium in the body is vague. Beyond the fact that
this element is a constituent of practically all the tis-
sue-; and fluids of the body, especially of the bones
and muscles, and that in general calcium and mag-
nesium appear to be antagonistic little is definitely
known. For the distribution of magnesium in a few
foods see Table V.
Sulphur occurs chiefly in the body in combination
with proteins and as such it gains entrance to the
organism, although some sulphur in the form of sul-
phates may also be ingested with the food. In the
disintegration of the protein materials incidental to
their assimilation, sulphur is oxidized to sulphuric
acid which is neutralized as rapidly as it is formed by
one of the basic elements and in this form is elimi-
nated by the kidneys. A smaller portion of the sul-
phuric acid formed is combined with an organic
radicle, usually but not necessarily derived from
putrefactive processes in the large intestine, for ex-
212
of the cells may be satisfactorily constructed from
the ingestion of inorganic phosphates, although it is
also undoubtedly true that the organism has a prefer-
ence for phosphorus in organic combination. Table
V. gives the content of phosphorus in a few f Is.
These figures do not indicate the nature of the phos-
phorus compound present and it is possible that the
four types of phosphorus compounds mentioned above
are not equally available for the restoration of body
phosphorus. Phosphoproteins and phosphatides arc
particularly abundant in eggs. In milk both phos-
phoprotein and inorganic phosphates are found,
Meats and fish contain phosphorus chiefly in the form
of inorganic phosphates. The salts of phytic acid,
collectively designated " phytin " are present in largest
quantity in both the inner and outer portions of the
various grains.
Condiments. — Under the general term of accessory
articles of diet are classed the condiments, flavors, and
stimulants. These substances are included in the diet
to increase the attractiveness of our food and although
in general they may impart a certain amount of energy
to the organism by their oxidation they are of nutri-
tional importance for entirely different reasons. The
condiments and flavors function by giving to the food
a sufficient degree of palatability which in turn by the
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Alimi'iit
so-called psychical stimulation facilitates gastric se-
cretion. Some of these substances may have an
additional value in that they increase the rapidity of
absorption from the stomach. Gautier 20 has divided
the condiments into the following classes: (1) Aro-
matics, comprising vanilla, anise, cinnai i, nutmeg,
and other similar essential oils; (2) peppers; (3) the
alliaceous condiments, garlic, mustard, etc.; (4) the
acid condiments, vinegar, citron, pickles, etc. ; (5) the
condiments, such as table salt : (6) the sugar condi-
I rider the head of stimulants are included
hoi, tea, coffee, cocoa, chocolate, and meat extracts.
ol. — The alcoholic, drinks contain from forty
to sixty per cent, of alcohol, as in rum, brandy, and
whisky, to from two to ten per cent., as in beer and
wines. Malt liquors contain, perhaps, the largest
iber of constituents, among others there being
ii-, dextrin, gluten, and various substances from
hops. The exact value of alcohol-' 1 as a food,
broadly considered, is uncertain. Experiments, care-
fully made on man, however, clearly show that when
rale amounts of alcohol are ingested, the alcohol
is burned up in the bodj- — i.e. oxidized like any non-
ogenous food. The potential energy of the alcohol
is transformed into kinetic energy, and consequently
hoi h to be considered as having some food value.
it may, therefore, be classified with the non-nitrogen-
ous foods. Further, as a non-nitrogenous food, alcohol
replace an isodynamic amount of fat or carbohy-
drate in the diet without change in the balance of income
and outgo. Alcohol serves to protect body protein
and fat from oxidation; i.e. like a typical non-pro-
tein food it diminishes the oxidation of tissue protein
by being itself oxidized. These facts, however, do
not imply that alcohol is necessarily a desirable food
or that it is physiologically economical. It is to be
remembered that, prior to its oxidation in the body,
alcohol may produce deleterious effects of various
kinds, more than counterbalancing any gain which
may result from its oxidation. It may likewise give
rise to changes, either directly or indirectly, in the
various metabolic processes of the body, which must
of necessity influence more or less its value as a food.
Moreover, the danger entailed when the dose is too
large prevents its ready acceptance as a practical
food-stuff. On account of its easy absorption it has
f't d suggested, however, as a useful substitute for
the solid, non-nitrogenous food-stuffs in sickness.
There are many reports of cases where alcohol has
served as the principal nutriment during the critical
periods of fevers and in other conditions which would
tend to lend support to the above suggestion. There
are also results upon diabetic patients which indicate
that in this condition alcohol used as a food dimin-
ishes the production of acetone bodies and protects
the protein. Alcohol has a direct and an indirect
influence upon the secretion of gastric juice. In this
direction it acts as a stimulant. It likewise stimu-
lates the secretion of saliva.
Tea and coffee owe their well-known stimulating
action to the presence of the alkaloid caffeine, or
trimethyl xanthine. This substance has a diu-
retic action upon the kidney and raises blood pressure.
This influence upon blood pressure is probably the
reason that sleepiness may be prevented by partaking
of tea or coffee. Muscular energy is augmented and
the sense of fatigue dissipated by nie use of these
stimulants.
Cocoa, or the chocolate made from it by the addi-
tion of sugar, has considerable nutriment due to
the presence of proteins, fats, and carbohydrates.
Its stimulating action, however, is caused in large
measure at least by theobromine or dimethylxanthine.
Meat extracts in themselves have very little food
value. They contain a trace of protein and gelatin,
but the peculiar value of meat extracts lies in the
presence of the so-called nitrogenous extractives,
namely : creatine, xanthine, hypoxanthine, etc. These
substances are likewise stimulants. They also
call forth a copious secretion ol gastric juice and
for this reason have been called secretogogues. They
are undoubtedly of great importance in thi~ respect.
The experiments of Folin M would seem to indicate
that creatine may serve as a real food-stuff when the
diet is deficient in protein.
The significance of some hitherto unrecognized com-
ponents Of the food is gradually being evolved. An
example may be cited in the disease beriberi preva-
lent among the Japanese. This condition of abnor-
mal nutrition has long been assumed to bear an indefi-
nite relation to the large quantity of rice consumed
by this nation. < inly recently, however, has it been
demonstrated that beriberi is caused presumably by
polished rice. Experimentally, it has been shown
that a pathological condition of the nature of poly-
neuritis may be induced in bints by feeding rice that
has been polished and hence deprived of the cortical
layers. Both beriberi in man 23 and polyneuritis
provoked in birds may be cured by feeding the cortical
layers df rice. The chemical nature 21 of the curative
substance has not yet been exactly determined for the
reason that it is present only in minute amount,
probably not more than 0.1 gram per kilo of rice. It
is probable that other equally striking relationships
bet ween certain at present unappreciated constituents
of the food and disorders of nutrition will be made
clear as detailed knowledge of the foods is increased.
Frank P. Underbill.
References.
1 Fischer: Untersuchungen ueber Aminosauren, Polypeptide, und
Proteine, 1906.
2 Protein literature may be found as follows: Schryver, The
General Characters of the Proteins, 1909: Plimmer, The Chemical
Constitution of the Proteins, 190S; Osborne, The Vegetable
Proteins, 1909.
3 Compiled from Abderhalden: Text-book of Physiological
Chemistry, 190S, and Osborne: The Proteins of the Wheat Kernel,
1907.
4 For literature on carbohydrates consult Armstrong: The
Simple Carbohydrates and the Glucosides, 1910.
4a cf. Schwartz: Nutrition Investigations on the Carbohydrates
of Lichens, Alga?, and Related Substances: Transactions Con-
necticut Academy of Arts and Sciences, 1911, 16, p, 247.
5 Lusk : American Journal of Physiology, 1910-11, p. 27, xxii,
6 Literature relative to fats may be found in Leathes: The
Fats, 1910.
7 Long: Text-book of Physiological Chemistry, 1905.
8 Atwater and Bryant : Bulletin 2S (Revised edition) U. S.
Dept. of Agriculture.
9 Sherman: Chemistry of Food and Nutrition, 1911, p. 118.
10 cf. Sherman: loc. cit. p. 221, for brief review.
11 Chittenden: Physiological Economy in Nutrition, 1904.
Chittenden: The Nutrition of Man, 1907.
11a cf. Mendel: Theorien des Eiweissstoffweehsels nebst einigen
praktischen Konsequenzen derselben. Ergebnisse der Physiologie,
xi., Jahrgang.
12 Taken from Sherman: loc. cit.
13 Murlin: American Journal of Physiology, 1907, 19, p. 285.
14 Hammarsten: Text-book of Physiological Chemistry, 1911,
p. S61 , for literature.
15 Albu and Neuberg: Physiologie und Pathologie des Mineral-
stoffn-echsels, 1906.
16 Herter: On Infantilism from Chronic Intestinal Infection,
190S, cf. also Albu and Neuberg, toe. cit.
17 Meltzer: Transactions of Association of American Physicians,
190S.
IS Compiled from Sherman, loc. cit.
19 McCollum: Research Bulletin. No. 8 Wisconsin Agricultural
Experiment Station and Fingerling: Bichemische Zeitschrift,
1912, 38, p. 448.
20 Quoted from Howell: Text-book of Physiology, 1911.
21 Atwater and Benedict: Bulletin 69, IT. S. Dept. Agriculture;
Chittenden, Mendel and Jackson: American Journal of Physology,
1898,1, p. 47; Rosemann : Alcohol in Handbuch der Biochemie, 1911,
iv, 1, p, 413.
22 Folin : Hammarsten's Festchrift, 1906.
23 Eykman: Virchow's Archiv., 1S92, 14S, p. 523; Ibid., 1897,
149, p. 187; Archiv. fiir Hygiene, 1906, 58, p. 150. Gryns quoted
by Schaumann : Archiv. fiir Schiffs-Tropenhygiene, 1910. Fraser
and Stanton: Studies from the Institute for Medical Research.
Federated Malay States, No. 12. The Etiology of Beriberi, 1911
24 Funk: Journal of Physiology, 191] , 43, p. 395.
213
Alimentary Tract
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Alimentary Tract. — See Digestive Tract.
Alimentation, Duodenal. — Every clinician knows
how unsatisfactory rectal feeding is. The food is
utilized only in a small degree, and, besides, the
rectum often becomes irritable, so that the enemata
' must be stopped. It is, therefore, desirable to have
some other way of feeding to the exclusion of the
stomach.
The duodenal pump, 1 which usually serves the pur-
pose of obtaining the duodenal contents, can also be
used for the introduction of food into the duodenum.
This kind of feeding the writer has designated,
" duodenal alimentation". 2 , 3 , 4
The method consists simply in introducing the
duodenal pump (Fig. 68) into the digestive tract, and
feeding is begun as soon as its end is in the duodenum.
The apparatus is left in the digestive system for from
ten to fourteen days. The thin rubber tube does not
inconvenience the patient, and thus every thing is
ready for the feeding. This is best done at intervals
of two hours. After the feeding, water is forced
through the tube, and finally air blown through and
t In- stop-cock is closed. We can introduce at one feed-
ins; between 240 to 300 c.c. of food slowly. All fluids
must, of course, be used at body temperature.
The injection of the food is facilitated by the use of
a specially constructed support for the duodenal
feeding apparatus. (See Fig. 2.)
Usually the following nutritive material is used
every two hours, from seven in the morning until
nine in the evening. Milk, 240 c.c; one raw egg;
sugar of milk, fifteen to thirty grams. The mixture
is well beaten up, strained, and injected at blood tem-
perature. At times I have added cream in order to
increase the nutritive value; sometimes have omitted
the milk sugar when there was a tendency to loose
bowels. In one case, I had to discard the milk en-
Fig. 67. — Patient Being Fed through the Duodenum.
tirely, since the patient had a marked idiosyncrasy for
this substance, even when passed directly into the
duodenum. Severe abdominal pains resulted as
well as diarrhea. In this case I used the following
scheme of nutrition: 7:30 a.m., oatmeal gruel, ISO c.c,
one egg, butter, 15 c.c, lactose, 15 c.c; 9.30 a.m.,
pea soup, 180 c.c, one egg, butter, 15 c.c, lactose,
15 c.c; 11.30 a.m., the same as at 9.30 a.m.; 1 .30 p.m.
bouillon, ISO c.c, and one egg; 3.30 p.m., oatmeal
gruel, ISO c.c, butter, 15 c.c, one egg, lactose, 15 c.c;
5.30 p.m., pea soup, 180 c.c, butter, 15 c.c, one egg,
lactose, 15 c.c; 7.30 p.m., the same as at 5.30 p.m.:
9.30 p.m. bouillon, ISO c.c, and one egg. Total daily
quantity oatmeal gruel, 360 c.c; pea soup, 720 c.c;
214
eggs, 8 ; lactose, 90 c.c. ; bouillon, 360 c.c. ; butter, 90 c.c.
The pea soup .was made from Knorr's pea flour, one
tablespoonful to 250 c.c. of water which was boiled
down for from one and a half to two hours to 180 c.c.
It is self-evident that many more substances might
be utilized for duodenal alimentation. Tin- main
point to be observed is that the mixture must be a
very fine fluid emulsion, without any coarser particles,
so as not to clog the narrow duodenal tube. I; i,
therefore best to filter the mixture first through a fine
sieve or through gauze. If these rules are observed
there will rarely be any difficulty.
Fig. 6S. — The Duodenal Feeding Apparatus, with Table Support.
A, Tube leading to syringe; B, tube leading to duodenal |
C, crank; D, tube leading to fluid; F, fluid; G, glass; T, t; I
or shorter support. When crank C is turned parallel to A. fluid
can be aspirated from the glass into the syringe. When C is
moved parallel to B, the fluid from the syringe can be em]
into the duodenum.
The patients may be given, besides, a quart of
physiological salt solution by rectum, according to
the Murphy drop method, or the water may be injected
directly into the duodenum, but very slowly, drop by
drop.
The advantages of duodenal over rectal feeding
are at once apparent; for while the rectum and colon
are simply organs for the expulsion of feces and for
the absorption of possibly remaining liquids, we have
to deal in the duodenum with an organ where the most
important digestive juices are secreted. In the colon
we have to do with the last part of the digestive tract,
in the duodenum, however, with the principal part of
the digestive apparatus, so that everything is here
utilized. Max Eixhorx.
References.
1 Medical Record, January 15, 1910.
2 Medical Record, July 16, 1910.
3 Interstate Medical Journal, vol. xvii., No. 10, 1910.
4 Medical Record, March 9, 1910.
Alimentation, Rectal. — Rectal alimentation is
employed whenever nutrition in the ordinary way (by
the mouth) is either impossible or not desirable. I
method of alimentation was already used in the Mid-
dle Ages and in ancient times. Aetius occasionally
mentions such method of feeding. The value of tliis
way of nourishing a patient, however, was belii
to be very slight, until extensive experimental re-
searches with reference to absorption of food from
the large bowel had been made. These defini
showed that digestion to a great extent can pn"
in the colon if the ingested food is suitably prepared.
Among the earliest investigators in this direct ion were
Hood and Steinhauser. Hood observed that a piece
of mutton introduced into the rectum and retail'
after some time showed evident signs of digestion.
Steinhauser experimented on a patient with a fistula
of the ascending colon, and found that pieces of al-
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Alimentation, Rectal
mmen introduced into the fistula could not be disco v-
,v,l in the feces. Pieces of smoked beef and apples,
,,, (fir oilier hand, were found either slightly altered
>r entirely unchanged in the stool.
Eichhorst stated in l.Si 1 that absorption of album in-
ites from the bowel is facilitated, if not made possi-
ile, by the addition of common table salt. He ex-
lerimented principally with egg albumen mixed with
he yolk and with milk. S e years later, Ewald
ibserved the very interesting fact thai raw eggs were
iiuch better absorbed from the large intestine than
artificially peptonized foods (Kemmerich's peptone).
Filippi experimented on animals by resecting por-
ions of the intestinal canal. He found that after
xtirpation of seven-eighths of the small intestine in a
there was no appreciable decrease in the absorp-
. i of food-; consisting of albuminates and carbohy-
-. while nineteen per cent, of the ingested fat
eturned with the feces. This clearly shows that the
ilon can vicariously do the work of the small intestine.
[I further demonstrates that albuminates can be ab-
ied from the large intestine and enter the lacteals
..ithoiit previous peptonization. These remarkable
meats have been confirmed by Aldor. This
er experimented principally with milk, and
il «i I t he coagulat ion of t he milk in the large bowel
action of bacteria, not to enzymes. He found
after the injection of from ten to fifteen ounces of
uilk into the bowel, intestinal lavage, performed
to one and a half hours later, showed only minute
particles of milk. The spontaneous evacuation re-
ulting thereafter likewise contained but very small
it tions of coagulated milk.
Aldor, in his paper, arrived at the following
conclusions:
1. A quart of milk, injected by means of a fountain
syringe into the bowel, produces no pains either
luring the injection or afterward. No irritation of
the intestine follows, and milk is most suitable for a
nutritive enema.
2. The coagulation of the milk, which is due to the
action of the bacterium coli commune, is rather detri-
mental to absorption. This coagulation can be pre-
vented, (a) by thorough lavage of the bowel before
giving the nutritive enema, (b) by adding 1 to 1.5
grams (gr. xvi.-xxiv.) of sodium carbonate to one
quart of milk.
3. No digestion takes place in the large bowel.
4. Carbohydrates are absorbed in an excellent
manner, albuminates in a great measure, and fats but
poorly.
5. After an injection of a quart of milk into the
bowel, there was never found either albumin or sugar
in the urine.
In America the attention of the medical profession
was first directed to rectal alimentation by Austin
Flint, who read an extensive and important paper on
this subject before the New York Academy of Medi-
cine in December, 1877. Flint mentioned a case in
which a woman was almost wholly nourished per
■turn for five years. After emphasizing the impor-
tance of rectal alimentation in instances in which the
usual mode of nutrition fails or is impossible, he gave
directions as to the mode of employment of the nutri-
tive^ enemata. From three to six ounces of fluid or
semi-fluid foods may be injected at intervals of
from three to six hours. He did not deem it neces-
sary to wash out the rectum prior to each administra-
tion of the nutritive enema. Flint, as well as Peasley,
lordyce Barker, A. H. Smith, and G. M. Smith,
who took part in the discussion of the above paper,
had all practised this method of feeding with best
results. A. H. Smith mentioned several instances of
gastric ulcer in which nutrition had been successfully
maintained by rectal alimentation for from eleven
to sixteen and twenty-one days. He was the first
who suggested the use of defibrinated blood for this
purpose.
Very shortly afterward W. Bodenhamer published
an instructive monograph on rectal medication, in
which he also laid stress upon t l t e practical value of
rectal alimentation as deserving much more frequent
application than heretofore.
Stillman, in his paper on rectal alimentation, says:
"The clinical fact remains th.it certain foods, digested
or undigested, are taken into the system when thrown
into the rectum; that the power of absorption there
may be good when the stomach is weak and rebellious;
that it is assimilated, for the body gains in flesh and
power, and that there may be merely the customary
evacuation as an excretory resultant. As far as 1
am aware, no danger attends feeding by the rectum,
when conducted with ordinary care and intelligence
on the part of nurses or attendants." In this paper
Stillman calls attention to the use of supplementary
rectal feeding, i.e. to the use of nutrient enemata
while the stomach is yet performing its functions to
quite a considerable extent, as, for instance, in chronic
gastritis, gastralgia, nausea, etc. He used principally
enemata of milk according to the following formula:
five grains of pancreatic extract and fifteen grains of
bicarbonate of sodium to a pint of milk.
The writer has had extensive experience with rectal
alimentation and is fully convinced of its great prac-
tical value, notwithstanding the impossibility of
keeping thereby the body weight in balance. The
indications for this mode of alimentation may be
summarized as follows:
1. In conditions in which the passage of food from
the mouth to the stomach or to the small intestine is
impeded or made impossible (strictures, benign or
malignant, of a high degree, of the esophagus or cardia,
spasmodic or paralytic conditions of the esophagus,
pyloric or duodenal stenosis).
2. In ulcer of the stomach accompanied by consider-
able hemorrhage, or when the usual methods of
treatment have failed.
3. Incessant vomiting, no matter to what cause it
be due.
4. In all conditions in which absolute rest for the
stomach seems to be imperative (intense pains soon
after ingestion of food; persistent hyperchlorhydria of
a high degree; intense chronic continuous gastro-
succorrhea; pronounced ischochymia).
5. In typhoid fever and other severe lesions of the
small intestine necessitating a complete rest of this
portion of the bowel.
For how long a period rectal alimentation should be
administered depends upon the condition necessitat-
ing it. In ulcers and irritating affections of the
stomach, rectal alimentation should be administered
alone, without any additional nourishment through
the mouth, for a period varying from one to two weeks,
when the natural mode of nutrition may be cautiously
resumed. In cases in which there is an organic
obstacle within the esophagus or at the pylorus
preventing the passage of food into the intestine,
rectal feeding must be carried on as long as the
impediment exists (in operative cases until a few days
after the operation has been performed; in inoperable
cases, indefinitely). Here, whenever possible, besides
the enemata, small quantities of liquid foods may
also be given by way of the mouth.
Shortly after operations on the esophagus, stomach,
and small intestine, rectal alimentation must be
administered for a period varying from four days to
a week or ten days.
Mode of Administration. — Before administering
the feeding enema, a cleansing injection (consisting
of a quart of water and a teaspoonful of salt) should
be given early in the morning, in order thoroughly to
evacuate the bowel. One hour later the first rectal
alimentation may be administered. The feeding
enema is best injected by means of a fountain syringe
or a Davidson syringe, or a plain hard-rubber piston
syringe, and a soft-rubber rectal tube, which is intro-
215
Alimentation, Rectal
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
duced into the anus for a distance of about five to
seven inches. The injection should be administered
slowly and without much force. After the with-
drawal of the tube from the rectum, the patient is
told to lie quietly and to endeavor to retain the enema.
The quantity of the feeding enema may be from five
to ten ounces. From three to five such enemata may
be given daily.
The following substances may be used as feeding
enemata:
(a) The different kinds of peptones and propeptones
in the market (Rudisch's or Kemmerich's peptone,
somatose, sanose, sanatogen), of which about one to
two ounces dissolved in from six to eight ounces of water
are to be injected. The different beef juices i Valen-
tine's beef juice, bovinine, Mosquera's beef jelly, etc.)
may also.be dissolved in water and injected in corre-
sponding quantities.
(6) The milk and egg enemata; these are the most
commonly used. Their composition is as follows:
six to seven ounces of milk, one or two raw eggs well
beaten up in it, one teaspoonful of powdered sugar,
and one-third of a teaspoonful of common table
salt. Pancreatin (one tube of Fairchild's pancreatin)
may be added to such an enema, to facilitate its
assimilation.
(c) Meat pancreas enema. Leube employs ene-
mata consisting of well-chopped meat (five ounces),
fresh pancreas (two ounces), one ounce of fat (butter)
— all these ingredients being thoroughly mixed with
about six ounces of water.
(d) Grape sugar enema. One ounce of grape sugar
in ten ounces of water or physiological saline solution.
Instead of always using one and the same nourish-
ing enema, the above combinations may be alternately
administered.
In conjunction with these food enemata, injections
of water into the bowel are made in order to increase
the amount of fluid in the system. These injections
of water for absorption are of great importance.
They are retained much better if injected very slowly
by the so-called "Murphy Drop Method." Usually
saline solutions are employed, in quantities varying
from a pint to a quart, which may be given twice a
day. Max Einhorn.
Alkalies, Antacids. — (See also under title of each
drug.) Medicines which are administered for the
purpose of correcting acidity. The terms are almost
synonymous, but it will be found that the drugs
arrange themselves into two groups, according ot
their solubility, which in a great measure determines
their therapeutic uses. In one we have potash, soda,
and lithia; in the other lime, magnesia, cerium. The
former are generally employed as alkalies, the latter
as antacids. Ammonia is intermediate; its character
would place it in the first group, but its therapeutic
use makes it belong rather to the second.
Alkalies are all powerful depressors. Potash and
lithia are the most injurious, and soda is the least.
They reduce the blood corpuscles and the proto-
plasmic tissue. In large doses they are cardiac poi-
sons, and their prolonged use in moderate doses
causes anemia, loss of body weight, and loss of mus-
cular power.
Potash, soda, and lithia salts are very soluble, and
are readily absorbed and as readily excreted; they
pass from the system in a very short time. They are
normal constituents of the blood, and their presence
in increased amount tends to render the plasma
more alkaline.
Those of the second group, comprising lime, mag-
nesia, and cerium, are much less soluble, and even their
more soluble salts (as the sulphate of magnesium,
etc.) are but slowly absorbed. In consequence their
action is almost entirely limited to the digestive tract.
Many of their soluble salts, as the chlorides, phos-
phates, and hypophosphites, are only mildly alka-
line, and are of value more for the acids in combina-
tion than for the alkaline base.
The action of alkalies upon the secretions of the
stomach, as formulated by Ringer, has been confirmed
by subsequent experience. His view is that the con-
tact of weak alkaline solutions with glands secreting
an alkaline fluid causes a lessening of the secretion
while on acid-secreting glands the effect is to cause
an increase of the acid secretion. Advantage has
been taken of this in gastric disturbances, when there
is a deficiency of acid during digestion. The admin-
istration of alkalies just before meals has proved
most serviceable in relieving this defect. They rnusl
be given well diluted and in moderate doses. The bi-
carbonate of sodium or the bicarbonate of potassium is
generally selected; it is to be given in five-grain doses.
Ammonia, in the form of the aromatic spirits, is
often combined with some stomachic, as tincture
of rhubarb, tincture of cardamom, capsicum, gin-
ger, or peppermint, and in addition a vegetable bitter.
This combination has been found to be valuable.
In addition to the local effect thus produced upon
gastric digestion, a further benefit is derived by the
action of alkalies after absorption. They rapidly pass
into and improve the blood, and during excretion
they cause a general stimulation of all secreting organs.
As alkalizers of the blood, they are used in gouty and
rheumatic conditions, in lithiasis, and in many dis-
orders of the skin in which there is supposed to be an
excess of uric acid or allied acids in the blood. Their
purpose is to keep these morbid products in solution
until they are carried out of the system. The potas-
sium salts are preferred, as their rapid absorption
renders the blood more quickly alkaline, while their
equally rapid excretion prevents any accumulation.
For immediate action the bicarbonate salt is selected;
but when a prolonged use is required, the citrate,
acetate, or tartrate is preferred. Sodium salts are
more slowly absorbed and are less powerful alkalies.
The normal alkaline state of the blood is due chiefly
to sodium salts, and as they are less depressing than
potassium salts, they offer many advantages when a
prolonged course of treatment is necessary. In
treating rheumatism with the alkalies, they require
to be given freely until the urine becomes alkaline,
and then they should be reduced, enough being given
simply to maintain this reaction. There may be given
a dram and a half of bicarbonate of sodium and
half a dram of the acetate of potassium every three
or four hours, well diluted, for four or five doses; fol-
lowing this, fifteen or twenty grains will usually be
sufficient. Lithia is very similar to potash in the
rapidity of its absorption and excretion.
The alkalies are excreted rapidly by all the secreting
organs. Their effect is most evident on the kidneys,
and during excretion they render the urine alkaline.
At the same time they augment the watery flow
through an increased activity of the renal cells. The
secretion of all organs is increased, as is also the se-
cretion of the mucous surfaces.
The alkalies are also of benefit when applied to the
surface of the body. In rheumatism a hot lotion of
carbonate of sodium with opium often affords relief to
the painful joint. In all forms of cutaneous disease
accompanied by a troublesome itching, an alkaline
wash of carbonate of sodium or potassium, half a dram
to the pint, is of service, and in eczema during the
early stage, with an alkaline watery discharge, the
same solution is curative. Burns and scalds may
be treated in the same way, the solution being con-
stantly applied. The alkali removes the heat and
pain and allays inflammatory action. The bites and
stings of insects and the urticaria produced by
poisonous plants are also benefited.
The oxides and carbonates of calcium and magne-
sium are the most serviceable salts as antacids, on ac-
count of their insolubility. If these drugs are given
216
K INFERENCE HANDHOOK OF THE MEDICAL SCIENCES
Allantois
n small quantities their action maybe Limited to the
tomach; when they are freely administered, their
ction is continued into the intestines. They neu-
ralize all acids with which they come in contact, and
iv contact with the mucous surface they exercise a
oothing and sedative effect. In addition to neu-
ralizing the local acids, they arc of value as antidote i
,, poisoning by acids, and also in poisoning by vege-
t ble poisons, the alkali precipitating the poisonous
Jkaloids and retarding their absorption. In the
ie the antacid action is continued, but the
iltimate effects of lime and magnesia differ; the for-
ts as a mild astringent, while the latter be-
omes converted into the bicarbonate and acts as a
axative.
The soluble alkalies are not so useful as antacids,
oid are of lit i Ie service when an effect in the intest ines
required. Sodium bicarbonate, however, is a well-
cnown antacid. Its disadvantages are that it tends
o generate a large amount of carbonic acid gas,
is stimulating instead of soothing to the mucous
•urface. The aromatic spirit of ammonia is simi-
ar in its action and more rapid. Cerium oxalate
ind bismuth are both useful antacids, their chief
value being due to the local soothing action which
I hey exert upon the mucous membrane. The ce-
rium salt has probably a sedative action on the ter-
minals of the nerves. Beaumont Small.
Alkaloids. — See Active Constituents of Plants.
Alkanet. — Orcannettc. The fleshy root of Alhanna
."■in (L.) Tausch. (fam. Boraginacem), a small
perennial herb of Europe and Asia Minor, largely
illltivated for its coloring matter. The dried root,
a foot or more in length and about a half inch in
thickness, its bark purple-red without, deep red
within, its wood pinkish-white, is sometimes marketed
entire, but more frequently as a stringy, shredded,
tough mass. Its only value is for coloring purposes,
the coloring matter being alkannin or alkanna red.
Alkannin is a dark, brownish-red, resinous mass,
insoluble in water, but soluble in alcohol and ether.
Acids intensify the red color, alkalies convert it to a
bluish-green, in which respect it acts like hematoxylin.
H. H. RusBY.
Alkaptonuria. — See Alcaptonuria.
Allantiasis. — See Food Poisoning.
Allantoin. — This is a colorless crystalline substance,
glyoxyl diureide, C 1 H ll N 1 3 , very slightly soluble in
cold water and cold alcohol, but readily soluble in
boiling water and warm alcohol. It may be obtained
by the alkaline oxidation of uric acid in the cold.
In some of the mammalia, in which it occurs in the
urine, it is probably an end-product of metabolism,
but is not so in man, the minute quantities some-
times found in healthy human urine being derived
from the food and excreted unchanged by the kidneys.
It is found in the allantoic fluid (whence the name),
in the amniotic fluid, in the urine of the new-born and
of pregnant women, in the urine of the dog, cat, and
certain other mammals, usually in minute quantity
in the urine of healthy persons, and in milk. It is
also found in the growing parts (buds, the bark of
twigs, etc.) of various plants, and especially in the
root of comfrey, Symphytum officinale.
Macalister 1 of Liverpool, investigating the healing,
or cell-proliferating, properties of this plant, a popular
vulnerary in domestic practice, found that they were
due to the presence of a crystalline substance, identical
in its empirical formula and chemical reactions with
allantoin. A number of experiments in the way of
the application of this substance to old ulcers, fistulre,
and other sores, made by Macalister, BramwelF, and
others 3 seemed to show that it is a cell-proliferant of
< siderable power. Ulcers which had long resisted
treatment healed readily when treated with allantoin
or with an extract of the root of comfrey. Sinuses of
long standing also closed promptly after the insertion
of wicks of gauze impregnated with a solution of
allantoin. T I,. S.
References.
1 . Macalister, Charles J Liverpool Medico-ChirurgicalJoumal,
January, 1912; British Medical Journal, January 6, 1912.
2. Bramwell, William: British Medical Journal, January6,
L912
3. Murray, R. W.: British Medical Journal, January 13, 1912.
Allantois. — (From N. T.., allantoides; Creek, dXXSs
(dXXovr-), a sausage, and (l~io$. form: sausage-shaped
The allantois is one of the fetal membranes peculiar
to I he group of higher vetebrates in which the embryo
is enveloped in an amnion, the Amninta. These are
reptiles, birds, and mammals. The reptiles and birds
are often grouped together on account of certain
anatomical similarities under the name, Sauropsida.
am
Fig. 69. — Median Longitudinal Section through a Chick
Embryo at the End of the Third Day of Incubation. X20. all,
Allantois; am, amnion; ho, hind gut; n, neural canal; rv, right
ventricle of the heart; up, splanchnopleure; t, tail. (After Marshall.
There is no allantois in the fishes and Amphibia,
but the Amphibia have a highly vascular urinary
bladder that is usually regarded as homologous with
the allantois.
In the Amniota the embryo is formed from a com-
paratively small part of the blastoderm (see Area
Embryonalis). At an early stage of development
the mesoderm becomes divided into two layers of
cells, with a cavity between known as the caelom, a
part of which becomes the body cavity. The outer
layer unites with the ectoderm to form the somato-
pleure, which gives rise to the body wall, the amnion
(see Amnion) and the chorion; while the inner layer
unites with the endoderm, or hypoblast, to form the
splanchnopleure, which gives rise to the wall of the
digestive tract and its appendages and to the wall of
the yolk-sac (see Fetus).
The allantois is a diverticulum of the posterior
end of the embryonic digestive tract and is composed
217
Allantois
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
of two layers of cells, endoderm and splanchnic meso-
derm. It grows out usually as a thin-walled sac
between the amnion and the yolk-sac, and blood-
vessels develop in its mesodermal tissue. In most
placental mammals the distal portion of the allantois
fuses with the chorion and forms the essential part
of the fetal portion of the placenta (see Placenta),
while the proximal part becomes dilated to form the
urinary bladder, and a part of the middle portion
finally loses its lumen and persists as the urachus,
connecting the bladder with the umbilicus.
In regard to the details of its origin, its structure,
and its relations to adjacent parts, the allantois
varies greatly in different groups of animals.
Fig. 70. — Diagram of Fetal -Membranes in a Hen's Egg. .1,
Remnant of the albumen: All, allantois; Am, amnion; C, chorion;
S, shell membrane; Y, yolk. (After H. Virchow, from Strahl.)
With respect to the allantois the Amniota may be
divided into two groups, first, those with a free
allantois, including the Sauropsida, the Monotremes,
the Marsupials, and most of the placental mammals,
such as the Insectivora, the Ungulates, the Lemurs,
etc.; second, those in which the allantois is more or
less enclosed in a connective stalk by which the em-
bryo is attached to the chorion from a very early
period in its development. This group includes
some Rodents, Tarsius, the Monkeys, and Man.
We may take the common hen as a type of the
Sauropsida. At about the thirty-sixth hour of
incubation the rudiment of the allantois first appears
as a shallow pocket in the endoderm, at the extreme
posterior end of the embryo. As the formation of
the tail fold progresses, this comes to lie on the ven-
tral side of the hind gut (Fig. 69). By the end of the
fifth day it has grown out into the ccelomic space
(exoccelom) between the yolk-sac and the amnion, as
a vesicle of considerable size. It then grows rapidly
until, uniting with the chorion, it spreads out as a
large, thin-walled, highly vascular sac, and com-
pletely surrounds the amnion and yolk-sac. It
serves as the organ of respiration for the embryo.
Finally a part of it nearly surrounds the remnant of
the albumen and probably assists in its absorption
(Fig. 70). A short time before hatching, its vessels
are cut off by the closure of the umbilicus, it dries
up, and is left behind when the chick emerges from
the shell.
The allantois has essentially the same history in
most reptiles. In a lizard (Lacerta), according to
Strahl, confirmed by Corning and Janosik, it arises
in a peculiar way independently of the gut and comes
into connection with it secondarily. And Giacomini
found that in another lizard, which brings forth its
young alive, Seps chalcidt ■*, it probably has a nutri-
tive as well as a respiratory function. In this species
both the allantois and the yolk-sac fuse with the
chorion, forming an allanto-chorion and an omphalo-
chorion. The egg is very small, without envelopes,
and the allanto-chorion becomes folded into a series
of ridges and hollows which fit into corresponding
inequalities in the wall of the viaduct, forming a kind
of placenta. A similar but less perfect connection is
formed by the omphalo-chorion.
In the most primitive of living mammals, the
Monotremes, which lay eggs, the relation of the' fetal
membranes is essentially similar to what obtains in
the Sauropsida.
The Marsupials are born in a very imperfect con-
pit ion and a true placenta is rarely formed (Hill, 1897),
In this group the allantois remains comparatively
small, and in the opossum, according to Selenka, it
does not even touch the chorion; and it begins to
degenerate before birth. The yolk-sac, on the other
hand, is large, filling most of the space between the
embryo and the chorion. It fuses with the latter, I e-
comes highly vascular, and serves during fetal life
both as an organ of nutrition and as one of respiration.
These conditions are usually regarded as primitive;
for the Marsupials are generally supposed to have been
derived from monotreme ancestors and to have given
rise in turn to the placental mammals.
Among the mammals with a free allantois the most
diagrammatic arrangement is to be found in the
mole, one of the Insectivora, a group that shi
many primitive characters. According to Strahl, in
a cross-section of a gravid uterus of the mole, Talpa
i uropea (Fig. 71), one may see the embryo surrounded
by the amnion, except on the ventral side, where
the yolk-sac and the allantois are attached. The
allantois has a large lumen, which occupies the
greater part of the space between the embryo and
the chorion. Its outer wall fuses with the chorion,
and the greater part of it gives rise to the thickened
placenta. On the opposite side the smaller yolk-sac
spreads out in a similar way and likewise fuses with
the chorion, but its outer surface does not become
vascular like that of the allantois. Except for the
increase in the size of the embryo and the correspond-
ing reduction in the lumina of the allantois and yolk-
sac, these relations persist until the end of gestation.
We may take the sheep as representing the type
of allantois common to the Ungulates.
Fig. 71. — Fetal Membranes of the Mole e. Embryo; am. amnion;
all, allantois; p, placenta; y, yolk-sac. (After Strahl.)
According to Bonnet, the rudiment of the allantois
appears in the sheep at about the end of the fifteenth
day after copulation. The tail fold has not yet
formed, and the allantois appears as a sac-like pos-
terior prolongation in the axis of the gut, which is then
being folded off from the general endoderm. With
the development of the tail fold the allantoic stalk
gradually assumes its normal position as an appen-
dage of the hind gut. Very soon the young allantois
begins to spread laterally, so that by the end of the
sixteenth day it has become a half-moon-shaped
appendage nearly half as large as the embryo. From
•J IS
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Allanlol-,
72. — Diagrams Showing the Developmenl of the Fetal Membranes of the Sheep.
e ec i "ii the twelfth day after copulation; />', thirteenth -lay; C, about
e; I), longitudinal section about the same age; K, transverse section of an
mbryo; F, diagram of the fetal membranes at the end of the first month; 'ill,
; nil ch, allanto-chorion; ach, amniogen chorion; am, amnion; ams, amnion
stalk; ro, cotyledon; eel, ectoderm; end, entoderm; ?;, cavity of yolk-sac. (After persistent lumem
Bonnet.)
this time on, its growth is rapid until it extends the
whole length of the chorion. As it becomes dis-
tended with liquid its mesodermal layer is pressed
closely against that of the chorion, and the two fuse
and form the important placental structures. At the
twenty-first day, when the embryo is about a third
of an inch in length, the allantois is a large sausage-
shaped bag measuring more than a
fool from tip in tip. The embryo en-
veloped in its relatively small amnion
lii is in a depression .-it the center of the
allantois, ami the yolk-sac has dwin-
dled to a hollow, thread-like structure
lying in a groove in one side of the
allantois and extending in both direc-
tions lo 1 1 10 ends of the chorion (fig.
72, /•').
The Carnivora have likewise an
allantois with a large lumen. The
allantois tit first bends dorsally and
enlarges into a mushroom-shaped sac.
lis outer wall unites with the chorion
and forms at first a discoidal placenta.
But the allantois continues to enlarge
until it has fused with the whole im i r
surface of the chorion. Ii completely
surrounds the amnion, containing the
embryo, and finally encloses also the
yolk-sac. \l lie' time lime (lie |i!:i-
centa extends around the equator of
the egg as a broad band, and finally
acquires its characl erisl ic zonary form.
In (he Rodentia (he allantois unites
with only a pari of the chorion mi (he
dor ,il side of (he embryo, the res) of
(In- chorion being fused with the large
cup-shaped yolk-sac, Keibel (1906).
In this group there are two types of
allantois. One of these is represented
by the rabbit (Fig. 73), and has a large
In the other type,
am
coel
Fro. 73. — Transverse Section through the Gravid Uterus of a
Rabbit at the End of the Nineteenth Hay of Gestation. X 1 3/4.
fi'\ Allantoic artery; all, allantois; am, amnion; cod, exoccelom;
nun. mesometrium; p, placenta; y, cavity of yolk-sac, which is
continuous with the uterine cavity owing to the absorption of the
lew er wall of the yolk sac represented by the dotted line yl. (After
Marshall.)
represented by the rat and the guinea-
pig, the lumen is very small or may
disappear altogether. According to Fleischmann, the
squirrel presents a form of allantois intermediate be-
tween these two types. Aside from these differences
in the allantois, the rodents are generally alike in
having a large omphalo-chorion, a smaller discoidal
placenta, a small amnion, and a large ccelomic cavity
filled with fluid, separating the allantois from the
yolk-sac (Fig. 73).
The second type of allantois is found in the Pri-
mates; that is Tarsius, the monkeys, and man. In
Fig. 74. — Diagram of a Blastocyst of Tarsius in Sagittal Section.
all, Allantois; am, Amnion; va, and ha, anterior and posterior
amniotic folds; c, exoccelom; n, yolk-sac; nc, neurenteric canal; j>,
placenta. (From Hubrecht.)
the earliest known embryos of both the monkeys and
man the fetal membranes are already more or less
established, and the earliest stages of their develop-
ment are therefore unknown. But there is no
reason to doubt that Hubrecht (1908) is correct in
his inference that the earlier stages in the higher
Primates are similar to what he found in an extraor-
219
Allantois
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
dinarily complete series of embryos of Tarsius. This
interesting animal is a small arboreal mammal found
in the forests of Borneo, Sumatra, Java, Banka and
the Philippine Islands. It is usually classified with
the Lemurs. But while all true Lemurs that have
been examined exhibit a free allantois, Tarsius
closely resembles the true Primates in the corre-
sponding stages of development (Fig. 7-1).
Emb Am
Fig. 75. — Embryo of the gibbon, Hylobales concolor. All,
Allantois; am. amnion; b.s.. connective stalk; emb, embryonic
shield; veu, neurenteric canal; yk, yolk-sac; Ye, blood-vessels.
(After Selenka from Minot.)
In Tarsius the embryonic shield (area embryo-
nalis) is developed on the surface of the blastocyst,
and is subsequently covered by the folds of the
amnion The development of the allantois begins
by a proliferation of mesodermal cells which extends
backward from the primitive streak, and forms a
ridge on the inner side of the somatopleure. This
ridge is the " connective stalk," which is continuous
from the first with the chorion.
At the point in the median line where the somatic
and splanchnic mesodermal layers join, a tubular
projection of the endoderm grows into the connective
stalk from the yolk-sac and forms the lumen of the
^fl&las
Fig. ,6— Human Embryo "von HerfT." Internal Diameter of
Blastocysts about 4 mm. Side view after removal of part of
chorion a. Amnion; 6, blood-islands (much more prominent in
original); c, chorion; «, connective stalk; ec, ectoderm of chorion-
HaudbuchT 1 "' * y0lt " SaC - (AftCT SpCe fr ° m Hert »'^
allantois. Even before the appearance of the area
vasculosa in the yolk-sac, there begin to develop in
the connective stalk blood-vessels that are destined
lSQoT" P lacental circulatory system (Hubrecht,
When Tarsius has reached this stage, it corresponds
to the youngest embryo of the gibbon, Hylobates,
220
described by Selenka (1900, Figs. 75), and to the
youngest human embryo described by Count von
Spree, the von Herff embryo (Keibel, 1906 FiVs - ■
and 86). The gibbon and man appear to dim',
however from Tarsius in that the blood-vessels
develop first in the area vasculosa of the yolk sai
i ■?' /. 7 -"- Human Embryo, same as Fie. 76. Diagram of «
longitudinal section. „, Amnion; all, allantois; c, chorion r,
connective stalk; e, area embryonalis; ec, ectoderm of chorion- „",'
mesoderm; y, yolk-sac. (After Spee, from Hertwig's Handbuch.)
and subsequently grow out into the connective stalk
and thence into the chorion to form the fetal vessels
of the placenta.
In a human embryo 2.15 mm. in length (Fig. 78)
the allantois is a long narrow tube extending from
the hind gut into the connective stalk parallel with
the allantoic vessels as far as the chorion, where it
ends blindly.
By the continued infolding of the somatopleure
the body wall is completed except at the umbilicus
where the extraembryonic part of the somatopleure
forms a tube enclosing the stalk of the yolk-sac and
exclusive 8 -T"™^. Em bryo "Gle." Dimensions of blastocyst,
TsA i m P ' 8 : 5 X 10X6.5 mm. ; length of area embryo
amnion ;>, r ?° d Si IP t,al SeCtim - - 4 "' Allantois; „„,.
amnion, 6. s ., connective stalk; cho, chorion; ec, ectoderm' . „l
from&r- mesoderm: *■ vUU: vk - yoi - sac - (A,ur
the connective stalk with their vessels; the whole being
he umbilical cord, of which the connective stalk m
the center. According to Lowy (Grosser, 1910) the
allantois remains hollow throughout its entire
length m human embryos of S mm. maximum length.
In older embryos its lumen soon begins to be obliter-
ated at the distal end, but even in the fourth month
ki:i i:ki:\( k handbook of the medical sciences
Alleghany Springs
remains of the duct lined by cubical epithelium may
be found in the cord near the embryo.
The allantoic fluid of the cow lias been shown by
Doderlein to differ from the amniotic fluid in being
rer in salts of sodium and richer in nitrogen. The
latter increases with the age of the fetus, indicating
that it is an excretory product; and according to
Foster and Balfour urates are abundant in the allan-
toic fluid of the chick by the sixteenth day.
The circulation in the allantois takes place pri-
marily through two pairs of blood-vessels, the allan-
toic or umbilical arteries, and the allantoic veins
:,| their branches. The allantoic arteries arise as
lireel prolongations of the primitive forks of the
iorta. When the hind limbs bud out, the external
iliac arteries arise as branches of the allantoic arteries.
In the chick the right allantoic artery does not grow
so fast as the left,
and it finally dwin-
dles and disap-
pears altogether.
In man the two
arteries persist.
They may be
traced from the
posterior end of
the aorta through
the umbilical cord
(see U m bil i c a I
Cord) to the pla-
centa, where they
branch freely.
The two allan-
toic veins in the
chick are formed
during the fourth
day. They unite
in the body of the
embryo, becoming
there a single allan-
toic vein, which
passes forward on
the left side and
joins the left vitel-
line vein. In man
and other mam-
mals the two allan-
toic veins at first
open into the sinus
venosus, one on
each side, in com-
pany with the corresponding Cuvierian and vitelline
veins. Later, while the allantoic veins remain dis-
tinct within the embryo, in the allantoic stalk they
fuse to form a single vessel. During the fourth week
in man the allantoic veins become separated from the
duus venosus. The smaller, right one soon after dis-
ears, while the left one unites with the portal
vein (formed by the union of the vitelline veins) and
increases in size.
Creighton has described (1S99) a series of lym-
phatic cylinders and capsules surrounding certain
allantoic vessels in the chick. They are found upon
the vessels where the allantois and amnion come
into contact, and are supposed to aid in the absorp-
tion of the yolk and albumen. (For a description
of the circulation in the placental portion of the
allantois, see Placenta.)
The principal adult structure developed from the
allantois is the urinary bladder. Of that part of the
allantois which lies within the body of the embryo,
the proximal portion begins to enlarge during the
second month to form the bladder, while the tapering
distal portion finally loses its lumen and becomes the
urachus, or ligamentum vesica? medium, connecting
the bladder with the umbilicus. The portions of the
allantoic arteries within the embryo are called the
hypogastric arteries, and are more or less homol-
Ftc. 79. — Human Embryo of 2.15 mm.,
Reconstructed from Sections. All, Allan-
is; Ao, aorta; Ht, endothelial heart;
/. , liver; Om, omphalo-mesenteric vein;
b . allantoic vein; IV:, yolk-sac. (From
Minot, after His.)
OgOUS with arteries of the same name in lower verte-
brates. At birth the dislal part of the hypogastric
on each side loses its I -n and become- a -olid cord
enclosed in the superior ligament of the bladder,
while the proximal part persists as the common iliac,
internal iliac ia^ far as the bifurcation), and superior
vesical arteries. The remaining allantoic or um-
bilical vein loses its cavity at birth and becomes the
ligamentum teres, or round ligament, connecting
the liver with the umbilicus I see Ft Ins).
Robert Payne Bigelow.
References.
Bonnet, R.: 18S3. Ueber die Bih&ute der Wiederkiiuer. Sits.-
Ber. Morph. Phys., Mum-hen, Bd. ii.
Creighton: 1S99. A system of perivascular cylinders and cap-
sules in the united amnion-allantois of the chick. Jour. Anat.
Phys. Vol xxxiii p, ">_'7 545.
Grosser, O.: 1910. Development of the egg membranes and the
placenta. Keibel and Mall's Manual of Human Kmbrvologv, p
91-179.
Herzog, M.: 1909. Contribution to our knowledge of the
earliest known stages of placentation and embryonic development
in man. Amer. Jour. Anat. Vol 9 p. 361— tOO.
Hill, J. P.: 1S97. The Placentation of Perameles. Q. J. Mic.
Sci., vol. xl.
Hubrecht, A. A. W.: 1896. Hie Keimblase von Tarsius.
Festschrift fur Gegenbaur, Kd. ii., p. 147-17S,
Hubrecht, A. A. W.: 1897. Descent of the Primates, New
York, Scribner's.
Hubrecht, A. A. W.: 1902. Furchung und Keimblattbildung
bei Tarsius Spectrum. Verh. K. Akad. v. Weten. Amsterdam,
Sect. 2, vol. viii.. No. 6.
Hubrecht, A. A. \\\: 1908. Early Ontogenetic Phenomena in
Mammals and their bearing on our Interpretation of the Phylo-
geny of the Vertebrates. Quart. Jour. Mic. Sci., vol. liii., p.
1-181.
Hubrecht, A. A. W.: 1912. Feetal Membranes of the Verte-
brates Proc. Seventh Internat. Zodl. Cong., 1907, 426.
Keibel, F. : 1902. Die Entwiehelung der ausseren Korperform
der Werbeltierembryonen. Hertweg's Handbuch, Bd. i., Teil 2,
1-176.
Minot, C. S-: 1903. Laboratory Text-book of Embryology.
Phila., Blakiston.
Schauinsland, H.: 1902. Die Entwickelung der Eihiiute der
Reptilien und der Vogel. Hertwig's Handbuch, Bd. i., Teil 2,
p. 177-334.
Selenka, E.: 1900. Studien iiber Entwickelungsgeschichte der
Tiere, Heft 7 and 8, Entwickelung des Gibbon. Wiesbaden;
Kreidel.
Spee, F. Graf von: 1S96. Ueber friihe Entwickelungsstufen
des mensehlichen Eies. Arch. f. Anat., p. 1-30.
StrahL H.: 1891. Eihiiute und Placenta des Sauropsiden.
Ergeb. Anat. u. Entwick. , Bd. i.
Strahl, H.: 1902. Die Embryonalhullen der Sauger und die
Placenta. Hertwig's Handbuch, Bd. i., Teil 2, p. 23.3-270.
Alleghany Springs. — Montgomery County, Virginia.
Post-office. — Allegheny Springs.
Access. — Ma Norfolk and Western Railroad to
Shawsville station, thence by carriage or omnibus
three and a half miles to springs. Hotel and cottages.
This well-known resort is located on the eastern
slope of the Alleghanies, on the head waters of the
Roanoke River. The hotel and principal range of
cottages occupy smooth and undulating hills, gently
sloping to a broad, grass-covered lawn of forty acres,
extending to the banks of the river. The accommoda-
tions here are first class, affording every convenience
and comfort to the pleasure seeker as well as to the
invalid. The hotel is large and spacious, and is
supplied with all requisite improvements. Contigu-
ous to the hotel are 150 double cabins, arranged with
a view to the comfort and good health of the guests.
The scenery in the vicinity is not excelled for pictur-
esque loveliness and variety at any watering place in
the Old Dominion. Only one spring, which flows
about thirty gallons per hour, is in use at the present
time. The water is limpid, and has a temperature
of 56° F. The following is the latest analysis of this
water:
221
Alleghany Springs
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
One Gallon, 70.000 Chains, Contains:
Grains,
Magnesium sulphate 50 . S8
Calcium sulphate llo.29
Sodium sulphate 1.72
Potassium sulphate 3.70
Copper carbonate trace.
Lead carbonate trace.
Zinc carbonate trace.
Iron carbonate 0. 16
Manganese carbonate 0.06
Calcium carbonate 3 .61
Magnesium carbonate 0.36
S1 fntium carbonate 0.06
Barium carbonate . 02
Lithium carbonate trace.
Magnesium nitrate 3 . 22
Ammonium nitrate O.o6
Aluminum phosphate 0.03
Aluminum silicate . 20
Calcium fluoride - • - - ■ . 02
Sodium chloride 0.2Ti
Silicic acid °- 8 8
Crenic acid trace.
Aprocrenic acid trace.
Other organic matter trace.
Cobalt carbonate trace.
Antimony teroxide trace.
182.95
Solid ingredients by direct evaporation gave 184.07
Half combined carbonic acid 1.89
Free carbonic acid* o 46
Hydrosulphuric aeidf trace.
Total amount of ingredients 191 -42
This water is distinguished for the great variety of
its mineral constituents. When taken in large doses
it is actively diuretic and cathartic, operating with
special activity on the mucous membrane of the lower
intestines. In smaller doses its action may be de-
scribed as tonic, alterative, and detergent. The
water has been found particularly beneficial in the
treatment of dyspepsia, for which it has a wide repu-
tation. Excellent effects are also observed in nervous
affections, in diseases of the liver and kidneys, in
catarrh of the stomach and intestines, diarrhea, and
dysentery, gout, rheumatism and troubles arising
from a faulty venous circulation, such as headache,
dizziness, and hemorrhoids. It is recommended in
small doses by many physicians in the treatment of
anemia and chlorosis, general debility, and other con-
ditions in which tonic and reconstructive effects are
sought. The water is used commercially.
Emma E. Walker.
* S. 455726 grains of carbonic acid is equal to 11.544067 cubic
inches.
t 0.000139 grain of hydrosulphuric acid is equal to 0.000369
cubic inches.
Allen, Harrison A. — Born in Philadelphia, Pa., on
April 17, 1841. He received the degree of Doctor of
Medicine in 1861, and held the position of Resident
Physician in the Pennsylvania Hospital up to 1862,
when he entered the Confederate Army. Upon his
return to Philadelphia in 1865 he was appointed
Instructor in Comparative Anatomy and Medical
Zoology in the University of Pennsylvania. In 186i
he was made Professor of Anatomy and Surgery in the
Philadelphia Dental College, and in 1870 he was
appointed a Surgeon in the Philadelphia Hospital.
From 1875 to 1885 he held the Chair of Physiology in
the University of Pennsylvania, and in 1S94 he
became the first Director of the newly founded
Wistar Institute of Anatomy. His death occurred
in November, 1S97.
Allen acquired considerable reputation both as an
authority in comparative anatomy and as a skilful
specialist in the treatment of laryngeal and nasal
affections. Among his published writings the follow-
ing deserve to receive special mention here:" Outlines
of Comparative Anatomy and Medical Zoology,"
1869; "Conformation of the Bones of the Orbit.''
1S70; "On Localization of Diseased Action in the
(Esophagus," 1877; and "On the Mechanism of
Joints," 1876; "A System of Human Anatomy.''
two volumes, Philadelphia, 1SS2-1884. A. H. B.
All-Healing Spring. — Livingston County, New
York.
Post Office. — Dansville.
Access. — Via Delaware, Lackawanna, and West-
ern Railroad.
This spring is charmingly located among the hills
of the picturesque Genesee Valley country of western
New York. The region is exempt from malaria.
The climate is equable and genial for its latitude.
The air is pure and dry. Nights throughout the
summer are cool, while the winters are unusually mild
with little snow. The soil is dry and porous. The
following is the most recent analysis of the water:
One United States Gallon Contains:
Solids. Grains.
Sodium sulphate 0.7a0
Calcium sulphate 432
Calcium carbonate 5.246
Potassium chloride 1 1 <
Magnesium chloride -'44
Silica "
Alumina and iron (t
Volatile and organic matter 0.641
Total solids ^1S0
This water is of marked value in rheumatism, gout,
gravel, neuralgia, and neurasthenia of toxic origii..
The water of the spring comes from rocky hen
far above any possible source of contamination.
Excellent accommodation for visitors to the
Springs may be found at the Jackson Health Resort,
a sanatorium located on the hillside at an elevation of
800 feet above sea-level. Emma E. Walker.
Alligator Pear. — Avocado; Abogate; Aguacate; Pal-
ta; Midshipman's Butter.
The above are the names of the fruit of Per$( a gra-
tissima Gaertn., a large tree of the Lauracew, and
they are also applied to the seeds, which have distinct
medicinal properties. The genus is related to that
yielding cinnamon. It contains about a dozen spe-
cies, which grow in the tropics of both contine
but the one under discussion alone possesses the prop-
erites here described. It is native in many parts .if
the American tropics, and is largely cultivated in all
tropical countries for its fruit, which is common in
northern markets. This is inequilaterally elongated-
pyriform, sometimes spheroidal or ovoid, and as large
as the very largest pears. The skin has a leathery,
rusty-green appearance, or deep purple in some var-
ieties. The solitary ovoid seed fills half of the inte-
rior, the remaining space being occupied by a ere
white pulp, penetrated by numerous gray or greenish
veins, of the finest and smoothest fatty texture, highly
nutritious and of peculiar flavor. On first trial, it is
disgusting to some persons, but they usually become
extravagantly fond of it on continuing to use it.
The juice of the seeds makes indelible stains on linen,
and is used for this purpose. The seeds are larg
used in the tropics as a local application in rheumatism
and neuralgia, am' some physicians have thus found
the fluid extract of service." They are also credited
with anthelmintic properties, and doses of fl. o '■ of
the fluid extract have been used to expel tenia.
H. H. Rushy.
Allomorphism.— A term used by Orth to cover the
conditions of pseudometaplasia or histological accomr
•_'!"_»
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
\ltM-
odation (change of cylindrical cells to flat cells in
is a result of pressure, change of flat endothelial
■IN. Bat serosa cells, and pulmonary epithelium into
ibo'idal or columnar cells, etc.) and prosopla a oi
ive metaplasia (change of colls of the salivary
: , i. into secreting cells, the cells of bile-ducts into
T-cells, etc.). Dysmorphism has also been used
- a synonym. Aldrbd Scott Wakthin.
Vloplasia. — A term suggested by Orth to designate
ie condition in which the cell-forms normally pre-
iminating in a given organ or tissue are replaced
cell-forms normally latent, so that the latter
:is an apparent metaplasia or heterotopia
iasia of Schridde). Such conditions as
;,. presence of squamous epithelium in the pros-
,i,-, bladder, urethra, uterus, trachea and bronchi,
of uterine mucosa in the mucosa of the
■rvi\' and on the inner surface of the hymen,
inds of gastric mucosa in the esophagus, intes-
aal glands in the stomach, pancreatic tissue in
ie stomach and intestine, bone in the intermuscular
etc., are grouped under this head. Since these
isias as a rule always represent tissue of an
•ordering directly upon the one affected, they
ie regarded as disturbances in the course of the
letic differentiation, and not as changes occur-
ter differentiation lias taken place — hence, not
rue metaplasias. Schridde classes these congenital
momalies as heteroplasias; Orth proposed the
rin alloplasia or dysplasia.
Aldred Scott Warthtx.
Allouez Mineral Springs. — Brown County, Wis-
onsin.
Post-office. — Green Bay. Hotels in Green Bay.
The Allouez Springs are beautifully located near
he base of an elevation, Astor Hills, in the Valley of
in the southern part of the city of Green Bay.
inning city, which lies at the head of the bay
f the same name, is one of the oldest settlements of
Northwest. In the year 166S Father Allouez
-tablished a missionary station here, and from that
leriod dates the first settlement of the citj-. The
are located but a short distance from the site
old mission, and are named in honor of its in-
repid and worth}' founder. The water bubbles out
rmn the hillside at a uniform rate all the year. It
emperature of 46° F. A pretty park surrounds'
nd an ornamental pavilion covers the spring, which
lushes up through an octagonal marble basin. An
nt in charge supplies water to the visitors.
i i- believed that the Menominee Indians used the
ipring for medicinal purposes. The following analysis
ras made by the Bureau of Chemistry, I T . S. A.,
inent of Agriculture, Washington, D. C, June,
.'JUT:
On~e TJ. S. Gallon- OnxTAiva grains
Magnesium chloride 0.99
Magnesium sulphate. ... .4.27
Magnesium bicarbonate. . . s 11
Calcium bicarbonate is 43
Calcium phosphate Trace.
Calcium silicate 1 ..50
Sodium chloride 1 .60
Sodium nitrate 2.11
i-sium chloride 17
Ammonium chloride Trace.
Liihium chloride Trace.
Ferric oxide and alumina 0.07
Silica 0.45
ToUil grains per United States gallon 3S.09
An alkaline-magnesic-saline-calcic water of rare light-
ness and softness, possessing marked diuretic and al-
terative qualities.
In his work on the mineral waters of the United
States the writer, Dr. .lames K. (rook, classified this
asau alkaline-saline-calcic mineral water. It contains
a very fortunate combination of mineral ingredi-
ents. The bicarbonate of magnesium gives it valuable
antacid and laxative properties. Authorities are
agreed that the carbonate oi magnesium is an ex-
cellent antilithic in those cases in which uric acid is
too abundant. The chloride of sodium anil bicar-
bonate of magnesium contribute to render the water
diuretic. In diseased states ii - best effects have been
observed in diabetes, Bright's disease, disorders of
the stomach and liver, and in gout, rheumatism, and
vesical calculi. The water is soft and sparkling, anil,
as it contains no trace of organic or vegetable matter,
is well adapted for general table use. It has also
tonic effects.
The spring is isolated and is protected from surface
water by circular stone walls, well cemented. This
wall development extends to the gravel strata, and
is capped by a marble slab, sealed except at center or
point of overflow into the marble basin.
< liven Bay offers numerous advantages as a health
resort. Its elevated location renders the air cool and
refreshing during the summer months, and malaria
is unknown. The magnificent Fox River, which
Hows into the bay at this point, is spanned by five
bridges. The streets are embowered with avenues of
maud old trees, and there are excellent drives in all
directions for miles around. Small steam, motor, and
sailing yachts, with their burdens of pleasure seekers,
ply the placid waters of the bay, forming, during the
spring and summer months, a picture of serene and
restful beauty. Emma E. Walker.
Allspice. — See Pimento.
Ally! Tribromide. — Tribromhydrin, tribrompro-
phenyl, CJIIir,, is obtained by the action of bromine
on oil of garlic (allyl sulphide). It is a heavy, color-
less, or faintly yellowish liquid, which is insoluble in
water and soluble in alcohol, ether, and. volatile
fixed oils. Liquid at ordinary temperature, it solidi-
fies at 10° C. (.50° F.). This remedy, containing as
it does eighty-five per cent, of bromine, may well
replace the alkaline bromides as sedative and anti-
spasmodic. In asthma, pertussis, laryngismus stridu-
lus nervous irritability, and especially in epilepsy it
has had a marked effect. In hysteria on the other
hand, it has been of no value. Its dose is two to
ten minims (0.13-0.6), given in capsule or on sugar,
two or three times a day; or it may be given hypo-
dermically dissolved in ten or twenty minims of
ether or oil. W. A. Bastedo.
Almonds. — See Amygdala.
Aloe. — Aloes. The inspissated juice of the leaves
of various species of Aloe, a genus of nearly a hundred
species, in the family I/Macece, widely distributed
through tropical Africa, on the continent and islands,
and at least two species extending, through introduc-
tion, into Asia, and one into Southern Europe and the
West Indies.
They are plants of desert or arid regions and
strongly succulent, as is common among plants of
such localities. They have large, fleshy, bayonet-like
leaves, densely arranged in a distichous or tristichous
manner, and tall spikes of fleshy flowers, often
similarly arranged. All method i of producing aloes
from them are based upon the fact that the}' contain
two distinct juices, the one thin and flowing at once
when the leaves are cut, the other thicker and not
readily flowing except under pressure. It is the
former of these juices which yields the drug, and
which is therefore allowed to flow from the cut leaves
without pressure.
This juice is then inspissated, either spontaneously
223
Aloe
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
or by boiling, and yields a yellow, yellow brown, gray-
brown, green brown, or nearly black mass, which may
be hard and brittle or of a soft, tarry consistency, or
of any intermediate degree. It may be dull, waxy,
or glassy, and opaque or translucent, and its odor
varies greatly. It is thus seen to be unfitted for any
general description.
The places of manufacture give the names to the
different commercial sorts. It is one of the oldest of
medicines; valued — according to tradition — long
before the Christian era. Certainly it was known to
the Greeks and Romans of the first century, and to
the rest of Europe during the Middle Ages. It has
always been extensively used and highly prized, as
the fanciful names given to many of the older aloes
compounds testify. The variety earliest known,
socotrine aloes, is, singularly too, the same which is
still considered the best in England and America, and
is nominally obtained from the same little, obscure,
out-of-the-way island that Alexander is reported to
have peopled with Greeks, in order to protect and
improve its production. Of all the known commercial
varieties of aloes, the U. S. P. recognizes the following:
Aloe Socotrina or Socotrine Aloes, from A. Pcrryi
Baker; Aloe Curussarira or Barbndensis, the Curacao
or Barbados Aloes, from .4.. vera (L.) Webb and
Aloe Capensis or Cape Aloes, from A.ferox Miller.
Barbados aloes, which used to come in gourds, is
no longer produced, although the Curacao product,
usually packed in boxes, is now sometimes sent in
gourds, to imitate the other. They are identical in
character. This plant is the most widely distributed
of the genus, growing through Northern Africa,
Southern Europe, and the East Indies, as well as in
the West Indies, where it is cultivated for the pro-
duction of aloes. It grows to a height of nearly two
feet, with a thick head of bluish-green, blotched
leaves, and a dense spike of greenish-yellow flowers,
each a little more than an inch in length, and of an
elongated, contracted-campanulate form. From the
Pharmacographia the following account of the prep-
aration of Barbados aloes is quoted:
" The cutting takes place in March and April, and is
performed in the heat of the day. The leaves are cut
off close to the plant, and placed very quickly, the cut
end downward, in a V-shaped wooden trough, about
four feet long and twelve to eighteen inches deep.
This is set on a sharp incline, so that the juice which
trickles from the leaves very rapidly flows down its
sides, and finally escapes by a hole in its lower end
into a vessel placed beneath. No pressure of any
sort is applied to the leaves. It takes about a quarter
of an hour to cut leaves enough to fill a trough. The
troughs are so distributed as to be easily accessible
to the cutters. Their number is generally five, and
by the time the fifth is filled, the cutters return to the
first, and throw out the leaves, which they regard as
exhausted. The leaves are neither infused nor boiled,
nor is any use afterward made of them, except for
manure.
" When the vessels receiving the juice become filled,
the latter is removed to a cask and reserved for evap-
oration. This may be done at once, or it may be de-
layed for weeks, or even months, the juice, it is said,
not fermenting or spoiling. The evaporation is gen-
erally conducted in a copper vessel: ai the bottom of
this is a large ladle, into which the impurities sink, and
are from time to time removed as the boiling goes on.
As soon as the inspissation has reached the proper
point (which is determined solely by the experienced
eye of the workman), the thickened juice is poured
into large gourds, or into boxes, and allowed to
harden. "
This product varies from an orange brown to a
chocolate brown. The latter when broken up ex-
hibits the orange brown color also. It is commonly
of a waxy luster, dry and brittle or friable, but is
occasionally harder and of a glassy luster. Its pecu-
liar odor constitutes its most characteristic feature.
About sixty-five per cent, of it is soluble in cold water'
the solution assuming a purplish-red color. It is the
chief source of Aloin, and is regarded as a very good
article, though cheaper and less desired than the next
A large amount of it is, however, sold under the title
of the next.
Socotrine Aloes comes from the Island of Socotre
although the mainland yields an almost identical
article. The drug was formerly brought into Europe
via the Red Sea and Alexandria. After the dis-
covery of the route around the Cape of Good Hope,
it followed the course of commerce in that direction'
at present, Socotrine aloes is apt to go to India, and
from there to England, with the enormous mass of
Indian products.
The preparation of Socotrine aloes is said to differ
from that of Barbados, in that the heat of the sun is
relied upon for its evaporation. Although sometimes
imported in large barrels, it is usually in small kegs
or small skins. The latter is a cheaper grade, dry and
brittle, the former a soft-solid, at least at the center
where it is frequently very soft, so as to flow. Si
trine aloes is typically of a brownish-yellow or yellow
brown, rather than an orange brown like the last, but
it is occasionally darker, nearly of a brown black.
There should never be any hint of green in its color. If
exposed to the atmosphere, it at length becomes hard,
through evaporation. Its odor is much finer than
that of Barbados. Although not, strictly speaking,
less strong, it is less rank and heavy. It is its odor
which is relied upon for identification, as well as fur
an indication of its quality. At least sixty per cent,
of it is soluble in cold water, the solution assuming a
yellow color.
Exported from India is an article known variously
as Moken (or Mochen), East Indian, or Fetid Aim:-,
which, although totally unlike the Socotrine variety,
has been very largely imported, sold, and used for it, in
the United States. It is a disgusting substai
black, semi-liquid and of a stinking odor, like putrid
animal matter. It contains much albuminoid
matter. Its use is wholly indefensible.
Cape Aloes is commonly hard, brittle, more or less
glassy and translucent. It turns to green black, red
black, or even bluish-black. Not less than seventy-
five per cent, of it is soluble in cold w r ater, the solution
being pale yellow.
All official varieties agree in the following characters.
They have a saffron-like odor. They should yield
not more than 1.5 per cent, of ash and should contain
not more than ten per cent, of water. A nearly clear
solution should result from mixing one gram with
50 c.c. of alcohol, gently heating and then cooling.
If one gram be mixed with 10 c.c. of hot water, and
1 c.c. of this mixture be diluted with 100 c.c. of
water, a green fluorescence should be produced
upon the addition of a five per cent, solution of
sodium borate; or, if 1 c.c. of such dilution be
shaken with 10 c.c. of benzol, upon separating the
benzol solution, and adding 50 c.c. of ammonia
water, a permanent deep rose color will be produced
in the lower layer.
All, on being dissolved in water or alcohol, yield a
crystalline sediment of aloin. All consist chiefly of a
resin-like substance which is soluble in alcohol and
hot water, but precipitated from the latter solution
by boiling. A small amount of volatile oil is found
in all.
Aloe Purificata, U. S. P., is Socotrine aloes which
has been heated, dissolved in alcohol, strained through
a No. 60 sieve, evaporated, cooled, and broken up.
Aloe Natalensis, or Natal aloes, has a dull surface
and a grayish-yellow brown color. It is crystalline
and contains aloin, but is weak in odor and taste.
Hi putie aloes is a name which has come to be applied
to any form having a distinct liver-brown color.
Considering its immense importance as a drug, the
224
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Alopecia
action of aloes is a remarkably simple one. Aside
from iis action in the mouth and stomach as a simple
hitter, its operation is almost entirely confined to the
lower part of the large intestine, where, by its irritant
properties, it powerfully stimulates peristalsis ami
moderately stimulates secretion. It is therefore a
•.ery dilatory, but quite active cathartic. Its action
is quite apt' to be griping and painful, especially to
those affected with hemorrhoids. Although it has been
claimed that this condition can be relieved by the
skilful, continued Use of aloes, this is doubtful; while
it is certainly true that the condition is thus frequently
ravated in a serious degree. A diuretic effect fre-
quently ac ipanies the purgation, and is probably
hief part due to a mere extension of the irritation.
The same is to be said of its emmenagogue effect, and
to he remembered that this may lead to abortion.
I'll.' intensity of the action of aloes is quite variable,
only in different individuals, but in the same
individual at different times, and this is especially
true when aloin is used alone. This is believed to be
to variations in the solution of the aloin. The
I. ilc is its natural solvent. Glycerin acts similarly,
and either of these solvents, injected into the rectum
with aloes, will cause it to take effect. Taken inter-
nally, alkalies increase its activity, as does iron. Aloes
can be absorbed by the subcutaneous tissue, excreted
into the bowel, and become active. Because of its
slowness, and its limited field of action, it is usually
preferred to combine it with some differently acting
cathartic. Its peculiar mode of action indicates that
aloes is especially useful in those cases of constipation
which result from torpidity of the intestinal muscles.
The dose of aloes is exceedingly variable, according
to the patient and the effect desired, being from 0.03
to 0.6 gram (gr. ss.-x.).
The Pharmacopoeia provides a large number of
preparations, as follows:
Liquids. — Tinctura Aloes, containing ten per cent.
of aloes and twenty per cent, of licorice root, made
with dilute alcohol, dose 1 to 4 c.c. (fl. 5. i~i-); Tinc-
tura Aloes et Myrrhas, containing ten per cent, each
of aloes, myrrh, and licorice root, made with alcohol;
dose the same as of the last.
Solids. — Extractum Aloes (aqueous), dose 0.03 to
0.2 gram (gr. ss.-iij.); Extractum Colocynthidis
Compositum, containing purified aloes 50 per cent.,
extract of colocynth 16 per cent., resin of scammony
and soap, each 14 per cent., cardamom 6 per cent.,
dose 0.06 to 1.0 gram (gr. i.-xv.); Piluke Aloes, each
containing 0.13 gram (gr. ij.), each of aloes and soap;
Pilulse Aloes et Ferri, each containing 0.07 gram
(about gr. i.) each of aloes, dried sulphate of iron, and
aromatic powder, with a little confection of rose;
Piluke Aloes et Mastiches, each containing 0.13 gram
(gr. ij.) of aloes, 0.04 gram (gr. §) mastic, and 0.03
gram (gr. ss.) of red rose; Pipulas Aloes et Myrrhae,
each containing 0.13 gram (gr. ij.) aloes, 0.06 gram
(gr. i.) myrrh, and 0.04 gram (gr. f) of aromatic
powder; Pilulas Rhei Composita?, each containing
0.13 gram (gr. ij.) rhubarb, 0.1 gram (gr. iss.) aloes,
0.06 gram (gr. i.) myrrh, and a little oil of peppermint.
H. H. Rusby.
Aloinum. — Aloin. "A neutral principle obtained
from aloes, varying more or less in chemical com-
position and physical properties according to the
source from which it is obtained. Chiefly prepared
from Curasao aloes." (U. S. P.)
Aloin is a minutely crystalline powder, lemon
yellow to dark yellow, having a slight odor of aloes,
intensely bitter, slightly hygroscopic and soluble in
water and alcohol. It exhibits slight differences as de-
rived from the different varieties of aloes, and the
Pharmacopoeia describes only that from Curasao
aloes (barbaloin).
Aloin is the principal active constituent of aloes,
Vol. I.—U
and its action and uses are essentially the same.
The dose is about one-fourth that of purilied aloe .
II. II. ROSBY.
Alopecia. — Alopecia is a partial or general loss of
hair, from any cause whatever, and that in sufficient
quantity to be noticeable to the naked eye.
The word "alopecia" is derived from the Creek
d\u>7T7)S, meaning fox. Why this word has been
used to express baldness, it is difficult to say. tine
explanation might be that the fox is said to have,
normally, twai bald spots over his eyes, and another,
that he is especially liable to i he di i.i e.
The term as it. is used to-day covers a broader
field than it did formerly. It includes not, only all
varieties and degrees of dystrophies and atrophies
of the hair of the scalp causing baldness, but also
similar conditions of the hair upon any other part of
the body.
In text-books the alopecias are usually divided into
two main classes, congenital and acquired. In the
present article this classification is not followed, but
we will attempt to give a more scientific one instead.
Alopecia may be due to a local disease of some
hairy part of the body, and in this case it would be
limited throughout its whole course to the part in
which it commenced, or it may be the result of disease
elsewhere, and then the consequent baldness is only
incidental to the other affection.
This line of thought also evolves two principal
classes: (1) Alopecke essentiales, idiopathicoe sive
primaries; (2) Alopecias symptomatica^ sive secund-
arke. The first class includes the congenital and
senile forms, and those primary affections of the
hair that are premature, comprising alopecia presen-
ilis, alopecia pityrodes, alopecia areata, folliculitis
dccalvans, and dermatitis papillaris capillitii.
(We are well aware of the fact that strict logic
would really not permit alopecia pityrodes to be
placed in this class, but it stands out so prominently
among those diseases causing baldness that for prac-
tical purposes it may be classed among the essential
alopecias. Similar objections could be made against
the placing of alopecia areata among the "idiopathic
premature alopecias," and yet we find it there by the
consent of many good authorities.)
The second class contains first, alopecia toxica,
which includes those instances of alopecia caused by
the use of drugs like mercury and acetate of thallium
and also those caused by the toxins of systemic
infections such as syphilis, typhoid fever, etc.; second,
alopecia dynamica sive destructiva, in which loss of
hair is principally due to atrophy caused by mechanical
force, such as pressure atrophy (lupus erythematosus),
or to the destruction of tissue the result of suppura-
tion (gummata, epitheliomata, sycosis, etc.), or to
severe local inflammation (acute eczema, erysipelas,
etc.); and finally, alopecia neurotica, which follows
traumatic or functional nerve injuries.
The following represents a brief schedule of this
classification:
I. Alopecia: Essentiales, Idiopathicce sive Primariai.
1. Congenita.
2. Senilis.
3. Prematura.
II. Alopecia Symptomatica; sive Secundaria;.
1. Toxica.
2. Dynamica sive destructiva.
3. Neurotica.
Alopeci.e Essentiales. — Alopecia Congenita.
(Depilatio Congenita, Atrichia, Oligotrichia). — Con-
genital alopecia is a rare affection. It may be com-
plete, the new-born babe being wholly devoid of hair,
even of lanugo. After some time has elapsed, from
a few months to a few years, let us say, lanugo hairs
may begin to form, and later on, full-sized normal
hairs may make their appearance. It may, however,
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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
be the case that growth of hair never takes place.
This has been frequently found to be true where there
was only a partial alopecia at birth. In an instance
like this the individual bald patches may multiply
in number until they spread over the entire scalp, and
they often show a tendency to increase in size.
In connection with this malady, anomalies of the
teeth and nails are often observed. Crocker reports
the case of an individual who had only four molar
teeth, and was never known to have perspired or
shed tears.
Alopecia congenita represents one of the evidences
of arrested development ; there is a marked hereditary
tendency, and more than one member of the same
household may suffer from it.
Schede 1 is apparently the only one who ever pub-
lished the results of a complete microscopical exami-
nation of this disease. He found the sebaceous glands
well developed, in many places sending their open
ducts through the somewhat atrophic epidermis; in
some of these rudimentary hairs could be observed,
in others the papilUe were merely indicated. The
cutis surrounding this region was changed into a
coarse areolar tissue interspersed with granules and
fat cells.
The prognosis in the universal congenital alopecia
is said to be not as bad as in the partial affection.
Treatment can only be hygienic, and is limited to
aiding the general nutrition processes.
Alopecia Senilis (Calvities Senilis) — With the
advent of old age, a loss of hair not only of the scalp,
but also of the eyebrows, the genital and the bearded
region is observed. Women are not as extensively
affected as men. While it is true that at the decline
of human life an increase in the growth of hair is often
seen, it is equally true that this growth never takes
place upon the scalp.
As a rule the hair becomes gray before there is any
sign of senile baldness, which begins upon the top of
the vertex, at its junction with the occiput. The
coarse hairs begin to fall out, at first from a small
circular area only; this loss of hair spreads at the
periphery, presenting a picture like the full moon
shining through the clouds, and later on assuming
the form of the tonsure of a friar. The disease
spreads forward along the vertex, and descends
laterally upon the temples and the region above the
ears, and finally also invades the occiput. As a rule,
it leaves a small rim of normal hair encircling the
lower lateral and posterior parts of the scalp. The
coarse hairs are replaced by lanugo hairs, but these
also finally drop out. The scalp is then left as a
smooth, shining surface, thinner and tenser than
before, but still freely movable over the cranium.
The mouths of the follicles may still be seen for some
time, but they too shortly disappear.
The whole process is incidental to the retrogressive
nutrition changes of senility. The prime factor is an
obliterating endarteritis, which here means occlusion,
lack of blood supply, atrophy, and death of these
structures.
From the pathology of this condition it is plain
that treatment is of no avail in averting the loss of
hair.
Alopecia Prematura;. Alopecia Presenilis. — When
the symptoms of the last-described malady appear
in younger persons who do not show any other evi-
dences of the degeneration of old age, it is called
"alopecia presenilis." Its course and pathology are
the same as in the senile form, and therapeutic efforts
are as useless. The wearing of stiff headgear, such
as derbys and silk hats, is considered by some as a
cause of this affection. They argue not only that the
hard brims impede the circulation, by pressure upon
the blood-vessels encircling the scalp, but that on
account of their tight fit the air from expiration
becomes so deteriorated as to be obnoxious. This
factor may be remembered when a case presents
itself. Invigorating treatment, and the avoidance
of injurious diet and habits, may in some degree
retard the progress of the disease. Active cell metab-
olism should be encouraged.
Alopecia Piti/rodes sice Alopecia Furfuracea Capil-
lilii. — Our reasons for placing this affection among
the essential premature diseases of the hair causing
baldness have already been given. Its true nature
is by no means definitely settled, as shown by the
various designations given to it, e.g. seborrheal eczema
inflammatory seborrhea, seborrheal dermatitis, besides
those that are now obsolete, as, seborrhea sicca, seborr-
liea oleosa capitis, acne oleosa, and others. It is one of
the most frequent causes of baldness. It is not con-
fined toany particular age, but still is oftenest seen in
persons who are at the end of the second, or at the
beginning of the third decade of life. Women suffer
from it more frequently than men. Elliot gives the
relative frequency of the disease in the two sexes to
be as five women to four males. Michelson states
that women are not as often attacked as men.
Symptomatology. — One of the first conditions no-
tire, 1 by a patient is an increased scaliness of the scalp
commonly known as dandruff. Associated with this is
an obstinate itching, and a sensation of burning heat.
The pityriasis increases as the years go on, when the
sufferer complains that more hairs than usual fall out
when combing. A woman will soon notice that her
braids grow thinner at the ends, and that hairs com-
mence to project from them. This phenomenon is
due to the fact that the life duration of the individual
hairs (a duration which, normally, is about four
years) has become less than normal; therefore they
do not attain the usual length.
The hairs taking the place of the shorter-lived ones
grow, in the course of time, not only smaller, but also
thinner. They lose their luster and natural curliness,
and finally are replaced only by lanugo hairs. An
associated senile alopecia may hasten their disap-
pearance. During all this time the dandruff increasea
in quantity, but at the appearance of the lanugo con-
dition it stops suddenly, as if the disease had spent
its energy. The pityriasis consists of whitish scales
made up of epithelium, sebaceous matter, and dirt.
According to the proportion of sebum in them, they
may feel greasy or comparatively dry. The amount
of dandruff is a good indication of the severity of the
disease.
In addition to the itching, heat, and headache,
there is now experienced a feeling of tension all over
the scalp. Michelson has observed increased pers-
piration in some cases at this period.
Although, strictly speaking, the loss of hair begins
simultaneously over the whole scalp (Pincus, Michel-
son), there are certain areas that are more rapidly
and more intensely invaded than others. As a rule,
there are two principal centers of development, and
both lie in the median line of the top of the head; the
anterior one begins about one-half inch behind the
border of the hair, and runs backward; the other one
starts from the junction of the vertex and occiput,
ami progresses forward, so that there remains a
bridge of hair between, which connects both parietal
region, and still remain even when the disease is far
advanced; but it also finally breaks down. The
occiput and lateral portions of the hairy scalp are
not seriously attacked. The small bunch of hair in
front of the anterior bald spot is also quite persistent.
The anterior temporal regions, "the corners of the
hair," may form two additional starting-points.
Pathological Anatomy. — According to the descrip-
tion given by Pincus the epidermis is not thickened
but made rather thinner than normal. Elliot found
processes of vacuolation in the epidermic cells, and
infiltration with wandering cells. The granular layer
is seen to be slightly increased. The subcutis is
the seat of marked inflammatory changes, as shown
in the dense, small, round-cell infiltration which is
226
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Alopecia
arranged especially around the blood-vessels, partic-
ularly around those supplying the hair follicles and
their papillae. The hairs in themselves show nothing
characteristic. They differ in no way from those
that have undergone the process of physiological death,
pt that in some instances the roots are smaller,
atrophied, and have pointed ends, instead of showing
the nollowed-ouf knob of the healthy hair. Increased
brittleness may also be observed; but this probably
occurs only in bad cases, and then only in the ad-
vanced stages of the disease. Later on, as evidences
of a chronic inflammation make their appearance,
the small round-cell infiltration is replaced by a
dense net work of fibrous tissue, which gives the feeling
of tightness to the scalp, and prevents its being lifted
up between the fingers. The subcutaneous fat is
greatly increased in quantity.
Ft iology. — Some diseases, such as syphilis, diabetes,
typhoid fever, etc., are predisposing factors. French
writers consider "arthritisme" as an important cause.
Heredity also plays quite a role here. Any condition
or malady that leaves the system in a weakened
must naturally be looked upon as furnishing a
favorable chance for the invasion of the disease. Lad
hygienic surroundings, defective cell metabolism,
neglect of proper care of the scalp, general malnutri-
tion, increased ingestion of sugars, loss of sleep —
all of these have to be looked upon as probable pre-
disposing factors. How really sensitive the hairs of
the scalp are is shown by the loss of their healthy
luster and oiliness after a single protracted dissipation,
with its attendant loss of sleep and subsequent
general depression.
Numerous are the organisms described by those
who have attempted to verify the parasitic nature
of the disease. Malassez considered his flask-shaped
bacillus (called by Sabouraud Bacillus asciformis) as
the cause of alopecia pityrodes. Unna holds that
alopecia pityrodes is identical with his eczema seb-
orrhoicum, and is caused by the morrococcus or
mulberry coccus. Merrill, in connection with Elliot,
found a diploeoccus with sufficient frequency to be
able to attach to it some etiological importance.
Sabouraud, after some painstaking experiments,
believed that he had established the identity of some
follicular affections hitherto regarded as separate
diseases — i.e. comedones, acne, seborrhea, alopecia
pityrodes, alopecia senilis, and alopecia areata. He
describes a punctiform bacillus almost resembling a
coccus, lft in length and 0.5/i in diameter. It has
the power of penetrating deeply into the hair follicles
and into the sebaceous glands, while, according to
him, the flask-shaped bacillus of Malassez is confined
to the funnel-shaped enlargement of the mouths of
the diseased follicles. He sums up his explanation
of the pathogenesis of alopecia pityrodes by stating
that the presence of the microorganism described by
him first causes an irritation, and thus a hypersecre-
tion of the sebaceous glands; then there follows an
hypertrophy, and by further invasion, a progressive
papillary atrophy, with malnutrition and atrophy
of the hair producing cells, hence death of the hairs
that are formed, and cessation of the growth of new
one-;.
Right here it would seem appropriate to mention
the fact that the parasitic theory of alopecia pity-
rodes was first advanced by Lassar and Bishop 2 after
some experiments in which alopecia followed the in-
unction of a mixture of vaseline and finely cut hairs,
taken from a tyr cal case of this disease. In the
case just mentioned alopecia appeared in the third
week, and could be transmitted from the first series
of animals to others. Michelson remarks that he was
able to produce the same effects with rancid olive oil.
Saalfeld, 3 repeated the experiments of Lassar and
the bacteriological studies of Unna and Sabouraud.
He was able, like Lassar, to produce a loss of hair,
but not a typical alopecia pityrodes. He also suc-
ceeded in producing the same conditions with simple
non-rancid oil, and even with the somewhat vigorous
strokes of a brush. Using rancid oil, he obtained
the same effects as Michelson. Ee has found micro-
organisms which may be considered identical with
tho e of Unna and Sabouraud, but he looks upon
them as incidental. He was unsuccessful in proving
that they produced alopecia pityrodi
Fig. SO. — Alopecia Areata. (From a photograph of one of the
author's cases.)
The direct exciting cause is probably a local exogen-
ous toxemia from organisms situated in the skin; and
the predisposing cause and the more important one,
an endogenous or metabolic toxemia or an exogenous
toxemia from the digestive tract, making the soil
favorable for the organisms directly concerned in
causing the inflammatory process.
Diagnosis. — The disease may be readily recognized
by its occupying usually the median portion of the
scalp, the lateral and posterior parts being compara-
tively free from the furfuraceous scales always pres-
ent in greater or less quantities, and from the sensa-
tions of itching and heat.
It is distinguished from senile, and more espe-
cially from presenile alopecia, in that these two forms
begin upon the vertex of the head, wdiile the anterior
portions are invaded much later. There is no pity-
riasis in these diseases, and the loss of hair is more
rapid. Psoriasis does not attack the scalp as a whole.
Its lesions are usually isolated and sharply limited ;
its scales are silvery and dry and comes off in lam-
ellae; and it never attacks the scalp alone.
Eczema seborrhoicum is especially noticeable by
the margin along the front of the hairs; this margin
is more or less continuous and covered with yellowish
greasy scales. As a rule, the chest and the back are
affected at the same time. The diagnosis is some-
times impossible.
Alopecia syphilitica, while it may be seen all over
the scalp, is, however, generally situated upon the
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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
sides and the occiput; often the external halves of
the eyebrows and the eyelashes fall out.
Alopecia areata can hardly be confounded with
alopecia pityrodes. Like the preceding it completely
lacks the furfuraceous desquamation.
Pincus has called attention to the disproportion of
the sharply pointed hairs, those that are so small
that in cutting the hair they escape the shears or
the barber; and those which, on account of their
length are clipped, and therefore present to view a dull-
pointed end. If the proportion is as 1:8 of hairs of
thirteen centimeters length, and as 1 :10 in those hav-
ing a length of from five to eight centimeters, the shed-
ding is abnormal; and this circumstance, in connection
with the other symptoms described, gives the diagnosis
of alopecia pityrodes. The way in which it is recog-
nized in women has already been alluded to under the
heading of Symptomatology.
Prognosis. — The disease is curable, but can be com-
bated only by energetic and long-continued treatment
which may last weeks, months, or even years. As it
it not in human nature to spend the time and energy
necessary for the cure of an affection where the dam-
age done is simply an offence to the esthetic, the
disease as a rule, is permitted to run its regular course
to the end, which is perhaps put off for a few years by
intermittent attempts at treatment. Heredity, and
the appearance of this form of alopecia in the earlier
years of life, render the prognosis less favorable.
Treatment. — We will not enumerate all the reme-
dies advised for the cure of alopecia pityrodes, but
simply lay down the principles for its treatment, and
cite one or two examples. Any other plans and
methods advocated can then be readily appreciated
by the reader. The first step must be to remove the
pityriasis. This procedure removes at the same time
a good many organisms, and by the mechanical force
applied, massages the scalp, and hence helps to re-
move some of the inflammatory exudates. The
next step is to apply some antiseptic medicament
which should not only cover the scalp, but should
also penetrate, if possible, into the hair follicles, so as
to reach organisms situated there. Through the
washings, and the applications of antiseptics which
are usually dissolved in alcohol, the natural oil of
the scalj) will be removed. This must be replaced, and
this replacing constitutes the third and last step of the
treatment. An ointment having as a basis vaseline
or lanolin is rubbed into the scalp. It is a good plan
to add to this some antiseptic, so as to have the dis-
eased parts in constant contact with a germ-de-
stroying agent.
This treatment has to be repeated daily for from
one to six weeks; then once every other day for a
similar period of time; then three times a week; after
that once a week, and this latter must be continued
for a period of years for, as stated above, if the scalp
is not treated energetically and persistently the dis-
ease is certain to recur. No method, however, can
resuscitate the atrophied hair-producing structures;
but the simply diseased ones may be restored to
health, if treated before the changes are too far
advanced.
Twenty or more years ago Unna recommended a
simple remedy, which, according to him, is attended
with good results. It consists simply of an oint-
ment of ten per cent, precipitated sulphur in unguen-
tum pomadini. The hair is parted first in a sagittal,
then in a coronal direction, the parts being a distance
of about one centimeter away from each other, and tin-
salve is lightly spread along the furrows. This is
done every night. The scalp is washed every three
or four days to cleanse it from the scales and the salve.
In the second week, or later, according to circum-
stances, the intervals between the applications be-
come longer and longer, until finally treatment is
stopped altogether after a cure is thought to have been
obtained.
The method laid down by Lassar meets all the indi-
cations for treatment. The scalp is washed daily
with a good tar soap for at least ten minutes, warm
water being used at first, and the lather then rinsed
off with cool, and finally with cold water. After
this the hair and scalp are thoroughly dried — this is
very important. Now a solution of one-half per ci
corrosive sublimate in equal parts of glycerin and ;
water is used, being applied to the scalp with some
friction. This is followed by the use of a solution of
one-half per cent, of ^-naphthol in absolute alcohol.
As the parts are now completely dehydrated and poor
in fat, the latter has to be replaced and now any fur-
ther antiseptic added is taken up very eagerlv on
account of the dehydration. Lassar recommends the
following: fy Acidi salicylici, 10; Tincture benzoini,
3; Olei bubuli, 100. In severe cases the corrosive
sublimate solution may be used several times dur-
ing the day. If there be a tendency to great greasi-
ness of the scalp, resorcin of from three to five per
cent, strength is suggested, instead of the /3-naphthnl
or salicylic acid in the ointment; or, it may be added
to the same, the percentage of the latter being then
of course reduced accordingly. The combination
of resorcin and salicylic acid is, besides, very appro-
priate from a pharmaceutical standpoint, for resorcin
has the tendency, when used alone, and especially
when combined with alkaline media, to turn red in
color; a change which does not take place when in
union with acids.
When the hair is very dry sulphur acts better than
resorcin. Of course, when sulphur is used, the wash-
ing with corrosive sublimate is omitted. The sul-
phur in that case is incorporated into the pomade in
combination with salicylic acid and also with resorcin,
if we choose. As the greasy ointments are often
objectionable to women, we may add the ingredients
to a basis of a lower melting-point than lard or vase-
line; as, for instance, benzoinol or liquid albolene.
This treatment of the scalp must be repeated daily
for at least one week, and, in more marked cases, for
as long as six weeks; after this once every other day;
then three times a week; and finally once a week
will be sufficient, but this must be continued for
months if necessary.
Corrosive sublimate 1 to 1000 in bay rum is a
cleanly preparation and usually gives satisfactory
results. It is to be used as a daily dressing of the
hair.
Alopecia Pityrodes Universalis. — Under this name
Michelson' described a variety of the former disease
affecting all the hairy regions of the body. Kaposi
had observed a similar condition in connection with
seborrhea. The disease may begin like a simple
alopecia pityrodes affecting the top of the head, hut
si urn the whole scalp becomes involved, and si-
multaneously, or a little later, all the hairs of the body
begin to fall out; at the same time there is an abun-
dant production of pityriasis in the parts affected.
Lanugo hairs take the place of those that have dis-
appeared, and in places the stumps of hairs I
have been broken off may still be seen. This affec-
tion somewhat resembles a universal alopecia,
areata, but differs from it in the pityriasis present.
and in the fact that the scalp is tense and tightly
stretched over the cranium, while in alopecia areata
it is thin and readily movable. A greatly debilitated
system seems to lie at the bottom of this malady.
The prognosis is not unfavorable; the new hairs
that grow in may be different in color from the old
ones. The diagnosis is readily made, if it be remem-
bered in what points it differs from alopecia areata.
The pathology is essentially the same as that ol
alopecia pityrodes localis.
Michelson has noticed a peculiar brush-like deform-
ity of the ends of the diseased hairs, a deformity
which he attributes to the affected papillae being
unable to furnish enough cement substance to li"M
228
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Alopecia
the individual cells together. The lower parts of
the hairs show an increa ;e in nuclei and pigment.
Besides the local treatment, which consists of
in\ igorating l>aths, as ft)! 1 instance these of salt water,
and that special treatment described under the local
form of this alFection, particular attention is to be
directed to the general nutrition, which must be
improved.
Alopecia Simplex. — Pineus described instances in
which there is a general loss of hair of the scalp; the
crop of hair becomes thinner and thinner, just as it
does in alopecia pityrodes, but there is no pityriasis in
nection with the loss of hair. This latter fact
made it seem proper to give this special form of the
disease a separate name. The treatment is similar
to that in alopecia pityrodes, only the shampooing
- remove dandruff may be omitted as unnecessary.
Alopecia Areata (Area celsi, area circumscripta,
i accidentalis, tinea decalvans, teigne pelade,
pelade). — The term "alopecia areata," as it is used
to-day, is rather vague and ill defined. Several
diseases are probably included under it.
The affection is a disease of the hairy parts of the
body, producing a loss of hair in circumscribed areas,
which commence as small spots and gradually in-
crease at the periphery, the underlying skin being
apparently little or not at all affected. The regions
most frequently attacked are the scalp, the beard,
and the eyebrows. The disease may occur on any
part of the body where hair is found. The loss of
hair may be partial or complete. The mild cases are
usually limited to the head, beard, and eyebrows.
Crocker, in order to substantiate his belief in a
connection between alopecia areata and ringworm,
has pointed out that it is more frequent in those
countries where the latter prevails (France and
England), while both affections are far less frequent
in Germany and America. Men are more often
attacked than women, persons between the ages of
tin and twenty-one more frequently than others;
dark-haired persons suffer more from the affection
than blondes.
Symptomatology. — Constitutional or local prodro-
mal symptoms are absent as a rule; there may be
some malaise, loss of appetite, headache, slight itch-
ing, and other paresthesia?. H. Schultze, 5 who ob-
served the disease on himself, made note in his case
of a unilateral headache upon that side, which, later
on, became invaded by alopecia areata.
The parts of the scalp most generally affected are
those surrounding the junction of the occiput and the
parietal bones. There is no symmetry in the lesions
as a rule. The formation of the individual patches
is about as follows: A person may notice that in a
certain spot his hair conies out very freely. He
observes a bald space. He attempts to pull out
some hairs, and finds that they can be removed very
easily and wholly without pain. Afterward the
hairs may fall out spontaneously along the periphery
of the small patch first seen. The patch grows larger,
rapidly or slowdy, and in all directions. The increase
in size may progress more rapidly in one direction
than in another, thus creating oval or irregular patches.
There may be only one patch, or there may be several,
beginning at the same time, or, as is usually the case,
there may be successive crops of bald spots.
The areas of baldness are from one-half to two
inches in size, but by the coalescence of several areas
very large patches are sometimes formed. Individual
areas are not always very sharply defined from the
surrounding healthy structures in the first stages of
the malady. The periphery is surrounded for a short
distance by a thinner crop of hair. There may be
some few healthy hairs left even in the center of the
bald areas, hairs which cling to their papilla;. Some
broken-off hairs projecting from their follicles are
often noticed upon close inspection. The skin at the
seat of the affection is smooth, shiny, thin, and can
readily be lifted up between the fingers. It looks
paler than the normal skin, and on being pricked with
a needle blood oozes less readily. There are no
vesicles, crusts, or scales, no efflorescences of any
kind. In some feu- cases I have observed a slight
caling, redness, and some edema at the beginning
Of the disease. The level of the affected skin is felt
to be below that of the neighboring normal skin.
This is duo to the fact thai tie skin has sunken in,
on account of I lie ab ence of so many hairs in the
now collapsed hair follicles, and not, as some believe,
to an atrophy of the cutis. The nervous impressions
are not impaired. The tactile, temperature, and
pressure senses may be slightly increased ( Michelson).
Neumann, however, has observed anesthesia. \\ hen
the disease at a given patch has come to a standstill,
the hairs at the periphery become more normal in
number and cannot be as easily plucked out as before;
the affected area is now sharply defined. The period
of baldness of such a patch is, as a rule, of several
weeks' duration, and if at the expiration of this time
there are no signs of regeneration, it is difficult to
determine when the hairs will make their reappear-
ance. The malady may go on for years and years.
Recovery has been observed after a period of from
ten to fourteen years, and even after a much longer
time; it may, however, never take place.
Reproduction of healthy hair begins almost always
at the periphery and progresses from without inward.
First, small lanugo hairs begin to appear. These,
after a short struggle for existence, may fall out again,
to be replaced by stronger and longer hairs. This
replacement of the new hairs by others may repeat
itself several times before the normal hairs finally
make their appearance, and these latter may even
then lack color for a long time. The affected area
may long after be recognized as the site of a previous
alopecia areata.
A seborrheal eczema condition sometimes precedes
the alopecia area but in my experience it occurs only
in a small percentage of the cases.
Alopecia areata of the other hairy regions presents
analogous phenomena. The beard, eyebrows, axil-
lary and pubic hairs may fall out. All the hairs of
the body may disappear, thus constituting the al-
opecia maligna of Michelson.
Pathology. — Nothing characteristic of this affec-
tion can be obtained from an examination of the
hairs. They show the same simple atrophy as seen
in the hairs shed in the physiological way. In some
the roots are not bulb-shaped, but pointed, a fact to
which we have already called attention, in connec-
tion with the pathology of alopecia pityrodes.
My observations of the microscopical changes of
the skin were reported to the Ninth International
Medical Congress at Washington (1887). Many pieces
of skin were taken from seven different patients.
In spite of the clinical appearance of the dis-
ease, the presence of an inflammatory process in
every case could be observed. S. Giovannini and
Sabouraud have also found perivascular small round-
cell infiltration, consisting of mast cells and mono-
nuclear leucocytes. This, according to Sabouraud,
goes to show fhe presence of an agent with decided
chemotactic influences upon these cells, an agent
probably emanating from a microorganism. In my
sections, the subcutaneous tissue was normal, the
lymphatics were somewhat dilated and contained
micrococci. Whether they have any etiological
relationship to the pathological phenomena, I have
so far been unable to demonstrate.
Some hair follicles showed replacement of the normal
hair by lanugo. The hairs in some were broken, or
stubbed and split. The lower parts of the follicles
were devoid of pigment, this explaining the loss of
color of the returning hairs during convalescence.
In cases of permanent alopecia of long standing, hair
follicles and sebaceous glands had been destroyed.
229
Alopecia
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
The blood-vessels showed a thickening of their walls.
Etiology. — There is in dermatology hardly a single
disease whose nature is so much disputed as that of
alopecia areata. Three views are held in regard to
it: first, that it is a trophoneurosis; second, that it is
of parasitic origin; third, that what we understand
under alopecia areata to-day is not a clinical entity
at all, but that under this name are grouped several
diseases, some of which are neurotic, while others are
parasitic.
In my opinion every case of alopecia that com-
mences as a small spot and gradually increases in
area by extension at the periphery and shows the
clinical characters I have described, is due to the
local action of an organism.
In support of the first view are cited the nervous
prodromal symptoms, such as neuralgia, headache,
and the various paresthesia?, and the fact that loss
of hair in patches often follows nerve injuries. Kap-
osi enumerates many instances of this kind. Best
known are the experiments of Joseph and Mibelli,
who observed alopecia following the excision of the
second cervical ganglion. Moskalenko and Ter-
Gregoryanitz {Vrach, 1899) have produced typical
alopecia areata in dogs, cats, and rabbits by per-
forming the same. operation, and also by cutting the
nerve roots. Injury to the peripheral nerves pro-
duced no typical alopecia areata, as the patches that
showed themselves were not round. If the disease
were always due to nerve injuries, the triangular
form, corresponding to the area of supply of a given
nerve, should be more frequent. Besides, there arc
undoubted cases in which the lesions spread without
regard to blood-vessel or nerve supply.
According to my view of the subject, the cases of
circumscribed loss of hair following nerve injuries
are not instances of alopecia areata, if we understand
this term to mean an affection in which the hair falls
out in round patches which spread at the periphery,
and only such cases should be called cases of alopecia
areata.
The fact that regeneration progresses from without
inward has been brought forward as an argument
against the theory; if justly so, remains to be seen.
Another argument against it is the absence of all
inflammatory symptoms usually seen upon the sur-
face — i.e. vesicles, scales, crusts, etc.; but as already
mentioned, an inflammatory process is always present.
Numerous organisms have been found. As early
as 1843, Gruby had described his Microsporon au-
douini, but it was found that it represented one of
the forms of the ringworm fungus. Others who
called attention to parasites are Malassez (1875),
Thin (1881, bacterium decalvans), von Sehlen
(18S4, areacoccus), mvself (1SS7), and Vaillard.
Vincent, Nimier (18S9), etc. In 1S9G Sabouraud 6
brought to notice an organism which he named
" microbacillus alopecia? areata?," and not being
certain as to its etiological importance, "le micro-
bacille de l'utricle peladique." He admits that it
may be identical with Unna's and Hodam's organism
found in comedones, and in acne. In the following
year (1897) he stated that in his opinion comedones,
acne, seborrhea, alopecia pityrodes, and alopecia
areata are all caused by the same organism, varying
only in intensity and location.
As reported to the American Dermatological
Association, I have experimentally produced small
areas of alopecia with all the objective characters of
alopecia areata by the subepidermal injections of
Staphylococcus epidemicus albtis. The patches did
not extend beyond the area injected.
In support of the parasitic theory, frequent refer-
ence is made to the instance of contagion as cited by
Crocker, many French authorities, and by Bowen
and Putnam 7 of this country, and again by Bowen. 8
In France the disease lias been observed especially in
(lie army, and is believed to have been due to the same
hair-clipping machines having been used, or to the same
caps and helmets having been worn. .Sabouraud has
observed that many patients applying for treatment at
the Hopital St. Louis came from the same section
of the town, and that some had employed the same
hairdresser. The epidemic in an asylum, described
by Putnam, is remarkable. Sixty-three out of sixty-
nine girls were infected, and there was no trace of
ringworm. A girl, who was believed to have spread
the disease, left the institution, and went home
where in a short time her stepfather became infeel
In the mean time the epidemic at the asylum had
come to a standstill. A'few years after, this Ban
girl was again received at the institution, and in a
very short time twenty-six out of forty-five children
showed evidences of the disease. Hutchinson and
Crocker think that there is some relationship between
ringworm and alopecia areata.
I have seen several examples of an almost simul-
taneous appearance of the disease in two or more of
the same family.
Diagnosis. — A typical case can be readily recog-
nized by the lesions being round and spreading at
the periphery. The thin, smooth, shiny skin, sunken
beneath the niveau of the surrounding health}- skin,
and showing no signs of an inflammatory process
makes the diagnosis easy. Alopecia areata has to
be differentiated from ringworm, favus, syco
syphilis, folliculitis decalvans, and the loss of hair
after traumatism. Alopecia maligna must be dis-
tinguished from alopecia pityrodes universalis (vide
above).
In ringworm we find dermatitis, broken-off hairs,
and the ringworm fungus under the microscope; in
favus, also, the organism producing it, as well as the
yellow cups, scar tissue, and a grayish discoloration
of the atrophied hairs. Folliculitis decalvans pre-
sents evidences of follicular inflammation and sear-
tissue formation. Alopecia syphilitica shows irreg-
ular patches, not depressed, especially affecting the
outer portions of the scalp and the eyebrows; besides
these, there are concomitant symptoms of the
disease.
Cases of the falling out of hair in patches, in con-
sequence of nerve injuries, have been observed, and
the characteristics of the resulting bald spots were
similar to those of the ordinary cases of alopecia
areata. The clinical history of the manner of forma-
tion of the patch is, however, different. I consider
those cases only to be true examples of alopecia
areata in which the patches grow by extension at the
periphery.
Prognosis. — As alopecia areata tends to a spon-
taneous recovery in the majority of cases the prog-
nosis is favorable. Even if regeneration does net
show itself for years, hope should not be entirely
abandoned, for regeneration may ultimately take
place. This was true in several instances, where
new hairs grew even after a decade or more from the
beginning of the malady. It is my experience, how-
ever, that if a patch remains quite free from lanugo
hairs for several months, it shows that the follicles
are probably destroyed and that there will be a per-
manent alopecia. The older the patient, and (he
longer the area has been affected, the graver becomes
the outlook as to recovery. The possibility of
relapses must not be forgotten.
Treatment. — On account of the fact that recovery
is often spontaneous, it is exceedingly difficult to
appreciate the value of any therapeutic agent other-
wise than by means of a long series of observations.
A host of remedies has been recommended. Inter-
nally, arsenic, cod-liver oil, tonics, and jaborandi may
be tried in connection with dieting, physical and
mental hygiene. While such a therapy may not
have any direct effect upon the cause of the lesions,
it may help to render the system more resistant to
the disease. Tincture of jaborandi is administered to
230
Kill KKKXCK HANDBOOK ( >!•' TIIK MKDICAL SCIK.WKS
Alopecia
produce a local hyperemia of the pale patches who e
blood-vessels are abnormally contracted.
The older methods <>f I oral treatment wore addressed
to stimulate the nutritive processes of the part;
lav, when the parasitic theory prevails, para-
siticides are used. Chrysarobin, in my opinion,
ds out far above any other remedy. It is must
ctual when incorporated in vaseline or lanolin;
much more so than when combined with liquor
ta percha or traumaticin. As a rule, a six- to
ten-per-cent. preparation is applied daily for one or
two weeks, and then stopped for a short time to
erve if the disease has been cured. If lanugo
■a do not appear soon, or if the hairs at the pe-
riphery continue to fall out or can be easily pulled out,
the treatment is continued. Care should be taken
that the application does not reach the eyes, as a,
re conjunctivitis might follow. Because of this
ible danger it cannot be used upon the eyebrows.
it" recommends for these that carbolic acid be
ned biweekly. The slight mahogany discoloration
rved around the neck and in the face after the
of chrysarobin is the first danger signal of an
approaching dermatitis. The remedy should now
either be stopped at once, or the strength of the oint-
| be reduced. The hairs around the periphery
Id be removed as soon as they become loose.
1 believe the great majority of the cases can be cured
within two or three weeks by this treatment if seen at
an early stage. Croton oil, which is a pure irritant,
be of benefit in chronic cases. It should be
I with olive oil, equal parts, and applied every
day until a dermatitis is produced.
Balzer and Storianowitch have obtained good re-
sults with a fifty-per-cent. solution of lactic acid in
water or alcohol. The affected parts are first freed
from oil with alcohol and ether, and the remedy is
then applied with a swab of cotton until slight redness
appears. Besides this the scalp is washed with a one-
cent. bichloride solution. After the stimulation
has become well marked, the applications of lactic
acid are interrupted for a few days. Boric acid
line is spread upon the surface in the intervals.
The alcoholic solution is said to be the less painful.
Recovery was obtained fifteen times out of nineteen
is, in from two to three and a half months. Lan-
ugo hairs made their appearance at the end of the
md week, at the earliest. McGowan recom-
mends tricresol used pure upon the scalp, and upon
the face in a fifty-per-cent. solution. He was led to
use this remedy from his experience with pure car-
bolic acid.
Scarification with subsequent application of a
•ion of corrosive sublimate 1:2,000, as in erysipe-
as, seems to be a rational mode of treatment, but
•till there is some danger here of infection with pus
irganisms. Injections of bichloride 1:40, made at
ii'.fcrent points, are recommended by Moty of Paris.
Finsen of Copenhagen, who obtained such brilliant
'csults, especially in lupus vulgaris, with the applica-
tion of concentrated violet light rays was successful
n treating alopecia areata by the same method.
lesfld who followed Finsen in his treatment, states
;hat it cures alopecia areata in two months, instead
jf the three to six months necessary by the use of
older methods.
Brisquet uses oil of cinnamon (Chinese) and sul-
phurous ether 1:3. He avoids washing the scalp
!o exclude humidity (after the hairs have ceased to
ill). The sulphur preparations are often of prompt
ind decided value; e.g. an ointment of one to two
hams of precipitated sulphur to an ounce of vaseline,
rubbed well into the scalp daily, after a thorough
washing of the whole scalp with soap and water.
In my opinion, as already stated, cures can be
obtained more quickly, and with greater certainty,
rom the use of chrysarobin than by any other method.
After the hairs have ceased to fall out, some stimulat-
ing and antiparasitic application should be applied
for a few months.
Relying upon internal medicine and hygienic
measures alone I believe to be a serious mistake
and accountable for many cases of permanent alo-
pecia. Such measures if employed should invari-
ably be accompanied by a vigorous local antipari n ic
i real merit.
Folliculitis Decalvans. — Within the last decade
French authors especially have called attention to the
hair follicles being attacked by some affection whose
nature still remains obscure. Each authority in turn
has considered the individual disease before him as a
new one, and has stamped it with a new name, so that
in wading through their literature, we meet with a
formidable array of names, "the sum of which has
brought despair to every humble reader." 10 Some
of these affections are identical, some represent only
novel aspects of well-known diseases.
The following are a few of the titles given: "Follicu-
lites et perifolliculites agminees destructives du
follicle pileux" (Brocq); "folliculite epilante" (Quin-
quaud); "folliculites et perifolliculites decalvantes
agminees (Brocq); "alope'cie cicatricielle innomineV
(Besnier); "acn6 decalvante" (Besnier, Lailler, Rob-
ert); "lupoid sycosis" (Milton, Brocq); "ulerythma
sycosiforme" (Unna).
A description of a few of these types may suffice.
" Pscudo-Pelade," Simple Folliculitis Decalvans. —
This affection somewhat resembles alopecia areata,
but on close inspection a mild folliculitis and peri-
folliculitis may be noticed. There are rose-colored,
inflammatory tumefactions, soft to the touch; the
hairs fall out, and are easily plucked out; they are not
broken; there is a marked atrophy in the older spots;
these are depressed, shiny, and, unlike those of alo-
pecia areata, hard and irregular, and, as a ride,
smaller. The disease spreads in an irregular manner.
"Folliculite Epilante" of Quinquaud. — This form
corresponds to the acne decalvante of Lailler and
Robert. It resembles the former with the addition
of suppuration in the follicles. Besides the scalp, the
beard, axilla;, and pubic regions may be involved.
Permanent alopecia appears also, caused by the
cicatricial destruction of the hair-producing areas.
The bald spots are round or irregular; along "their
periphery or in islands of healthy hair within them,
small pustules, perforated with a hair, are usually
to be seen." Quinquaud found micrococci, but was
unable to establish their causative effect.
"Alope'cie cicatricielle innominee" of Besnier is
almost identical with Quinquaud's disease. It is
slightly more superficial, more chronic, and more
obstinate; the cicatricial changes are greater; the
margins are not sharply defined; the disease spreads
by continuity. Besnier himself considered both
diseases the same, but Quinquaud stated that they
are not identical.
"Dermatitis Papillaris Capillitii." — Under this
name Kaposi has described a follicular disease appear-
ing at the junction of the nape of the neck and the
-alp, invading the latter often as far as the vertex.
It is doubtful whether this affection is a clinical
entity, or simply a variety of some other disease.
According to Kaposi it commences in the form of an
isolated papule of the size of a pin's head. These
papules later on aggregate to form elevated red
plaques, which are quite hard and from which the
hairs project in brush-like bunches. The hairs are
not readily removed; they break and are atrophied;
pustules may be noted in places. After the disease
has invaded the scalp and lasted a long time, papil-
lomatous vegetations are formed, two to three centi-
meters in diameter, covered with crusts from which
oozes a foul-smelling secretion. Abscesses may de-
velop also.
Microscopical examination shows an extremely
vascular papillary outgrowth, very much resembling
231
Alopecia
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
granulation tissue. The disease finally progresses to
the formation of connective tissue and scar tissue,
with the subsequent death of the invaded hair fol-
licles. Nothing is known positively as to its etiology.
It occurs at all ages and in both sexes. It is undoubt-
edly a local parasitic affection.
Diagnosis. — The disease would have to be differen-
tiated from a papular syphilide. Coccogenic sycosis
and eczema do not show such a firm induration, and
their clinical history is different.
Prognosis. — The disease has no tendency to spon.
taneous recovery, but it is usually slow in its progress-
The general health remains unaffected. The lesions
may return after excision of the affected area.
Treatment. — Mechanical removal of the growth is
the only means of treatment so far as we know.
Curetting, excision, and cauterization with chemi-
cal, electric, or actual cautery must destroy the base
of the disease or there will be recurrences. A*-ray
treatment has given good results in my hands.
Ai.opeci.e Symptomatica. — Alopecia Toxica. —
In the course of some infectious diseases there are
noticed grave disturbances of nutrition from the
toxins in the system, disturbances which also affect
the growth of hair. It seems as if the toxins them-
selves can produce baldness, when it occurs during
the attack of the infectious disease, as in alopecia
syphilitica. The loss of hair may be subsequent to
the general grave nutrition disturbances, as when it
appears during convalescence after typhoid fever.
This form of alopecia is also seen in the cachexia;
that occur with malignant disease, chlorosis, etc.
Some drugs may produce it, as mercury and acetate
of thallium. S. Giovannini and others have observed
general loss of hair following the administration of
doses of 0.1 of this latter remedy given for the sup-
pression of tuberculous night sweats.
Alopecia sypliilitica is perhaps of sufficient interest
to warrant a short description, on account of its com-
parative frequency, its often very typical course, and
the importance of making a correct differential diag-
nosis. We refer here only to that variety that is
noticed at the beginning of the secondary period. It
may be complete, all the hairs of the scalp, the pubic
region, and the axilla; disappearing, or the hair may
fall out in larger or smaller patches which arc usually
symmetrical. It is highly characteristic of this affec-
tion that it invades especially the outer border of the
scalp, the temporal, parietal, and occipital regions,
and, unlike alopecia pityrodes, avoids the top and
front of the head. What is stated by Fournier to
be almost typical of syphilitic alopecia is the falling
out of the outer halves of the eyebrows on both sides.
Any concomitant, syphilitic lesions will aid in dis-
tinguishing it from alopecia areata, which it often
resembles.
Its prognosis is good, even the complete alopecia
yielding to proper antisyphilitic treatment. Alo-
pecia pityrodes, however, often follows in its wake.
It is obvious that attention must be paid, to this
according to the rules prescribed for this disease.
The prognosis in all the alopecia; due to toxins is
very favorable. Cessante causa, cessat effectus. The
underlying cause should therefore be removed, if
possible.
Alopecia Dynamica sive Destructiva. — Loss of
hair may be caused by toxins in connection with
local destructive processes. It is then purely mechan-
ical, due to the loss of tissue or to pressure atrophy.
This may occur in severe or deep local inflammations,
as in long-continued sycosis, aggravated forms of
acute eczema, erysipelas, impetigo contagiosa, or in
inflammations accompanied by ulceration spreading
over the surface, as in pustular, tubercular, and gum-
matous syphilides, lupus vulgaris, lepra, the kerion
of tinea trichophytina, and ulcerating neoplasmata,
most frequently epithelioma. Finally, the hair fol-
licles may be choked to death, so to speak, by some
chronic inflammatory processes which do not sup-
purate, but have a tendency to scar-tissue formation
causing atrophy, due to the mechanical cutting off of
the blood supply. Lupus erythematosus, sclero-
derma, lichen planus, and the keratosis follicularis of
Brocq belong in this class.
The prognosis depends upon the severity of the
local primary disease. In most of them the "resulting
alopecia is permanent. The treatment is that of the
underlying affection.
Alopecia Neurotica. — Traumatism to an individ-
ual nerve, or to the central nervous system, as a
fractured skull, concussion of the braiii, shock, or
their combinations, may cause loss of hair — a 'loss
which may be complete, as in the three case:: cited
by Michelson, one of which showed not even a single
lanugo hair; this occurred after a fall, followed by a
period of unconsciousness lasting for a year. It. may
Ik- unilateral, or partially limited to the area of dis-
tribution of a single nerve; in the latter case the
resulting bald spot is, as a rule, triangular.
Fisher observed complete alopecia of the extremi-
ties following gunshot wounds. These cases wen-
remarkable from the fact that they were preceded by a
decided increase in hair growth.
The so-called functional psychoses and neuroses.
such as melancholia, migraine of long standing,
hemiatrophy of the face, produce discoloration
and falling out of the hair. Persistent neuralgias di
the same, but here the alopecia is never complete.
There always remain lanugo hairs in the affected are
Some cases that are looked upon as examples of alope-
cia areata undoubtedly belong in this category.
A. R. Robinson
References.
1. Schede: Archiv fur klinische Chirurgie, Bd. xiv
2. Lassar: Monatshefte fur praktische Dennatologie, 1882, i
3. Saalfeld: Virchow's Archiv, vol. clvii.
4. Michelson: Zeimssen's Handbuch der Hautkranken.
5. Schultze: Virchow's Archiv, vol. lxxx.
6. Sabouraud: Annales de Dermatologie et de Syphiligraphie,
1S96, i.
7. Bowen and Putnam: Journal of Cutaneous ami Ge&ito*
urinary Diseases, 1S97.
8. Bowen: Journal of Cutaneous and Genito-urinary I
1899.
Jessner: Monatshefte fur praktische Dermatologie, 1900.
10. Robinson: Morrow's System of Genito-urinary I
Syphilis, and Dermatology.
Alphozone. — Succinvl peroxide, succinic dioxide,
(COOH.CH 2 .CH,.CO),b 2 , similar in structure to
hydrogen dioxide, the hydrogen atoms being i
by succinic acid radicles. It occurs in the form of a
white, fluffy, odorless, crystalline powder, soluble in
thirty parts of water. It is a powerful oxidizing
agent, and consequently an antiseptic and deodorant,
but does not effervesce in the presence of organic
matter. It is employed as an intestinal antiseptic
in typhoid fever and dysentery, and as an external
application in the treatment of ulcers and inflamma-
tions of the mucous membranes of the nose aid
throat. For the latter purpose a solution of 1 3,000
to 1-1,000 is emploved in the form of sprav.
T. L.S.
Alps. — The extensive and lofty group of mountains
occupying the central region of Europe, in S
land. Savoy, Southern Bavaria, and Western Am tria
and separating Italy from the colder countries h
he to the north of it, presents to the invalid a
variety of places of resort, some chiefly serviceable
during the summer months, some during the winter
season, and some of them available as sanatoria aj all
times of the year. The climatic and other pcculiariti
of this region are discussed in the articles treating of
the several Alpine resorts, such as Arosa,
Engadine. Meran Vevey, etc.
232
RE ERENCE IIW'DHOOK OF Till: MEDICAL SCIENCES
\ I in ii hi
\lston, Charles. — Born in 1683 in the west of
otland. Studied medicine in Leyden, Eolland,
,1,-r the teaching of the celebrated Boerhaave.
lr ing his stay of three years in that city he formed
strong friendship with Alexander Monro; and
, two Mien, upon their return to Scotland, formed
,. project of greatly strengthening the College of
Unburg as a center of medical education. With this
n view they secured the cooperation of Ruther-
il, Sinclair, and Plummer. It is undoubtedly true
it tilt' ureal celebrity which the Edinburgh Sell, .el
Medicine subsequently attained should !»■ attribu-
I in large measure to the efforts made by these five
>n and to the wise and skilful manner in which they
,1 the business. Alston filled t In- chair of
m\ and materia mediea in the reorganized
and performed this duty acceptably up to the
no of his death, November, 22, 17(1(1; but the
ititude of posterity is due to him, not so much for
contributions to this department of medicine, as
r the reorganization work to which reference has
been made. A. H. B.
\ltcratives. — Formerly this term was applied
a group of remedies supposed to exert a very de-
led action in removing morbid conditions of the sys-
tnand promoting the patient's general well-being. It
,~ understood to mean "remedies which would rees-
hlish the healthy functions of the animal economy
thout producing any sensible evacuation." With
e advance in physiology and therapeutics and the
cognition of the importance of excretion as a factor
promoting health, a new conception of the term
and alteratives were defined as "agents which
ter the course of morbid conditions and modify
le nutritive processes while promoting waste."
v most modern therapeutists the term has been
cted as meaningless, or at least too indefinite
i be tolerated in any scientific classification of
•UgS, and at best alteratives may be defined as
remedies, such as arsenic, iodine, and mercury,
Inch act in a way to correct disordered metabolism
id promote repair." In addition to the drugs just
entioned, this class included sulphur, antimony,
)ld, guaiacum, colchicum, calcium chloride, and
ater, to which, were the class still recognized, would
■ added thyroid extract and other organothera-
mtic agents. T. L. S.
Althaus, Julius. — Born in Lippe-Detmold, Ger-
i my, on March 31, 1833. He pursued his medical
tidies in Bonn, Goettingen, Heidelberg, Berlin,
ienna, Prague, and Paris, and finally settled in
ondon in 1857. In 1866 he established, in the
eighborhood of Regent's Park, a " Hospital for
Ipilepsy and Paralysis." His death occured on June
I. 1900.
Of his published writings the following deserve to
e mentioned: "A Treatise on Medical Electricity,"
lird edition in 1873; " Diseases of the Nervous Sys-
•m," 1X7!); "On Failure of Brain Power," fifth edi-
inn in 1S9S, and "The Value of Electrical Treatment,"
hird edition in 1S99. A. H. B.
Althasa. — Marshmallow. "The root of Althma offi-
inalis L. (fain. Malvaceae)" deprived of the brown
orkey layer and small roots, and carefully dried "
l'. S. P.) The Marshmallow is a tall, perennial
alt-marsh herb of temperate European sea coasts,
t is also largely cultivated, sometimes for ornament,
nit chiefly for its root, in Southern Europe. The
oot of commerce is from six inches to nearly a foot
ong, usually about half an inch in greatest thickness,
simple and regularly tapering. It is nearly white,
rom the removal of the outer bark, and marked
with several broad grooves ami numerous small,
brown, slightly elevated spots. It is more or less
fuzzy with loan, hair-like, partly detached ba I
fibers. Ii snaps readily, owing in ii- large amount of
starchy parenchyma, bul the parts still cling together
by their tOUgh bat liber.-,. It ha- a sweetish and
Strongly mucilaginous taste. It i.-, about one-third
gum and another third starch, with about ten per cent.
of peel in, eight pea' cent . of SUgar, and one pel- cent, of
asparagin. In properties are wholly nutritive ami
demulcent. There IS no pleasanter ad.ju\ a at than the
official Syrupus Althoece of five-per-cent. strength.
The leaves and flowers are also rich in gum, and
both are much used in domestic practice in Europe
for poultices and demulcent drinks.
IIesry II. Rusby.
Altitudes, High. — See Climate and Climatology.
Altmann's Granules. — These are granules of an
acid-protein nature present in the cells of nearly all
normal tissues, the chief exceptions bring the cells of
unstriped muscular tissue, squamous epithelium,
ami the cells of the pyramidal portion of the kid-
ney. The granules are demonstrated by fixing in for-
mol-Muller fluid (formalin, 2, in Midler's fluid, 98) for
one week, then staining skin sections (5/<) in aniline
acid fuchsin for three minutes at 60°C, and differ-
entiating with picric acid alcohol (two minutes) or
ammonia (half a minute). According to Henry
Beckton 1 , the absence of Altmann's granules from
a new-growth, originating in cells normally con-
taining them, is an indication of malignancy. On the
other hand, " the presence of Altmann's granules in all
or nearly all the essential cells of a new-growth is
usually associated with non-malignancy or only with
malignancy of a special kind or limited degree." In
a tumor the diagnosis of which lies between inflam-
mation and sarcoma the presence of Altmann's gran-
ules indicates the former, the absence of them points
to sarcoma.
1. Eighth, ninth, and tenth reports of the Cancer Research
Laboratories of Middlesex Hospital, 1909-1911.
Aluminum. — Aluminum is a metallic chemical
clement, with symbol Al, and atomic weight 27. It
is not found free, but in contamination (chiefly as
silicates). It is white, has a valence of three, melts
at about 626° C, somewhat resembles tin in colors
and is a constituent of several useful alloys.
General Medicinal Properties of the Com-
pounds of Aluminum. — As compared with the ma-
jority of the heavy metals, aluminum exerts but an
insignificant constitutional action — one useless in med-
icine, and not certainly recognizable even in poisoning
by aluminum compounds. All the evidence there is
of constitutional action by this metal is that, in toxic
doses of alum, there have been observed along with
the symptoms of local irritation, tremors, spasms,
fainting fits, and, in severe cases, death, with dispro-
portionately slight local lesions. Locally, aluminum
compounds are astringent — the freely soluble, such
as alum, highly so, but yet with less conjoint irritation
than is usual with astringent metallic salts. The
main therapeutic use of aluminum preparations is
for a local astringent effect, for which purpose these
compounds combine potency with freedom from bad
taste, undue irritation, or power to stain.
The Compounds of Aluminum Used in Medi-
cine. — These are the hydroxide, sulphate, and the
aluminum and potassium sulphate (potassium alum).
Aluminum Hydroxide. — Aluminum hydroxide, Al 2
(OH) , is official in the U. S. P. as Alumini Hydrox-
iihim. It is prepared by precipitation, a boiling hot
aqueous solution of alum being poured into a similarly
hot solution of sodium carbonate. The precipitate
of the hydroxide is then washed with hot distilled
233
Aluminum
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
water, drained, dried, and pulverized. The product
is a " a white, light, amorphous powder, odorless and
tasteless, and permanent in dry air. Insoluble in
water or alcohol, but completely soluble in hydrochloric
or sulphuric acid, and also in potassium or sodium
hydroxide. When heated to redness it loses about
thirty-four per cent, of its weight." (U. S. P.) This
preparation, from its insolubility, can exert active prop-
erties only through chemical conversion. Locally
applied, it operates as an absorbent powder, develop-
ing, possibly, a faint astringency. Its employment
is almost exclusively German, and consists in its
application to the skin in inflammatory affections.
Aluminum Sulphate.— The salt, A1,(S0 4 ) 3 + 16H 2 0.
is official in the U. S. P. asAlumini Sulphas. It occurs
as "a white, crystalline powder, or shining plates, or
crystalline fragments, without odor, having a sweetish
and afterward an astringent taste, and permanent
in the air. Soluble in 1 part of water at 25° C. (77°
F.), and much more freely in boiling water, but in-
soluble in alcohol. When gradually heated to about
200° C. (392° F.), it loses its water of crystallization
(4.3.7 per cent, of its weight). The aqueous solution
of the salt has an acid reaction upon litmus paper."
(U. S. P.) Aluminum sulphate is powerfully astrin-
gent, and also antiseptic. Its use is local only, as a
conjoint astringent and detergent, or, in saturated
solution, as even a mild caustic in simple hyperplasias.
Aluminum and Potassium Sulphate. — This double
salt, A1K(S0,) 2 + 12H,0, is official in the U. S. P
as Alumen, Alum. Alum is in "large, colorless,
octahedral crystals sometimes modified by cubes,
or in crystalline fragments, without odor, but having
a sweetish and strongly astringent taste. Soluble
in nine parts of water at 25° C. (77° F.), and in 0.3 part
of boiling water; it is also freely soluble in warm
glycerin, but is insoluble in alcohol. When gradually
heated, it loses water; at 92° C. (197. 6° F.) it fuses,
and if the heat be gradually increased to 200° C. (392°
F.) it loses all its water of crystallization (4.5.5.5 per
cent, of its weight), leaving a voluminous, white
residue. An aqueous solution of alum has an acid
reaction upon litmus paper." (U. S. P.) Alum is
decomposed by the alkalies and their carbonates,
lime, magnesia and magnesium carbonate, potassium
tartrate, and lead acetate. The salt is highly astrin-
gent, and, internally, in dose of from oi-ij. (4.0-S.O)
or more, is promptly and efficiently emetic, with little
nausea or depression. In large concentrated dosage
it is an irritant poison, but death is rare. Alum is
principally employed locally as an astringent. For
limited application to an accessible part a smooth
crystal may be swept over the surface, but more com-
monly aqueous solutions are used, ranging in strength
from one-half of one per cent, to three or four per
cent., according to the sensitiveness of the part. A
domestic but serviceable form of application is alum
curd, made by boiling alum in milk, one part to sixty,
until coagulation ensues, then straining and applying
the curds like a poultice, between layers of fine linen.
Or the curd may be obtained by mixing 30 grains
(2.0) of powdered alum with the white of an egg.
Alum may be used almost universally for astringent
purposes, except that as a gargle it is objectionable
because of an injurious action upon the teeth, and as
a collyrium because of its attacking and softening the
tissue of the cornea wherever the protective influence
of the epithelium may be wanting, as in case of abra-
sion or ulcer. Internally alum may be used as an
emetic in the doses stated above, and has been held
for a century — off and on — to be of peculiar avail
in lead colic, abating all the symptoms, even to break-
ing the tendency to constipation. For internal as-
tringent medication alum is nowadays comparatively
seldom used, other astringents being preferred. The
<\
cence and becoming dark on exposure to light ami
air; it is also slightly soluble in alcohol, and it pre-
cipitates albumin and gelatin, the precipitate being
soluble in excess of either. Alkalies cause the for-
mation of a flocculent precipitate of aluminum
hydroxide.
Alumnol combines the astringency of alum with the
antiseptic power of naphthol. Externally it may lie
applied to ulcers and wounds, having a strong tend-
ency to check exuberant granulations and to stim-
ulate healing. Although it coagulates albumin, it
does not form a slough in the wound if spread thinly,
because the precipitate formed is soluble in excess of
albumin. For such local application it may be em-
ployed in from two to ten per cent, strength, diluted
with starch or talc. For abscesses a ten-per-cent. solu-
tion has been used as a dressing. Applied in one-half to
two-per-cent. solution as a spray it is very efficacious
in ordinary catarrhal conditions of the nasal and
pharyngeal mucous membranes, lessening the ci in-
gestion and the edema and relaxation of the soft
palate and uvula. For insufflation in chronic rhi-
nitis or laryngitis, a ten to twenty per-cent. snuff with
camphor and starch may be used.
In gonorrhea' a solution of from one-half to four per-
cent, strength may be injected into the urethra, after
the acute symptoms have subsided. Alumnol has
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Amar.yllldaieie
I n suggested as an intestinal astringent, but data
rning its internal use are wanting.
\V. \. Babtedo.
ilum Rock Springs. — Santa Clara County, Cali-
I da.
ICCESS. From San Jose by electric railway seven
, northeast. San Jose is a terminal point and
center to all parts of the Easl and Pacific
i ,st. San .lose is called the Garden City of Cali-
u'a.
springs are located on the western slope of the
si range in a romantic canon called Alum Rock
. M>n Park, the pride of San .lose. This is a canon
r yground of 1,000 acres, a city reservation six
, t of the town in the Coast .Mountains. Here
sixteen mineral springs already developed and
id free to the public. The nearness of the
to San Jose 1 and the excellent accommoda-
fered at the hotels, with the many natural
iges of climate and scenery, make the Alum
l k Springs a favorite resort for tourists, summer
itors, and invalids. The summer temperature is
above 90° F., and in the winter it is never too
I .■ for comfort. Trout and mountain quail abound,
irding good sport for rod and gun.
The analyses of four of the springs are given below:
Alvelos. — The milky, resinous juice of Eupho
heterodoxa Miiller (fain. Ewphorlnaceae). This Bra-
zilian product is employed in its own home as an heroic
application to "cancerous" tumors, which are there,
for the most pail, syphilitic ulcers. The drug i- a
powerful irritant, and sets up inflammatory suppura-
tion. Many years ago an attempt was made to intro-
duce it to scientific medicine, but the allempt was
abandoned. If. II. Rusby.
Alypin. — Trade name of the monohydrochloride of
benzoyl - tetramethyldiamino -ethylisopropyl alcohol,
(„ II „".o..\,.llci = iriu.vi ii.rr.ii , : ,'c, iu :< K I)
,1 II XiCH ,).,11CI. It occurs as a white crystalline
powder, of bitter tasie, melting at 109° C. (336°+F.).
It is highly hygroscopic and consequently very freely
soluble in water and alcohol. Aqueous solutions are
neutral and do not become turbid on the addition of a
small quantity of sodium bicarbonate. Solutions
may be sterilized by boiling for a brief period; if heat
is continued, however, the alypin is decomposed. It
has a strong bitter taste. Because of its hygroscopic
nature, alypin should be kept in securely stoppered
vials to exclude the air. From 2 to 4 per cent.
s.ilut ions are stable; weaker ones soon become mouldy.
Alypin is one of the many local anesthetics which
have appeared as surrogates for cocaine. It is claimed
to equal cocaine in intensity and duration of anesthe-
Soda Spring.
Grs. per gal.
Blue Sulphur
Spring.
Grs. per gal.
White Sulphur
Spring.
Grs. per gal.
' .~;i!i Condiment.'
Grs. per gal.
a 1.21
m sulphate .S3
ni bicarbonate 10.57
; Hum chloride 126.94
: lium bicarbonate 267 . 12
I lium sulphate
hia (with spectroscope) slight trace
en chloride .50
nil sulphate
gnesium carbonate 7.45
I ;cium carbonate 20.82
I lium .sulphate .18
ii mi phosphate 3.04
n and alumina (carbonates and phosphates) .... .35
acid (with spectroscope) well marked trace
Totals ! 4:i!l ill
ionic arid gas, cubic inches per gallon 215.62
-*■ hydrogen sulphide gas, cubic inches per gallon
1.19
3.27
1.30
3.03
7.; 68
159.45
13.68
slight trace
39
5.00
19.52
.20
1.17
.49
well marked trace
3S.S9
115 44
13.77
very slight trace
.31
7.81
12 as
1.03
.97
.29
well marked trace
3.52
5.88
146 67
25 11
116.51
trace
24 . 30
1 5 45
19.91
-,r, ,;'i
.32
.58
,vell marked trace
278.04
174.03
5.60
195 S7
98 50
10 31
414.64
At Alum Rock there are two thermal sulphur
rings which have a temperature of S5° F. They
e used for bathing purposes. Sulphur plunge baths
all sorts are to be provided.
The waters at this resort have gained considerable
natation in the treatment of rheumatism, anemia,
ilorosis, chronic malaria, nervous prostration, and
•bility. They ought, furthermore, to be useful in
e hemorrhagic diathesis, to menorrhagia, etc., on
count of the iron, alum, and acids which the waters
mtain. Emma E. Walker.
Alum Root. — Heuchera. Under this name the
lizome of Heuchera Americana L. (fam. Saxifragacece)
used as a simple astringent, by reason of the four-
•cn per cent, of tannin which it contains. It is a
ooked, tuberculate rhizome, five or six inches long
id half an inch thick, of a purplish or reddish color,
itbin and without. The plant grows abundantly in
le Eastern United States and is represented through
te West by other species of the genus, with similar
imposition and properties. The dose is from one to
air grams fgr. xv.-lx.). Either water or alcohol will
xtraet its tannin. H. H. Rusby.
sia; that its use does not affect the accommodation,
produce mydriasis or intraocular pressure, and that it
is less toxic than cocaine. Injections are followed by
a transient hyperemia.
In intralaryngeal and urethral intervention alypin
seems to be an ideal substitute for cocaine. It is used
externally to the unbroken skin or mucous membrane,
as well as hypodermically and subcutaneously, and also
to induce spinal anesthesia. Indications for its use
are the same as for cocaine. Solutions should be
freshly prepared and may be combined with any one
of the suprarenal preparations. Locally alypin is
used in 10 per cent, solutions; hypodermically, 1 to
4 per cent.; instillations into the eye, 1 to 2 per cent.
Alypin nitrate may be combined with silver nitrate
when treating urethritis or cystitis and to anesthetize
the urethra before the introduction of instruments.
T. L. S.
Amaroids. — See Active Constituents of Plants.
Amaryllidaceae. — The Amaryllis family. A family
of some seventy genera, growing chiefly in tropical or
warm countries, and very largely cultivated for floral
decoration. Many species, especially of the Narcis-
235
Amaryllidaceie
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
sus group, are known to be poisonous. They are
almost unknown to medical literature, but the agave
or century plant is an important source of fermented
and distilled liquor in Mexico. The family may be
expected to yield important additions to the materia
medica. H. H. Rusby.
Amaurosis. — See Blindness.
Amber. — Succinum. Arribra flava. A fossil resin
produced by Pinites succinifer Goeppert (JPityoxylon
sucdniferum Kr.), and other tertiary and long extinct
Coniferm. Amber has been found from Alaska
westward to Greenland, and southward in New Jersey
and Maryland, but our supplies come chiefly from the
shores of the Baltic. It is east up by the waves,
fished from the bottom, and mined upon the shore
and under the edges of the sea. The grades that are
unfit for ornamental purposes, and the trimmings,
are used medicinally.
Amber is found in hard, brittle tears and lumps of
more or less rounded but often irregular shape. They
are usually small, rarel}' exceed a few grams in weight,
and vary very much in clearness and transparency.
They often contain coarse impurities, vegetable
remains, and dirt. Occasionally entire insects are
beautifully preserved in them. The color of amber
is generally yellow or brownish, but varies from
almost white to nearly black; it is rarely greenish.
The external or natural surface is usually rough or
irregular, the interior often beautifully transparent.
It is harder than most resins, has no odor or taste,
breaks with a conchoidal fracture, and is capable of
receiving a high polish.
It is insoluble in water and cold alcohol, but may
be dissolved in boiling alcohol, benzol, etc. It softens
at a moderately high temperature, but does not melt
until 29° C, when it begins also to decompose.
The use of amber itself in medicine is long past. It
is sometimes an ingredient of fumigating powders or
pastilles; directions also for making an ethereal
tincture are in pharmaceutical works. The oil of
amber {Oleum Succini) is an empyreumatic liquid,
obtained by dry distillation and purified by distilla-
tion from water. The crude oil is a thick, dark red,
offensive-smelling liquid. The redistilled oil is a
colorless or pale yellow, thin liquid, becoming darker
and thicker by age and exposure to air; having an
empyreumatic balsamic odor, a warm, acrid taste,
and a neutral or faintly acid reaction. Specific
gravity about 0.91.5. It is readily soluble in alcohol.
It is extensively adulterated. Internal dose, 0.2 to
0.5 gram.-(ni iij. viij.=gtt. v.-xv.) — it is said to be
stimulant and antispasmodic. Externally it is rube-
facient, and is occasionally used as an ingredient of
liniments. The residual pitch, "amber resin," left
after the distillation of the oil, is dissolved to make
a slowly drying, but very hard and durable var-
nish. Succinic acid is also one of the products of the
disintegration of amber. H. H. Rusby.
Ambergris. — Ambrn grisea (gray amber). A pe-
culiar fatty material, found in lumps, generally on
the surface of tropical seas, occasionally in the intes-
tines of the sperm-whale, Physeter macrocephalus
Shaw, where it is supposed to be a pathological
formation. The balls are often of concentric struc-
ture, and in appearance and position are analogous
to concretions found in other animals. Pieces vary
in size from small fragments to great masses of fifty
kilograms or more in weight. It is a waxy, tasteless
sulwtance, crumbling, but also softening in the hand,
having about the consistency of some gallstones, its
color usually grayish or brownish, streaked or spotted
wiih whit-. Odor slight, peculiar, not nauseous.
At the temperature of boiling water it melts, and at
a higher one is dissipated, leaving but little residue.
Soluble in alcohol, ether, fixed and essential oils, etc
Ambergris consists to the extent of about eighty-
five per cent, of a peculiar non-saponifiable, crystalliz-
ahle fat, ambrein, besides small amounts of extractive
benzoic acid, etc.
Ambergris is almost wholly used in perfumery, but
has been employed as an antispasmodic of the
type, though it is probably weaker than that. Its
medical use is nowadays not worth serious i i
In perfumery, like musk, it has the property of holdiiic
and developing the vegetable odors.
The dose may be accepted as from 0.2.) to I
gram (gr. iv.-xvi.). A tincture would be a suitabl
preparation. H. H. Risby.
Ambidexterity. — This is to be equally and indif-
ferently efficient with either hand. From time to
time ambidexterity has been extolled as universally
desirable; and some educators consider that the
development of the left hand, along with that of
right, should be begun with the entrance of little
children into our schools. It is therefore worthy
discussion in what manner right-handedness has
become habitual among ninety-six per cent, of human-
kind; and whether ambidexterity is a really de-
sirable human qualification.
The lower animals, at least those which have not
been taught tricks, use their forepaws indiscrimi-
nately; the cat strikes at a fly indifferently with either
paw; the squirrel manipulates its nuts quite as indif-
ferently. Even in monkeys and gorillas, which mosl
of all animals use the forepaws as hands, there is no
preferential use of, or superior expertness in, the left
or the right hand. But animals can be tutored to
one or the other paw. The dog is taught to shake
hands with the right paw; the monkey to si
manwisc, with the musket butt at the right shoulder.
Among microcephalic idiots, in whom the small
headedness is due to arrested development, lclt-
handedness or ambidexterity has been found to reach
a proportion of fifty per cent. But as we rise in
the evolutionary scale of normal creatures, and
we exclude disease, ambidexterity progressively gives
way to single-handedness, generally right-handedn
Sir' James Crighton-Browne holds that "by
superior skill of his right hand man hath gol
himself the victory." To try to undo his dextral ,
eminence were to make for devolution.
Glimpses of right-handedness in man are, it
manifest in the bronze and paleolithic age-. It is
evident in the arts of the ancients — Assyrian, Gre-
cian, Egyptian. Historic investigation shows that
all peoples, however savage, have uniformly used by
preference not only one but the same hand — the n
It is said that some races to-day manifest either-
handed ness; but this is very doubtful. It has I
said that the Japanese are by practice and bj
ambidextrous; but Baron Komura has given positive
assurance to the contrar}'. Crighton-Browne abi
quoted believes it doubtful whether, "strictly spi
ing, complete ambidextry exists in any fully di
oped and civilized human beings, though so
very close approximations to it occur." Most hui
beings, then, are right-handed; though of COU
there are those of great intellectuality who are in
more or less degree ambidextrous, having educated
themselves to this end. But these latter are exc
tional and by reason of the peculiar and special train
ing they have subjected themselves to.
The origin of right-handedness lies much d
than the individual's voluntary selection as to v\ hit her
he will use his right hand or his left, or whether he will
be ambidextrous. The reason is to be found largely
in human anatomy, in the position of the heart,
and in the cerebral structure and organization,
which all voluntary movements are directed and
controlled. The heart and the great arteries are
236
REFERENCE HANDBOOK OF TIIF. MEDICAL SCIENCES
Ambulances
,,1, though in the primordial organism from
,,.|, thr ran- has evoluted there was, it serins, no
. Ii asymmetry. The savage, from time iminemo-
',1 has protected his heart with his left, his shield
/■liit his aggressive motions have been made with
,t, his spear arm. The modern savage, too,
: iugn he bears no shield — which would be useless
modern weapons — fires his musket uniformly
mble sense) from the right shoulder, sighting
> h his right eye; the sword also is wielded in the
(hi hand. Such things are now. as they have been
oul history, absolutely fixed in our military
. torn.
Hie sec. md important fact is that in human
I ttomy all voluntary movements are directed and
, trolled in the cerebral structure and organization.
I the brain's two hemispheres, the right presides,
as of the decussating nerve fibers, over the
of the body; while the left brain presides
, r the right side. And functional differences in
sides are connected with and contingent upon
ces in the two hemispheres. The left brain.
, all right-handed people, is more highly developed
ie right brain. It is said that this greater
i elopmenl of the left brain in the right-handed is due
t the fact that the heart, being on the left side of the
nds its blood with greater force and directness
i tii.' left brain; this is a fact worthy of consideration
i .ugh not very weighty, because the (low of blood
ise of the brain is pretty well equalized in the
if Willis.
An important anatomical point is that in right-
) tided people the speech center is situated in
oca's convolution, in the cortex of the left frontal
be; while in left-handed people the speech center
in the same position, but in the right frontal lobe.
!>W, it has been found that damage to Broca's con-
lution in the left hemisphere has deprived the
ht-handed man of speech, which is unimpaired in
■ left-handed man in the same circumstances: the
t-handed man would suffer contrariwise, were the
in the right side. The hand and arm centers
the brain are intimately linked in the cortex witli
e speech centers. Crigliton- Browne's inference is
at the preferential use of the right hand and arm
voluntary movements is due to the leading part
ken by the left brain. " We could not get rid of
r right-handedness, try how we might — it is woven
the brain."
Of course there are professions and trades in which
ertain amount of ambidexterity is essential. The
mist, in playing the fugues of Bach, must strike
down on the key board) almost the same notes
th the fingers of the left hand as he does with those
the right; and he has to hit harder too, for the base
il the piano are more heavily- wired than those
the treble. A certain amount of ambidexterity
tial also in the surgeon; yet this gift has its
-advantages withal, as when a colleague skilled
this way admitted that before doing a thing he
-i.d appreciable time wondering which hand to
iploy.
It may be objected, in favor of general training in
obidexterity, that when a clerk, for example, lost
3 writing hand, he would then not be debarred from
rning his living. On those rare occasions of right-
ind mutilation, however, there will in good time
How, through education and practice, an adequate
tvelopment of the right brain, with a very fair skill
the use of the left hand. John B. Hubeb.
Amblyomma. — A genus of eyeless ticks, family
I . which is common on cattle, particularly
warm countries. .1. americanum occurs from
aborador to Florida. It burrows into the skin
id may T cause tumors. Ticks of this genus are
so known to carry germs of certain infections
iseases. See Arachn'ida. A. S. P.
Amboceptor. — Amboceptors or immune bodies are
antibodies of I'.hrlieh's third order. They are .!.■ . I-
opi'd in the serum as one of the re till nt the inject ion
oi cells of various kinds. The amboceptor i- belie ed
t.. consist of t v. o elements, the ci implement! iphilr group
which combines with the alexin or complement , and
the cytophile group whereby the immune body be-
comes attached to the cell. Amboceptors are al-o
called cytolysitis. for it is by means of these substances
that the complement is joined to the cell body and
thus permitted to exercise its lytic effect. It is evi-
dent therefore that lysis is impossible except in the
presence of both tin mces. The amboceptor
is thermostabile. that is, it is nol destroyed by heating
at 55° C. for on.- hour, and it may be kept with but
little deterioration for long periods of time. Ambo-
ceptor differs from complement in being very highly
specific. An immune body developed by the injection
of the red cells of a rabbit, for instance, will not unite
with the red cells of any other animal. The comple-
ment of normal serum, on the other hand, will activate
many different amboceptors. These antibodies appear
in the serum usually within from five to ten days after
experimental or accidental infection, and form one of
the strongest defences that the body is able to present
against an infection. Almost all animal cells are able
to stimulate the body to the production of ambocep-
tors. In some instances experimenters have been able,
by the injection of amboceptor, to stimulate the pro-
duction of antiamboceptor, but the results have not
been constant and there is still some doubt as to the
accuracy of this explanation of the results obtained.
The chief importance of the immune bodies is the
part they play in the recovery of an animal from an
infection, but they can also be employed in the diagno-
sis of disease and in the identification of unknown
organisms. An immune serum should cause lysis of
the bacteria which have acted the part of antigen if
sufficient complement is present. Therefore if either
the bacterium or the serum is known, the other can
be identified. For a discussion of the relation of the
amboceptor to the general subject of immunity the
reader is referred to the article on Immunity.
Ralph G. Stillmax.
Ambulances. — An ambulance is a vehicle specially
designed for the transportation of sick or wounded.
It owes its origin and general characteristics to the
needs of civilized warfare. The growth of humane
practices in the wars of the eighteenth century pro-
duced an increasing demand for some method of carry-
ing wounded both effective and merciful, and the
French wars following the Revolution of 17;S9 brought
the ambulance service along with all their other
military innovations.
An organized system for the transportation of
wounded was first introduced by Baron Larrey, the
French military surgeon, in the Army of the Rhine
in 1792. Only slight improvement upon his system
was made during the wars of the first half of the nine-
teenth century, and it was not until the latter part
of the Civil War that the ambulance obtained proper
recognition and development in the introduction of a
uniform system by act of Congress in March. iv. 1.
The need for civil ambulances, though increasingly
felt, was, of course, in these earlier day- less urgent,
but shortly after the close of the war a modified sys-
tem adapted for use in cities was recognized to be an
important requirement of a well-organized hospital
system; its adoption was repeatedly discussed in
several of the hospitals of New York City, and in
December, 1S69, the first service was established by
the Commissioners of Charities and Corrections in
Bellevue Hospital. Though crude and limited at
first, the Bellevue service was rapidly improved and
extended, and was soon copied by the other hospitals
of New York.
237
Ambulances
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Important modifications in the army type were, of
course, required in the adaptation of the ambulance to
civil hospital work. The necessary changes were ap-
parent and were quickly made; the civil could be
lighter, and therefore faster, than the army vehicle
on account of better thoroughfares; it would not be
required to carry so many people, but for use in nar-
row and crowded streets it must be able to turn in
the arc of a small circle. Since the differentiation
in the types of the two wagons in the more funda-
mental particulars referred to, the evolution of the
civil ambulance has been along lines chiefly of mechan-
ical construction, and the very great substitution
of mechanical for horse power since the introduction
of motor vehicles. The type of horse drawn vehicle
has remained essentially the same, but the restric-
service is the most elaborate and enterprising, and will
probably remain as the standard for this country.
The eagerness of foreign medical authorities to
accept American innovations effecting improved con-
ditions of service, especially of a mechanical character
has never been marked, and, in the case of the am-
bulance system, has amounted almost to disin-
clination. For one thing, the foreigner does not feel
the constantly expressed desire of the American for
rapidity of transit of all kinds. The hurry call f„ r
fire and for accident relief does not seem to him bo
urgent, and the ambulance is not to be found in his
medical traditions. On the continent, ambulances
fur the transportation of the injured have i„
until very recently an unknown quantity. Tl.
of caring for the injured was and is in many cities
Fig. SI. — Horse Ambulance.
tions on weight being largely removed, the motor
ambulances are, as a rule, much larger, more comfor-
table and better protected from the weather.
The advantages of an ambulance system com-
mended themselves to the hospital authorities of
every city of consequence in the United States, and
ambulances were introduced as fast as means per-
mitted or the conditions of each case required. The
New York system has remained the most extensive and
elaborate. In many of the smaller American cities
where the number of hospitals is small, ambulances
are few and are used chiefly for sick cases; their
emergency use is restricted to a small area surround-
ing the hospital. Accident cases in other parts of the
city are attended to by the police patrol, which
still performs in a rudimentary way the functions of
an ambulance service proper. It is not so easy to
understand why this use of patrols should survive,
as it does, in many large cities, although there are
unquestionably abuses of the ambulance system
(hereafter touched upon) which are avoided when
the duty is performed by the police. The New York
238
carried on by voluntary societies established for the
purpose which maintained small stations in dif-
ferent parts of a city where stretchers, splints, an' 1 .
paraphernalia for first aid to the injured could be
found. Delivery wagons requisitioned for the exigency
and police patrol wagons were used to convej thi
injured to hospitals. The ambulances, and they were
often of a very primitive kind, were used only for the
transportation of the sick. Within recent yea
ever, there has been a marked change of attitude ail
ambulances are now to be found in almost all *>f the
large cities of Europe. They are still chiefly for the
transportation of the sick, but are being used more
and more for accident cases. They are admirably
constructed and equipped. A trained attendant, nol
a medical man, is carried. The conception of the
duty of the hospital differs in Europe and America
The European hospital considers it sufficient to pi
vide proper transportation, the American hi
considers it necessary to provide skilled treatment as
Automobile ambulances here and abroad have
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Vliililll.ini < .
ijgely taken the place of horse drawn ambulances,
It have not entirely displaced them. Automobiles
I vc not yet reached such a state of perfection that
i v are absolutely reliable, especially during inclem-
i winter weather with streets blocked with ice
: I snow. The number of horse ambulances Still
', ployed is, therefore, large.
liicyele ambulances have been tried in some places
i li but little success.
\ll horse ambulanees are so nearly alike that one
, description will coverall their salient features.
; ,. enclosed body of the vehicle is from eight to
ie feet long and from three to three and one-half
I I wide. As lightness is an important element, it is
! ill of as light material as is compatible with thorough
ength. The roof is supported by uprights, a hood
i. ding over the driver's seat, and only a short
i.incc is boarded in on the sides, the front and rear
ug open. In cold or stormy weather all but the
circumstances or the conditions of the streets require.
The average weight, of such a vehicle is from twelve
hundred to fourteen hundred pounds. The wheels
are made with solid rubber I ires, which are as satis-
factory and far more durable than the pneumatic
tires that were in vogue for a short time. A large
foot gong in front of the dashboard, or under it, can
be operated by the driver.
The most satisfactory situation for the stable is
within the limits of the hospital, but in a separate
building. By this adjustment the inevitable noise
and odor are minimized, and the ambulance is still
within close call. The interior arrangement of I he
stable need not differ from that, of any private one.
There should be one more horse than the number of
ambulances in service, in case of accident or disease
and to meet any emergency. One stall is kept for
the horse on call, where he stands with his bridle in
place, only the bit requiring to be inserted. The
Fig. S2. — Ambulance Showing Movable Bed.
ar can be closed in by leather or rubber curtains,
ie patient lies on a movable bed covered with leather,
id this runs on a track, and is so held by inverted
imps that it will still remain horizontal when drawn
it to its full length. A stretcher lies on this bed.
lie surgeon sits at the rear on a transverse seat,
-a over the tail-piece, so arranged that it can by
ised perpendicularly and clasped out of the way
lien the tail-piece is let down for the entrance or
cit of the patient. A step behind assists the sur-
-on to his seat, and there are straps to which he
ay-hold. Under the driver's seat, in front, is room
ir splints and other appliances, and the longer
ilints are suspended by straps from the roof. A
ntern is clamped inside, and two red lights on the
de indicate to other drivers the ambulance's right
way. The fore wheels can be cramped under the
ire part of the vehicle, which can thus turn in the
lortest possible space. Usually drawn by one horse,
may of course be changed to a double rig whenever
harness is patterned after that used by fire depart-
ments, and hangs suspended over the shafts ready to
be lowered; then the collar is clasped, one or two
straps are buckled, and in a moment or two the
trained horse is under way. Calls are sent to the
stable from the office by telephone or gong. There
must be one more ambulance than the number run-
ning, in order that repairs required by accidents and
wear and tear may be made without a disabling of
the service. So, also, an extra man is needed to take
care of the stable, horses, and ambulances, and to act
as a relief driver and stable watchman. His extra
time may be employed in the doing of other necessary
work around the institution.
A conventional assortment of medical and surgical
instruments, appliances, and supplies is always kept
in each ambulance, and others are carried by the
surgeon in a hand satchel. Among the former are
the long thigh and body splints that are suspended
under the roof, and the shorter splints that are kept
239
Ambulances
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
under the driver's seat, together with one or two
pairs of handcuffs. In an iron rack, in the enclosed
part, just back of the driver's seat, is kept an assort-
ment of bandages and cotton, and in other racks
variously situated are found stomach pump, antidotes
for poisons, bottles of carron oil, etc. In the satchel
the surgeon carries sterilized dressings and band-
ages, the ordinary instruments of a pocket surgical
set, catheters, hypodermic syringes and needles,
cardiac stimulants, tourniquets, and chloroform.
This enumeration includes the standard articles
carried, and hospitals differ as to the selection only
in minor details.
The cost of a horse ambulance complete with
rubber tires, etc., varies between $550 and $700. The
cost of equipping an entire service must include the
stable with its furnishings, horses, harness, and am-
and gasoline ones are now in active operation ir
all of the cities of this country. As indicated abov<
they are larger and of more solid construction thai
the horse ambulances. The sides are of wood 01
wood and glass and they frequently are closed behint
by a door. The}' are generally lighted by electricity
Their increased size, sufficient to accommodate twi
patients in an emergency, allows of many minoi
conveniences and greater comfort, although thi
tial features are the same as those of the horsi
lance. Electric ambulances have the advantage tha
solid rubber tires may be used and the unpleasant dela-\
incident to a punctured tire is avoided. On theothei
hand, the speed of these is much less and tin v la,
the power to drive them through snow which wouli
not prevent the passage of a gasoline ambulance
But no hospital, until motor vehicles have reachei
Fig. 83. — Electric Automobile Ambulance.
bulance, and demands a large initial outlay. The
expense of maintenance, however, is less than would
appear at first glance, and becomes proportionately
cheaper as the number of ambulances is increased.
Items to be considered are: Running repairs on
ambulances (annually about $50 to $100 each), feed
and shoeing of horses, wages of men and their board
and incidentals, cost of medical and surgical equip-
ment, etc. In New York the annual expense, com-
Euted from the figures of a number of different
ospitals, of running an ambulance service on the
basis of two ambulances constantly in use and one
for extreme emergencies, is between $2, 100 and $3,000.
In other localities the cost varies with price of feed
and of wages.
The first automobile ambulance was put in opera-
tion in New York in 1900. It was at once so success-
ful that others were rapidly introduced. Both electric
240
a greater state of perfection, could be sure of maintain-
ing an uninterrupted service throughout the yeai
without a horse ambulance for use in an emergency,
especially in the north where winters are seven-.
Besides its speed and size the advantages of the
motor ambulance are that it requires less room, it
does away with the noise and odors of a I
stable, it is always ready, no harnessing is nee
and it is less expensive when in actual operation.
The disadvantages are the great initial cost and the
expensive repairs, that more skilled and thi
more expensive labor is required, and that meter
vehicles alone cannot entirely be relied upon. Motor
ambulances cost between $3,000 and $5,000. I
cost for repairs and for tires cannot with any accuracy
be predicted.
Before the general introduction of telephone
were usually sent to hospitals in New York City bj
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Ambulances
■ tinging of a gong, as is now done by the Fire
partment. It was also customary at one time
; an ambulance to go to every fire call. Since
ephones have become so universal tliey alone are
ierally used. The ambulance work is under the
' iervision of the Police Department, and every call
[theoretically supposed to be sent by an officer,
ictically, however, every reasonable < ■; 1 1 1 suit by
; civilian is answered. The Fire Department
iomes an element in falling ambulances only when
re is a large fire with much loss of life. In .such
e following the alarm of fire which is rung in
: niisl all hospitals having an ambulance service,
all of three fours is rung to summon all available
ibulances in the city; immediate response is made
i the call
service'; the police system is undoubtedly more
economical. In some- cities public hospitals do all
i Ih> accident work, the private hospitals running am-
bulances only for sick cases. Sometimes then- are
ambulance stables distributed about t hi' city \\ il In nit
trained surgical attendants; these carry patients
directly to the nearest public hospital; in other cases
all calls are sent in to the hospital. The value of
prompt transportation without skilful assistance on
the one hand offsets the intelligent skill coupled with
delay on t he Ot her.
The most perfect but most extravagant method is
the establishment of an ambulance service in private as
well as in public hospitals, and the assignment to each
hospital of a limited area so that, all parts of a city
can be rapidly covered by intelligent workers. This
■aiiiaiias^
■af^
Fig. S-t. — Automobile Ambulance.
Cities differ considerably in the way in which their
cidenl service is done. Sick cases are everywhere
nulled in much the same way; patients who are too
or too poor to be taken in carriages are conveyed
' ambulances. The accident work in certain cities
done entirely by po'ice patrols. This system has
me peculiar advantages; it is not imposed on
norantly by civilians, or wilfully abused by the
■lice themselves; slight scalp wounds received by
Irunk and disorderly" unfortunates do not so often
fiipy the time of a hospital staff, and cases of pre-
nded illness are more carefully investigated, to the
lief of the temper of the hospital authorities, while
ills in outlying sections far from a hospital can be
iswered more readily and promptly. On the other
ind, the patients are not handled so carefully or so
.ilfuhy, and ignorance does in exceptional cases pro-
loe very serious consequences. On the balance of
lvantage, the individual benefits by the hospital
Vol. I.— 16
entails much expense on private institutions, which
may even be laboring under financial difficulties, but is
another refinement in the method in which many of
our cities look after the welfare of their inhabitants.
This is the case in the city of New York, where the
Board of Charities divides the city into districts and
allots to each district a certain number of police
precincts. The districts are so divided as each to con-
tain a hospital maintaining an ambulance service,
and the jurisdiction of each hospital within the
limits of its own district is complete.
In all cities cases of contagious disease are trans-
ferred to reception and contagious hospitals; this is
generally done by special vehicles, old city ambu-
lances altered into closed vehicles.
There are in many of the cities ambulances operated
by private individuals for the purpose of transferring
patients in as inconspicuous a way as possible; these
are built to represent an ordinary vehicle externally,
241
Ambulances
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
with a stretcher arrangement within like that of the
usual ambulance. The varieties are numerous, and
that one is best which least attracts attention.
That ambulance services are imposed upon there
can be no doubt; unfortunately there seems to be no
remedy for the evil. The imposition is sometimes
effected through ignorance, sometimes through design.
The convenient and efficient practice of calling ambu-
lances by telephone increases the opportunity for
mischief. To the hysterical layman every attack of
syncope means apoplexy, and every abrasion of the
scalp a fractured skull. When these or kindred
things come to his attention, he immediately sends
in a "hurry call" by the nearest telephone, often
Fig. So. — Interior of an Automobile Ambulance, with bed drawn
out to receive a patient.
without the knowledge or desire of the patient;
when it is answered with all possible speed, the
surgeon finds that the patient has gone home or
refuses treatment. By ambulances, also, ready
means is afforded to the policeman to dispose of his
obstreperous and slightly battered alcoholic charges,
and when no evidence of injury is apparent the sur-
geon is solemnly told that the patient was comatose
when the call was sent. A hospital that does not
leave anything to the discretion of the surgeon, but
insists on all cases being brought in, unless the pa-
tient refuses, of course suffers most in this way. No
remedy that will throw out all improper calls and
answer all the worthy ones can be devised, and, as in
the fire service, much time and money are sacrificed
in order that no single case requiring attention shall
be neglected.
The position of ambulance surgeon is usually filled
by internes or by physicians specially appointed for
the purpose, or by students nearing the completion
of their medical school course. There can be no
doubt of the inadvisability of allowing medical stu-
dents to occupy so important a position. Most cases
require simple treatment, but exceptional circum-
stances arise, and one untrained to meet them is
little better than a layman. Such training as a
service requires can be readily and thoroughly
acquired in an emergency ward, under competent
supervision, and as either of the first two methods
brings every benefit to the patient, the choice must
fall upon the one which better meets the requirements
of the service without affecting the administration of
the hospital as a whole. A very active ambulance
service is too much of a drain upon the strength of a
man busy with additional work; on the other hand
such a service is but a slight inducement to a capable
man, unless, as is seldom the case, it offers chance of
future advancement. The question is open, and is
decided in each case by existing conditions.
John Howland.
Ameba. — See Amoeba.
Amelie=les=Bains. — These baths, situated in the
extreme southwestern part of France, in the district
of the Pyrenees, are said to be " the best baths in
Europe where rheumatism can be safely treated in
winter." _ The village of Am^lie-les-Bains, situated
in the midst of pine trees, has a population of a!-
1.200, and is twenty-three hours by rail from
Paris.
The winter climate is dry, clear, and mild, and
possesses some of the characteristics of a mount
atmosphere. The average number of sunny d
during the three winter months is sixty-two; cloudy,
seventeen; and rainy, eleven. (C. B. Black. "South
of France," 1905.) The mean temperature of Jan-
uary is 45° F. ; of February, 47° F.; and of March,
53° F. " During the day, in the sun, the temperature
rises considerably above these figures, but during the
night and morning, especially in January, it falls con-
siderably below them.
Amelie is sheltered for the most part from the ci
northwest wind which sweeps over the plain of
Roussillon. The summer is hot, but the autumn i
cool, and the air possesses the tonic quality of thai
of the mountains and is not so relaxing as that atPau.
The scenery is very attractive and there are many
pleasant walks with fine views. The river Tech runs
through the town, on the left side of which is the
sunny and sheltered promenade called the "Petite
Provence," a favorite winter walk.
The springs are of the class of the hot sulphuron-
waters similar to those of Aix-les-Bains; they contain
the carbonate, sulphate, chloride, and silicate of
sodium with a trace of carbonate of iron and calcium
and free nitrogen. The temperature is from 90° to
148° F.
As with other warm sulphur springs, these wat> -•
are of value in chronic rheumatism in its various
forms; chronic catarrhal affections of the respiratory
organs; glandular tuberculosis; neuralgia; chronic
skin diseases, such as eczema, prurigo; syphilis;
uterine diseases, and certain bladder and kidney
affections. As has been before noted, AmeUie is
said to be the best station in Europe with hot sulphur
springs, which, on account of its mild climate, can
be utilized in winter.
In the higher part of the village near the springs
are the two hotels with baths: the hotel Them
Romains, which is warmed by the hot water of the
springs; and the hotel Thermes-Pujade, a part of
which is warmed by the vapor of the springs over
which it is located. In each case one does not have
to go out of the hotel for the baths. Both hotels are
in grounds of their own, and have sheltered walks.
Various kinds of baths are given similar to those at
other spas. The water is also used for drinking.
Not far from Am6lie-les- Bains are various othi r
thermal sulphur water spas: Preste-les- Bains; \ ernet-
les-Balns; Ax-les-Thermes, which is said to K
largest supply of thermal sulphurous waters in
Europe; and others. Edward 0. Otis.
242
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Amenorrhea
\menorrhea. By amenorrhea ia meant a sus-
osion or cessation of the menstrual function in a
, I, ,an who is not pregnant and who has not reached
e "change of life, or the period at which menstrua-
■ n naturally erases. The term should not be em-
,ved to include eases in which menstrual blood
slides from the uterine mucous membrane
r from that of the oviducts, since we accept the
ictrine that the Fallopian tubes take part in the
i.-t ion), but is prevented from making its appearance
illy by some malformation, such as an im-
rforate hymen. It should be borne in mind that
i hea is not in itself a disease, but simply a re-
It of some morbid condition affecting either the
at large or some part of the genital apparatus.
igical amenorrhea is that which exists prior to
iberty, during a normal period of gestation, and
equent to the establishment of the menopause.
Causes. — There is scarcely any derangement of the
neral health, especially if of a serious nature and
in its course, that is not prone to prove at
ist the predisposing cause of amenorrhea. Usually,
T, these deviations from health affect either
e function of hematosis, the general nutrition of the
■ iy, or the normal action of the nervous system, and
o, or all three, of these disturbances may be
unbined. Moreover, it may be said that defective
■ -mitosis is itself a nutritive disorder, and that all
regularities of nutrition may take their origin in
I nervous action. All this is true, but the
actical utility of these distinctions remains doubtful,
rertheless. Of the particular diseases that give
se to amenorrhea, the most noticeable are pulmonary
iberculosis and chlorosis. In both instances, the
ispension of menstruation seems to be a conserva-
ve effort on the part of nature to spare the system
cry unnecessary tax, and this consideration alone
ight to be enough to teach us that it is not the
istablishment of the menstrual flow that we should
m at, but rather the restoration of the general
lalth.
It has been doubted by good observers whether it is
'^ible for a woman in perfect health to suffer from
aenorrhea, and there is much to sustain this position;
H it is certain, nevertheless, that in many cases the
ipairment of the general health goes on for a long
^riod without producing amenorrhea, until, finally,
une additional factor comes into play, and may
uly be looked upon as the exciting cause of the
isorder. Among these exciting causes we may
•ckon almost all pelvic diseases, the functional
■rturbation consequent on exposure to cold during a
icnstrual period, emotional shocks, and traumatic
ijuries.
Amenorrhea may be an indication of imperfect
evelopment of the internal generative organs. This
not infrequently the cause of late appearance of
liberty, at eighteen to twenty years of age, the
terus being a small infantile organ. Of course,
ingenital absence of the organs of generation will be
ccompanied by complete amenorrhea and even by
n absence of the menstrual molimina. A curious
irm of temporary amenorrhea, undoubtedly hemat-
genous in nature, is that noted in young immigrants
ito a country. For from six months to a year or more
'iere may frequently be noted in these young girls a
>>tal suppression of menstruation, without any of
lie symptoms of anemia or chlorosis. Certain mental
iseases, especially those of the melancholic type,
■ ill be attended by varying periods of menstrual
impression; and certain of the neuroses (chorea
aajor, epilepsy) show the same peculiarity. A
arge uterine tumor (fibroma or myoma), while
;enerally causing menstrual anomalies in the form of
lysmenorrhea, monorrhagia, and metrorrhagia, may
iccasionally cause complete amenorrhea, and in
uch cases the diagnosis from pregnancy becomes
xceedingly difficult or even impossible until after
the normal duration of gestation has passed. Ovar-
ian cystomata, on the contrary, an- not infrequently
accompanied by absence of menstruation probably
because of the anemia which is present in these eases
in their advanced stage.
Doubt has been east upon the doctrine that the
menstrual function is dominated by the ovaries, but
it cannot be said that the doctrine lias been over-
thrown, and we have, therefore, to distinguish, for
purposes both of diagnosis and of prognosis, between
amenorrhea which is and thai which is not due to
failure on the part of the ovaries. In other word .
concerning ourselves only with the mechanism, and
leaving ultimate causes out of account for the t inn-
being, we have to distinguish between uterine and
ovarian amenorrhea. Practically, the only guide we
have to a failure of that ovarian action which should
serve to stimulate the menstrual flow, is the absence
of the menstrual molimen — the ensemble of symp-
toms usually attendant upon the flow, including a
sense of weight and pain in the pelvis, and in some
eases pain, tenderness, and swelling of the breasts,
with or without the various reflex disturbances that
sometimes attend the menstrual effort.
The uterine variety is to be recognized by the state
of the uterus, which will commonly be found to be
one of atrophy (including the so-called " superinvolu-
tion") or of impeded circulation due to the contraction
of old inflammatory exudates.
Diagnosis. — Amenorrhea, as it is here defined,
requires to be diagnosed only from retention of the
menses and from the physiological suspension due
to pregnancy. The diagnosis will necessarily rest
upon a physical examination, and for the details the
reader is referred to the articles on Pregnancy and on
Menses, Retention of.
Prognosis. — The question of our ability to restore
the menstrual function is to be answered wholly in the
light of the causes on which its suspension is found to
depend. Grave constitutional diseases, such as pul-
monary tuberculosis, render the treatment in that
direction not very promising, while the cure of any less
serious fundamental disorder may^ on the other hand,
be reasonably expected to be followed by the re-
establishment of menstruation. As regards the
local conditions, atrophy of the uterus and functional
inactivity of the ovaries must give rise to an un-
favorable prognosis, although temporary benefit
may be produced by treatment in some instances.
The prospect is better in the case of old inflammatory
disease within the pelvis, for such affections are often
amenable to treatment. In general, the causes will
be found to be remediable, and, therefore, the
prognosis favorable.
Treatment. — The patient should be made to
understand, at the outset, that her courses will come
on when her health has been reestablished, provided
no obvious anatomical defect exists, which can be
determined only by a careful physical exploration.
Another caution needs to be given. Women who
know or suspect themselves to be pregnant, fre-
quently consult a physician in the hope that, in the
attempt to bring on menstruation, he will really
succeed in causing abortion. Whoever, under such
circumstances, prescribes any measure, no matter
how innocent, with the understood purpose of in-
ducing the menstrual flow, is liable to have un-
pleasant charges brought against him in case abortion
actually does take place, even as the result of some
interference with which he had no connection.
When called upon to undertake the treatment of a
case of suppressed menstruation, it is prudent,
therefore, for the physician to satisfy himself that
pregnancy does not exist, and, in case of doubt, to
decline the management of the case unless he can
protect himself in some way, as by insisting that
some trustworthy person be made acquainted with
the facts at the start.
243
Amenorrhea
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Having undertaken the management of a case in
which treatment is sought for on account of amenor-
rhea, the physician should make a systematic in-
quiry into the patient's state of health, and whatever
deviation from the normal standard is found should
be made the subject of treatment. For the details of
such treatment, the reader is referred to the articles
devoted to the various diseases that may be found.
But, while insisting upon the general futility of
measures addressed to the organs concerned in the
menstrual function, without first attending to the
general health, it must be admitted, nevertheless,
that in a very limited number of cases stimulation of
those organs may be resorted to with some chance of
success when no other indication can be made out;
and. moreover, that, in cases in which there are other
indications at first, there often comes a time when the
result aimed at may be hastened by measures that
operate directly upon the pelvic organs.
There are but few therapeutic procedures that
have a direct and unequivocal influence upon the
function of menstruation, and, in so far as they tend
to relieve amenorrhea, those few act as local stimu-
lants. The so-called emmenagogues are not much to
be depended upon, although we may admit that
aloetics and chalybeates tend to produce a pelvic
congestion favorable to heightened functional ac-
tivity of the sexual organs. Tins is also true of sink
remedies as apiolin and oxalic acid, which in suitable
cases and in suitable doses will cause sufficient
pelvic congestion to establish the menstrual flow.
Their use, however, in the absence of other indications
than the mere failure of the menstrual flow, is not to be
recommended, although, if employed in conformity
with such indications, they undoubtedly exert a
certain influence.
The preparations of manganese have been recom-
mended by Ringer and Murrell. One-grain pills of
potassium permanganate may be administered, be-
ginning with one pill three times a clay, and increasing
to two four times a clay. The use of the drug should
be begun three or four days before, the time at which a
menstruation should take place, and be continued, if
the flow does not come on, until the time for the next
period. It should be kept up also during the flow.
Both sodium manganate and manganese binoxide are
said to be equally effective, and it is stated that
manganese acts as well with the plethoric as with the
anemic. The manganese treatment has not, on the
whole, justified the expectations with which its em-
ployment was begun. Oxalic acid in doses of one-
eighth to one-quarter of a grain three times daily, com-
bined with lemon juice or citric acid, may be tried
advantageously in certain cases.
There are several other drugs that have more or less
repute in the treatment of amenorrhea. Among
them is apiol or apiolin, which is said to act best in
cases in which whatever flow there may be is ill-
smelling. From eight to ten minims should be
given daily during the week preceding the day for
menstruation to begin, and fifteen minims on the
morning of that day. Cimicifuga has been thought
serviceable in cases of delayed or arrested menstrua-
tion. Senecio vulgaris has been recommended in
cases unaccompanied by pelvic lesions. In the ovar-
ian variety of amenorrhea, a preparation made from
the expressed juice of the fresh ovaries of healthy
young animals, has been used with success. Aloes
undoubtedly aids the action of the other so-called
emmenagogues, and should be employed if there is
constipation.
Electricity was formerly used more frequently as a
provocative of menstruation than any other agent.
Good effects were thought to have been produced by
either the galvanic or the induced current. The use
of electricity for this purpose has, however, largely
fallen into disfavor. If used at all, galvanism is more
to be relied on for increasing the blood-supply of the
244
uterus, while faradization may be useful to intensify
and precipitate the hemorrhagic effort. To ac-
complish the latter purpose, the application ou^ht to
be made at a time when the degenerative changes in
the endometrium have advanced to such a degree
that heightened blood-pressure, aided by muscular
action, may operate at the greatest advantage
producing rupture of tin' capillaries. This condition
can be judged to be present only when there are
symptoms of ovulation, or when the amenorrhea is ,,f
such recent date that the time for a menstrual Bom
to fall due is accurately known. In the
galvanism, it will generally be prudent to place both
electrodes on the external surface, unless the current
is quite weak and the sitting a short one; aiming
however, to pass the current directly through the
uterus. When the faradic current is' employed, or
the other hand, one electrode should be applied
within the vagina, or even within the canal of the
cervix.
Milder measures than the use of electricity will
often succeed, especially when there is not" com-
plete absence of the flow, but scantiness and lack of
color of the discharge. Among these measures,
refrigeration of that portion of the spinal region cor-
responding to the motor center of the uterus is of greal
value. The skin over the junction of the dorsal with
the lumbar vertebras may be sprayed with ether
but not frozen, three or four times a day, for five
minutes at a time, or ice-water compresses may be
applied. These means are supposed to exert their
effect by depressing the activity of the vasomotor
nerves. They are to be used only at the time when a
menstrual flow is due. In the interim, an auxiliary
measure of some value consists in the use of a very
brief cold hip-bath every night.
W. A. Newman Dokla.nd.
American Medical Association. — The American
Medical Association owes its existence largely to a
widespread demand which had prevailed in the British
Colonies of North America long before the Revolution-
ary War for a uniform and withal a more thorough
education, for those intending to practise medii
The first clinical lecturer on medicine in this
country seems to have been Dr. Thomas Bond, who
gave instruction to medical students in the first
permanent hospital in North America, which
opened in Philadelphia in 1752. This led to the
establishment of the Medical Department of the Uni-
versity of Pennsylvania which opened its doors to
students in 1765. Seventeen years later thi
medical school in the United States was establisl
in connection with Harvard University. These v.
the only permanent medical schools in this country
that were in operation prior to 1800. This was
nearly 200 years after the settlement of the country.
When, however, the great distances, the limited re-
sources of the people, the sparse settlements, and
the difficulties of transportation in America before
the Revolution are considered, there is little wonder
perhaps at, the slow development of American medical
schools.
In 1760, the General Assembly of New York, and
in 1772, the governing body of the Colony of .V.
Jersey, had "passed measures for restricting medical
practice by requiring an examination in 'physick
surgery."' In 1S27, the Medical Society of 'the State
of Vermont issued an invitation to the medical socie-
ties and ''Institutions," of the States of Maine, \<
Hampshire, Vermont, Massachusetts, Rhode Island,
Connecticut, and New York, to a conference which
was held at Northampton, Mass., June 21, 1827.
The object of the convention was solely the improve-
ment and standardization of medical education in the
United States. A set of regulations was adopted,
requiring a four years' course of study for the degree
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
American Medical
Association
doctor of medicine, as well as a good preliminary
nation, evidence of good moral character and the
tainmenl of the age of twenty-one years by the
iplicanl for the degree.
[,, the following year (1828) the Medical Society of
e stai<' of New York, recommended " the calling of
National Convention to consist of a delegate from
tlir regular medical colleges ami the State
societies to meet in Philadelphia for tin'
of suggesting a more uniform system of
■ilical education than now prevails."
movements seem to have accomplished little,
cept to direct attention to the unsatisfactory
itus of medical education in America in the early
rt of the nineteenth century. The United States
■re growing fast in wealth and population and
1830 and 1S45, the number of medical colleges
lan doubled. These institutions wore without
y supervision and had full power to confer the de-
doctor of medicine, and inasmuch as many
, had been started with insufficient equipment
d with little or no endowment, the eagerness to
indents was extreme, and the tendency to
lie courses of study leading to the doctor's
<- short and easy as possible, seemed to be
lie. The annual courses of lectures had been
ly shortened to sixteen weeks and in some
,s, to thirteen. Two of these courses, without any
or laboratory advantages, and a year or two
more or less nominal study with a preceptor, were
teemed sufficient to qualify a student to receive the
• degree and to practise medicine anywhere in
United States.
In 1835, the .Medical College of Georgia proposed
call a convention of delegates from all the medical
lieges of the Union to take these matters under
ration. In 1S39, the Medical Society of the
ate of New York took the matter up again at its
mual meeting. After a full discussion of the question
medical education in the United States, a resolu-
- passed by a large majority of those present,
daring that "the business of teaching should be
parated as far as possible, from the privilege of
anting diplomas." An invitation was sent to all
e medical societies and medical colleges in the
untry to send delegates to a convention to be held
Philadelphia in 1S40. This movement, however,
d not elicit enough enthusiasm to bring about the
■sired result, and the matter was dropped temporar-
-. But the subject would not down, and was again
ought up in the medical society of the State of
r\v York in 1S44, and was vigorously pushed by
athan Smith Davis, a young practitioner and a new
to the State Society from Broome County,
- made chairman of a committee to investigate
e entire question and report upon it at the next an-
uil meeting. This committee having communicated
ith practically every county medical society in the
ate of New York, had aroused much interest in the
i of medical education by the time of the next
inual meeting of the Society, when, after an arduous
bate, it was determined to call a national conven-
iq in New York City in May, 1846. The medical
'ess quite generally lent its aid in pushing this
oject and Dr. Ticknor, the President of the Medical
iciety of the State of Connecticut, proposed that
te convention should organize itself into a National
1 dical Society. The idea of a permanent national
■ ii-ty was enthusiastically embraced by Dr. Davis,
ho exploited it freely in the medical press.
The delegates met in the hall of the Medical De-
I of the University of New York on May 5,
^16. Of 119 delegates appointed by the various
icieties and medical schools throughout the
nion, about 100 were present, and took part in the
liberations. They represented sixteen of the
tales of the Union, an especially large delegation
-'ing present from the societies and medical schools
"i Philadelphia. The following propositions wen- laid
before the convention:
" 1. That it is expedient for the medical profession
of the United States to institute a National Medical
Association.
"2. That it is desirable that a uniform and elevated
standard of requirements for the degree of Doctor of
Medicine should be adopted by all the medical schools
in the United States.
"3. That it is desirable that young men, before
being received as students of medicine, should have
acquired a suitable preliminary education.
" 1. That it is expedient that the medical profession
in the United States should be governed by the same
code "f ethics."
Each of these propositions was referred to a com-
mittee of seven, with instructions to report at a con-
vention to be held in the City of Philadelphia in May,
1847. A committee was appointed to invite every
regularly organized medical society and chartered
medical school in the United States "to send delegates
to the Philadelphia meeting. A resolution was
adopted setting forth that " the union of the business
of teaching and licensing in the same hands is wrong
in principle, and liable to great abuse in practice"; and
recommending that "all licenses to practise medicine
should be conferred by a single board of medical
examiners in each State." This also was referred to a
committee to be reported upon at the meeting in
Philadelphia. Committees were also appointed to
report at the same time and place, upon the best
method of securing registration of births, marriages,
and deaths throughout the United States, and upon
the adoption of a proper and uniform nomenclature
of diseases and causes of death.
In Ma}', 1S47, the convention met in Philadelphia.
There were present about 250 delegates, representing
not less than forty medical societies and twenty-
eight medical colleges, which were the organized medi-
cal institutions of twenty-two of the twenty-six
States of the American Union. The reports of the
various committees appointed at the previous meet-
ing were read and after careful consideration, were, in
the main, adopted. The convention resolved itself
into the American Medical Association, adopted a
constitution and by-laws and a code of ethics, and
adjourned to meet in Baltimore the following year.
The large share which the Medical Society of the State
of New York took in initiating and carrying out the
work that had resulted in the formation of this
Association shows that the Empire State was the cradle
of the movement.
Membership. — The plan of organization provided
that "members of the American Medical Association,
should be either delegates from local institutions
i State, or county, or town medical societies, medical
colleges and hospitals, lunatic asylums, and other
permanently organized medical institutions, in good
standing"), or members by invitation, or permanent
members. Thus there were created three classes of
members, of which the delegates constituted the bulk,
and the most important part.
Each delegate was appointed for one year. The
basis of representation was one delegate for every ten
regular resident members of every regularly organized
medical society. Two delegates for even- regularly
constituted and chartered school of medicine, two for
every hospital containing 100 beds or more, and one
for all permanently organized medical institutions of
good standing, not included in the above summary.
In order to admit of representations from portions of
the United States not otherwise represented, provision
was made for members by invitation. If a physician
from a section of the country in which no medical
institution of any sort existed, attended an annual
session, the association could elect him a member by
invitation for that session only. He thus became an
unofficial delegate for a section of the country that
245
American Medical
Association
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
would otherwise have been without representation.
Any member belonging to one of these two classes, after
his appointed service, and such other persons as the
association might select by unanimous vote, might
be made permanent members. These were entitled
to attend the meetings and to participate in the busi-
ness of the association, but had no right to vote.
In 1850, at the third annual session of the associa-
tion, a resolution was offered that members by invi-
tation should become such only after a committee had
passed upon their eligibility. In the following year
(1S51) a minority report from the committee on
amendments to the constitution, allowing the per-
manent members to vote, was defeated by a large
majority.
Thus it can be seen that from its earliest history,
the association established the principle which has
been adhered to up to the present time, that it is
essentially a representative body exercising powers
delegated to it by State and county medical socii i ies
and medical institutions distributed over the entire
country.
No further change of any importance was made in
the matter of membership in the American Medical
Association, until the session of 1S69 at New Orleans,
at which an amendment was adopted that a continu-
ous membership in a county or State society, where
one existed, was essential for membership in the
National Association; and that without a continuous
membership in such local or State society, no one
could retain his membership in the American Medical
Association. This applied to all classes of members.
In 1874, at the twenty-fifth annual session at
Detroit, a provision was adopted limiting the dele-
gates to those selected from the members of per-
manently organized State societies, and such county
and district medical societies as were duly represented
in their State societies, and from the medical de-
partments of the Army and Navy of the United
States. The United States Marine-Hospital Service
was subsequently admitted to the same representation
as that of the Army and Navy.
In 1881, a fourth class of members was provided
for, viz., "members by application." It was voted
that members of State or county societies, certified to
be in good standing by the president and secretary of
such a society, might become members of the Ameri-
can Medical Association "by application." They
were entitled to attend the annual sessions, and to
receive the journal of the association, but had no
right to vote. These provisions regarding member-
ship remained in force until the reorganization in
1901, when the only societies recognized as having
the right to send delegates (i.e. to be represented in
the newly formed House of Delegates) were the State
societies.
Primarily only delegates could become members,
and up to the time of the proposed establishment of
the Journal (1881) the only means of becoming a
member was to attend an annual session of the Ameri-
can Medical Association, either as a delegate, or a
member by invitation.
Membership by application was devised to allow
members of county and State societies to become
members of the American Medical Association (and
to receive the Journal) without attendance upon an
annual session of the Association, and without
having been elected delegates to such a session.
The basis of representation was changed from one
delegate to ten members of a constituent society, to
one delegate to every 500 members of a State society.
At the former rate there would have been 6,000
delegates at the annual meeting in 1901; since the
constituent State societies contained an aggregate
of 60,000 members, or about half of the entire num-
ber of physicians in the country at that time.
The House of Delegates is now limited by the
titution to 150 members, of which seventeen
represent the sections of the Association and the
public services. When the membership in the State
societies shall have increased so that the aggregate of
delegates shall exceed 150, on the present basis of rep-
resentation, this will be raised, so that the total num-
ber of delegates shall not at any time exceed the
present total.
At the second meeting of the Association in Balti-
more in 1848, the registration was 266, representing
societies and medical institutions in twenty-one
States and the District of Columbia. The Presidi
Dr. Nathaniel Chapman of Pennsylvania, decline
election and advocated the plan of rotation in office,
a rule which so far as the office of president and th.i-i-
of the vice-presidents are concerned, has been rigidly
adhered to ever since.
The scientific and literary work of the Association
was presented in the form of reports of the com-
mittees which had been appointed for this purpose at
the original meeting. To the report of the conim
on surgery were appended three papers on anest
agents in surgical practice. These papers led to an
interesting discussion in which Dr. J. C. Warren of
Boston, Professor of Surgery in the Harvard Univer-
sity Medical School, who had but recently performed
the first major surgical operation in the world upon a
patient who had been rendered insensible by the in-
halation of ether, took an active part. Dr. Olivet
Wendell Holmes, Professor of Anatomy in the Harvard
Medical School, presented the report on Medical
Literature, and Dr. Alexander H. Stevens of Ne
York, the newly elected President, and also at that
time President of the College of Physicians and
Surgeons of New York, presented the report on
Medical Education.
Dr. Holmes criticized with severity the rather un-
satisfactory character of the current medical litera-
ture and exhorted the members of the Association
to produce original medical brochures and text-books,
instead of contenting themselves with editing thos
foreign authorship.
A communication was received from the medical
department of the National Institute in referent
the sanitary condition of the United States, stating
that they had appointed a committee to take
matter up and urging the cooperation of the Associa-
tion. This request was acceded to and a cooperating
committee appointed. Dr. T. O. Edwards, then a
member of Congress from Ohio, presented a memorial
to the Association relating to the adulteration of
imported drugs, and urging Congress to take action to
prevent this, and to require an inspection of all im-
ported drugs and medicines. Another report was
presented demanding a careful study and report upon
the medicinal properties of all the indigenous plants in
the United State*. Committees were appointed to
visit the British and Provincial Medical and Surgical
Associations.
Considering all that had been accomplished in the
first year of its existence, the remarks of its president
on taking the chair, do not seem extravagant. II
expressed the hope that the Association might "ex-
hibit in a new form to our brethren in Europe, the
easy adaptation of our institutions to the great eni
promoting the happiness of mankind."
The State Societies and the Medical Colleges. — During
the period intervening between the sitting of the con-
vention in Philadelphia and the next annual meeting
in Baltimore (1846-47), new State societies '
organized in South Carolina, Alabama, and Pennsyl-
vania and the already existing State societie
Georgia, Mississippi, Tennessee, Ohio, and Wisconsin
were aroused to renewed vigor and efficiency. In all
of these societies and in others in the New
and Middle States, resolutions were adopted appro'
the proceedings of the National Convention, es
cially those relating to medical education,
ommendation that the course of study in the medical
246
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
American Medical
A SSOI hi t litu
ioo |s I"' increased to six months in each year, met
I, general approval, except that the delegates from
the medical schools objected, fearing that the
i ,uls in which they were interested would lose
However, the University of Pennsylvania
end its course-; of lectures to six months, and
■ College of Physicians and Surgeons in New York,
■ oldest and most influential of the medical schools
i the metropolis, extended its lecture period to five
While most of the other medical schools
■d themselves with adding to their curricula
o to four weeks of optional preliminary
ion,
\i the annual meeting in 1N53, thirty States and
(ritories were represented by delegates, as well as
Hi of Columbia, the Army and Navy of the
lited States, the American Medical Society of
id one member was present by invitation "from
and one from Canada West. The whole
■nber of members in attendance was 573, and the
umber of institutions and societies represented
Previous to the organization of the National Associa-
' ii' medical societies had been formed in about
jlf of the States of the Union. But a large proportion
had practically ceased an active existence.
en State societies and eleven local ones were
tited in the National Convention held in 1846.
Philadephia, in the following year sixteen State
were represented, all that were known to be
active existence in the United States at that time.
ght years after the organization of the Association,
enty-six State societies were represented in its
;nual meeting, together with delegates from the
ietv of Minnesota Territory and that of the
1 erokee Nation, and from more than 100 county,
,-trict, and town societies.
The Code of Ethics. — It is a noteworthy fact that
■ 're has been only one schism or split of any con-
llerable consequence in the ranks of the American
lical Association since its foundation, and that
1 'urred in the State of New York; which, as already
iitcd out, is the State in which the Association
illy had its origin.
The quarrel was over the so-called code of ethics,
lich like the theological tenets of former ages, led
many prolonged and bitter controversies. It is
ble in a limited space properly to consider the
de of ethics in all its bearings. Suffice it to say
at one section of this document, which all members
the Association were obliged to subscribe to, for-
ile consultation with any practitioner whose prac-
e was based upon "an exclusive dogma." The
dical society of the State of New York had long
afed under a too strict interpretation of this pro-
lition. and many of its members maintained that it
is unjust and improper to refuse to consult with le-
lly qualified practitioners, no matter whether they
•re bound by an exclusive dogma, or not. Steps were
ken to induce the National Association to modify
code of ethics which had been preserved intact
ice its original adoption in 1S47, but without avail,
nally, at the annual meeting in February, 1882, the
Ural Society of the State of New York adopted a
le of ethics, or rather statement of principles,
the effect that "the only ethical offenses for which
'■y [the medical profession of the State of New York]
um and promise to exercise the right of discipline
" those comprehended under the commission of acts
■ worthy a, physician and a gentleman." At the meet-
g of the National Association following this action,
e Judicial Council ruled that the New York Society,
iving adopted a revised code several provisions of
iich were in conflict with the code of ethics of the
ssociation.was not entitled to representation by dele-
tes in the American Medical Association. There-
ter for over twenty years the Medical Society of
State of New York was not represented in the
councils or scientific work of the .National Associa
tion.
The State, however, was not long without represen-
tation, for in 1884 a number of physicians in New
York, .who were willing to subscribe to the code of
ethics of the American Medical Association and who
wished to retain the right of membership in the Asso-
ciation, established a new society entitled the New
York State Medical Association. There were then
three classes of pracl itioners in Now York State : those
who believed in the old code, those win, had adopted
the new code, and those who regarded all codes as
unnecessary.
When the American Medical Association was re-
organized in 1901, it was hoped that some modifica-
tion would be adopted in 1 lie cod,- of et hies, or in its
enforcement, so that a union might lie brought about
between the two medical societies in the State of New-
York, and all their members might be eligible to
membership in the National Association. The last
named body, however, declined at that time to modify
its code of ethics, and the union was postponed.
However, the leading men in all three of these socie-
ties were by this time striving for harmony, and
finally in 1903, the National Association abrogated
the compulsory clause in its code of ethics which had
made all the trouble, and adopted in place of the old
code certain"principles of medical ethics' which it pro-
mulgated as "a suggestive and advisory document."
There was then no longer any cause for dissension,
and on January 1, 190(3, one hundred years after the
establishment of the Medical Society of the State of
New York, this society and the Medical Association
of the State of New York, having overcome certain
legal difficulties in their way, were amalgamated, and
with much satisfaction and general good feeling, laid
to rest forever the objectionable feature of the code
of ethics.
The Journal. — The history of the progress of the
Association for the first thirty years of its existence,
is not especially noteworthy. Gradual progress was
made along the lines laid down by its founders.
Two or three sessions were missed during the troub-
lous times of the civil war. With these exceptions,
however, not a year has passed in the sixty-seven
years of the existence of the Association in which a
meeting has not been held and more or less good
scientific work done, as well as some effort made to
bring about improvements in medical education for
the enactment of better health and quarantine laws
and the furtherance of many good objects which the
founders of the Association had in mind.
Still the Association lacked coherence, and it
lacked funds. Its loose organization precluded
almost any sustained and effective scientific or legis-
lative work. Its means of communicating with its
members were inadequate, and it was without power
to discipline either its own members, or the profession
at large. It was obvious that one potent means of
accomplishing a stronger organization would be the
establishment of a journal. Hence, as early as 1S52,
it was proposed to start a journal. Again in 1870,
Dr. Samuel D. Gross of Philadelphia offered a resolu-
tion that the transactions be periodically published in
a journal. This resolution was passed and then
rescinded. In 18S0, Dr. Louis A. Say re of New York
made a similar proposition to the society which was
referred to a committee who after a careful investiga-
tion, recommended that another committee be
appointed to report in detail a plan for journalizing
the transactions of the Association. Again the inde-
fatigable N. S. Davis came to the fore and by his
industry and perseverance secured pledges from 2,100
physicians to sustain the Journal. Dr. Davis became
its editor and the first issue appeared in 1SS3. At
that time the membership of the Association was
about 2.000. The annual dues were .S3. 00 which
were in many cases uncollectable. The financial
247
American Medical
Association
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
outgo was between five and seven thousand dollars,
the greater portion of which was spent in printing,
binding, and distributing the annual volume of
transactions.
With the publication of the Journal, a new era in
the life of the Association was begun. In fifteen
years the edition of the Journal of the American
Medical Association had risen, under the editorship
first of Dr. Davis, then of Dr. John B. Hamilton,
from 3,800 to 11,270. In 1S9S the present editor,
Dr. George H. Simmons, took charge. The member-
ship of the Association has now reached over 34,000
(about a quarter of all the physicians in the United
States), forming a body about one-half as large again
as that of the British Medical Association, which was
started in 1S32, but which did not complete its present
organization as the National Association of Great
Britain until 1S56, about ten years subsequent to the
establishment of the American Association. The cir-
culation of the Journal has increased to nearly 54,000,
including the membership list, and the assets of the
Association have increased since 18S3, from a deficit on
the Treasurer's books to over one-half a million dollars,
of which, $100,000 represents interest-bearing invest-
ments and over $350,000 represents real property, ma-
chinery, furniture, and supplies. The gross revenue
amounted last year in round numbers to over $459,000
and after all expenses covering insurance, deprecial inn
of plant and machinery, etc., had been deducted, over
$53,000 was added to the assets of the Association.
Organization. — By the reorganization in 1901, as
already stated, the American Medical Association was
divided into a scientific and legislative body. The
latter has already been described as the House of
Delegates which does all the business of the Associa-
tion including the election of the officers. The
scientific work is done in fourteen sections covering
every branch of medicine and surgery. From 3,000
to 6,000 members attend the annual meetings of the
Association.
The finances of the Association and the business
management of the Journal and of the investments
and the care of all the property, are in the power of the
Board of Trustees. This consists of nine members,
three going out of office yearly and being succeeded
by new men, elected by the House of Delegates.
The judicial council consists of five members (one
elected each year) and the secretary of the Associa-
tion. They look after and regulate all matters need-
ing adjudication between members and between the
American Medical Association and other medical
societies, and harmonize the action of the diverse
interests over which the Association lias supervision.
There are besides, three permanent councils:
1. That on Health and Public Instruction, consisting
of five members and the secretary of the Association.
2. That on Medical Education, consisting of five
members and a secretary.
3. That on Pharmacy and Chemistry, consisting of
fifteen members and a secretary.
A brief review of the work of these councils will
serve to outline some of the major activities of the
Association since its reorganization in 1901.
The council on Health and Public Instruction has
conducted a Publicity Bureau and has sent informa-
tion on matters affecting public and personal health
to 5,000 newspapers and periodicals in the past year
only six of which have declined to receive and make
some use of the information. This is sent out in
weekly bulletins, and covers practically the entire
range of hygiene and preventive medicine. A sub-
committee of this council has waged war against
preventable blindness, with great success. The
council also maintains a corps of healfh lecturers, at
present consisting of 100 speakers, who will go any-
where in the United States upon request, and address
lay and professional audiences on matters of State and
personal sanitation.
248
The council on Medical Education has finished its
third complete report upon every medical teaching
institution in the country. In the past five years
fifty-six medical schools in the United States have
closed their doors or merged themselves into other
schools, evidently as a result of the publicity to which
they have been exposed. All the medical schools in
the United States are carefully classified in the
Council's report, as good, fair, and poor. Of the 14::
schools now active in this country, nearly one-half
are reported to be inadequately equipped, or defective
in some important particulars. Fortunately, a
college diploma no longer confers the right to practise
medicine, inasmuch as the appointment of a 81
medical examining board has been secured in every
State in the Union. Efforts are now being mad'' to
equalize the requirements for license to prai
throughout the country, and to elevate and improve
the personnel of the State examining boards. Further-
more, an effort is also being made to require at lea I
one year's internship in a recognized hospital before
a physician shall be licensed to practise.
The work of the Council on Pharmacy and Chem-
istry is almost too well known to require comment.
They will examine and report upon any remedy,
new or old, that is advertised to be useful in the
treatment of disease. The amount of work that
they have done in bringing to light frauds :
deceptions in the drug and medicine business
almost incredible. It is to be hoped that their efforts
to establish standards of purity and reliability in the
entire drug business, and even in that of handling and
preparing food of all sorts, will be abundantly
successful.
Besides the Journal of the American Medical
Association, the Board of Trustees have authorized
the publication of two other periodicals, "The
Archives of Internal Medicine" and the "American
Journal of the Diseases of Children." The Associa-
tion has also compiled and published a register of
every physician in the United States and Canada,
which is claimed to be complete and authoritative.
It should not be forgotten that for over fifty years,
the American Medical Association has struggled for a
National Department of Public Health and is still
bending its energies toward the establishment of that
great boon to our common country.
Of the great objects with which the founders of the
Association charged themselves, all have bet
accomplished, or are in fair way to be accomplish
Like the statesmen who founded our government,
and gave us our national constitution, the wise men
who founded the American Medical Association
"builded better than they knew."
Richard Cole Newton.
Ammoniacum. — Ammoniac. Gum Ammoniac. \
gum resin obtained from Dorema ammoniacum Don
i lam. Umbellifera:). The ammoniac plant abounds in
the deserts of Persia and Beloochistan. It is a stunt
perennial herb two meters or more in height with a
few coarse leaves at the base and a large terminal
panicle of flowers. It grows from a large turnip-like
root, which has a domestic use under the name " l J ">in-
bay Sumbul." The milky juice exudes from punc-
tures made by beetles, and concretes upon the
often falling to the ground in irregularly rounded 01
ellipsoidal nodules or "tears" often nearly an inch in
diameter, which constitute the drug of commerci
In the best grades, these tears are dry and separate,
but are sometimes soft and agglutinated. Tiny a
brownish cream-colored externally, darkening
namon brown with age, creamy white, or pure white
within. They break with a conchoidal fracture, dis-
closing a waxy, but shining surface. The odor is
peculiar, rather disagreeable, but faint, excepting u
masses or upon warming. The taste is bitter and
REFERENCE IIWIMtiioK OF THE MEDICAL SCIENCES
Ammonia and Ammonium
Sails
i her acrid. It is a difficult drug to powder, unle
, v cold or very dry. When heated it softens, but
, , s I,,, i melt. Alcohol dissolves about three-fourths
, i. Water disintegrates it, and forma with it a milky
, ulsion.
Ammoniac consists of about seventy per cent, of
■ in, fifteen to eighteen per cent, of .soluble gum, anil
Ki rest of insoluble gum, water, and from one-half
i four per cent, of volatile oil. The latter does no!
nil sulphur, and, therefore, is not similar to the
of asafetida, which drug is much adulterated with
moniac.
Vminoniac is stimulant, expectorant, and antispas-
IjidiC, but is scarcely used now internally. The dose
,., id to be 0.5 to 2 grams (gr. viij.-xxx.) thre ■
mes a day. An emulsion would be an eligible
i although a tincture would probably contain all
i is active in it. The principal preparation is
uiac Plaster (Emplastrum Ammoniaci), made
softening the ammoniac in diluted acetic acid, and
iporating to a suitable extent. It is a stimulating
: 1 rubefacient, sometimes blistering application,
i ful as a mild counterirritant.
One other species of Dorema, according to the
i icographia," yields ammoniac. Bentham
I Hooker include only two species in the genus.
e ammoniac of Dioscorides and Pliny, and other
i, nt writers, was obtained in Africa, and is a dif-
lent article, namely, a gum resin obtained from
ingitana Linn. It is rarely found in European
i irkets.
II. II. RUSBY.
\mmonia and Ammonium Salts. — General Med-
sai. Properties op Ammonium Compounds. —
umonium compounds, as a class, are irritant,
ally, to a degree greater than that shown by the
.'■responding compounds of sodium, but less than
: the case of compounds of potassium. They tend
be of high diffusion power, and are therefore,
len swallowed, quickly absorbed, and hence are
c from the purgative tendency of the low diffusion
Its of potassium, sodium, and magnesium. C'on-
tutionally they tend to increase the force and
[uency of the heart's action and to determine a
e of arterial tension; to excite the respiratory
nter in the medulla oblongata, causing fuller and
ire frequent respirations, and to enhance reflex
itability of the motor tract of the spinal cord — an
limn i incut leading in poisonous dosage in animals
tetanoid convulsions. General nutrition is not
riously affected by therapeutic doses. In long-
atinued excessive dosage the heart becomes
feebled and the quality of the blood deteriorates,
th marked impairment of the power of the hemo-
ibin to fix oxygen. An important difference be-
een the alkaline ammonium compounds and the
[•responding potassium, sodium, and lithium
eparations is that, whereas the latter carry their
kalinity through the system generally and into the
■ine, no such effect follows the ingestion of the
mnonium compounds. On the contrary, the
idity of the urine tends rather to be enhanced under
umonium medication. The explanation of this
•culiarity among ammonium compounds is an
sinned oxidation of the elements of the ammonium
dicle, leading to the formation of nitric acid as one of
ie products. By virtue of the properties described,
umonium compounds furnish important medicines
i restoring or sustaining flagging heart or lung
tiou; for relieving dyspnea, and for opposing the
tion of motor-paralyzing poisons.
The Ammonium Compounds Used in Medicine.
-These are ammonia, and the following ammonium
ilts: salicylate, carbonate, acetate, chloride, bromide,
dide, benzoate, and valerate. In the present
"tide will be discussed the first three only; for the
others see respectively Chlnriilcs, Bromides, Iodides,
Benzoic Arid, Salicylic Aral. I aleric Acid.
Ammonia. — Ammonia, NIL,, is used in medicine
only in aqueous or alcoholic solution, as afforded by
the following official preparations of the U. S. P.:
Aqua Ammonia Fortior, Stronger Ammonia Water.
This is an aqueous solution of ammonia, containing
twenty-eight per cent., by weight, of the gas. It
presents itself as a "colorless, transparent liquid,
having an excessively pungent odor, a very acrid ami
alkaline taste, and a strongly alkaline reaction.
Specific gravity, 0.897 a! 25° C. (77°F.)." (U. S. P.)
It is completely volatilized by the heat of a water
bath. On bringing a glass rod, dipped into hydro-
chloric acid, near the liquid, dense white fumes are
evolved. From the volatility of its contained am-
monia this preparation is directed to be kept in
"partially filled strong glass-stoppered bottles, in a
cool place."
Aqua Ammonias, Ammonia Water. "An aqueous
solution of ammonia, containing ten per cent., by
weight, of gaseous ammonia." This weaker solution
has the properties of the stronger, only not to so
intense a degree. Its specific gravity is 0.958 at 25°
C. (77° F.). It also should be kept cool, in glass-
stoppered bottles, but the precaution to avoid filling
the bottles completely is not here necessary. Dose,
about itstxv. (1.0).
Spirit us Ammonia;, Spirit of Ammonia. " An alco-
holic solution of ammonia, containing ten percent.,
by weight, of the gas." This solution is prepared
by subjecting stronger water of ammonia, in a still,
to a gentle heat, and conducting the ammonia gas
thereby volatilized to a receiver containing freshly
distilled alcohol. The product is assayed and brought
to standard strength by the addition of alcohol.
Spirit of ammonia is a "colorless liquid, having a
strong odor of ammonia, and a specific gravity of
about 0.S0S at 25° C. (77° F.)." (U. S. P.) It should
be kept in glass-stoppered bottles, in a cool place.
Dose, about njixv. (1.0).
Spiritus Ammonia: Aromaticus, Aromatic Spirit of
Ammonia. This is a composite preparation, contain-
ing, in 1,000 c.c., ammonium carbonate, 34 grams;
ammonia water, 90 c.c; oil lemon, 10 c.c; oil of
lavender flowers and oil of nutmeg, each, 1 c.c;
alcohol, 700 c.c; and the rest distilled water. It is a
"nearly colorless liquid when freshly prepared, but
gradually acquiring a somewhat darker tint. It has
a pungent ammoniacal odor and taste. Specific
gravity, about 0.900 at 25° C. (77° F.)." (U. S. P.)
Dose, about mrxxx (2.0). This spirit, like the other
ammonia solutions, should be kept glass-stoppered,
in a cool place. But in spite of this precaution, the
fact obtains generally with ammoniacal solutions that
they lose strength upon keeping, so that a sample a
year or more old may be almost wholly without
ammoniacal odor. Ammoniacal solutions are incom-
patible with acids, acidulous salts, and many salts of
the metals and earths; ammonia, however, does not
decompose calcium salts, nor, except partially, those
of magnesium.
Ammonia is a powerful alkali, and in gaseous form
is intolerably pungent, its fumes, if strong, exciting
vigorous spasm of the larynx. In strong solution,
it is intensely irritant. Either of the official ammonia
waters or the simple spirit will, if of standard strength,
excite severe irritation upon incautious inhalation of
the fumes, and if applied to the skin upon cloths so
covered as to prevent evaporation, will very speedily
cause burning pain and redness, and, after a few
minutes, blistering. Prolonged application may lead
to ulcerative inflammation or gangrene. Internally,
in proper dilution, ammoniacal solutions are locally
alkaline so far as the contents of the stomach and
bowels are concerned. Also, because of the pun-
gency and volatility of ammonia, they tend to allay
nausea and to expel flatus. Ammonia, being of
249
Ammonia and Ammonium
Salts
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
high diffusion power, is readily absorbed, whether
taken by swallowing or by inhalation, and then
quickly but evanescently exerts the peculiar effects of
the ammonium compounds upon the heart, respira-
tion, and motor tract of the cord, as already set
forth. Undiluted, the three first-named pharmaco-
pu'ial ~ . 1 1 1 1 1 i < . 1 1 ^ i.f ammonia arc so irritant as prac-
tically to be corrosive to the mucous membrane of the
stomach and bowels. Large doses are, therefore,
violently poisonous, capable of causing speedy death,
with all the usual symptoms of corrosive irritation.
In some cases death results in so short a time as a very
few minutes, probably from suffocation through
rapidly developed edema of the glottis. So small a
quantity as about a teaspoonful and a half of a strong
solution of ammonia, swallowed undiluted, has killed.
Dangerous, and even fatal, poisoning has also resulted
from inhalation of strong ammoniacal fumes.
The therapeutic uses of ammoniacal solutions are
local and general. Locally, according to strength of
application, ammonia may be made to serve as a
vesicant or rubefacient. To blister, a pledget of lint,
steeped in a strong solution, is covered with a watch-
glass or wooden pill box to prevent evaporation, and
then directly applied. In such way the stronger
water of the Pharmacopoeia has been used, but this
solution is unnecessarily and, unless very carefully
manipulated, dangerously strong. If employed, the
application should be held in contact with the skin
for only three or four minutes, or until the part is well
reddened, and should then be removed and a hot
poultice applied until the blister rises. It is safer to
dilute the stronger water with one-half its volume of
additional water. Ammonia is rarely selected as a
blistering agent, unless the need for the blister is
urgent, when the quickness with which ammonia acts
makes it preferable to cantharides. For rubefacient
purposes a clash of the stronger water is a very com-
mon addition to composite liniments, and there is
official in the U. S. P. Linimentum Ammonia, Ammo-
nia Liniment, or, as it is sometimes called, volatile
liniment. This preparation is made by mixing 350
c.c. of ammonia water (not the stronger water) with
50 c.c. of alcohol, 570 c.c. of cotton-seed oil, and 30
c.c. of oleic acid. An ammonia soap results, which
partly dissolves and partly remains emulsified in the
fluid, forming a white viscid mixture. The prepara-
tion is saponaceous, yet possesses mildly the irritant
qualities of ammonia, and makes a capital liniment
for rubef action. Still a third local purpose of ammonia
is to relieve the pain or itching of bites of insects. For
this purpose a drop or two of the weaker water, clear
or diluted, may be applied to the part. Internally,
ammonia may be used, first, to correct the gastric
malaise that attends a fit of acid indigestion, or to
allay nausea from any cause. For such purpose the
aromatic spirit is specially devised, to be given in
doses of from one-half to one teaspoonful, diluted with
three or four volumes of water. Secondly, ammonia
may be given for the constitutional effects of reviving
the heart in faintness, of supporting it in chronic con-
ditions threatening heart failure, of stimulating
flagging respiration, as in dyspnea from lung disease,
or in respiratory failure in poisoning by paralyzing
agents, of allaying mild spasmodic seizures, and of
opposing generally the action of narcotics and para-
lyzers. For all internal medication the stronger water
is entirely too strong, and the weaker water or. the
spirit is to be preferred. Of the water or of the
simple spirit from ten to thirty drops may be admin-
istered at a dose, largely diluted. If swallowing be
impossible, as in case of unconsciousness from a faint,
the effects of ammonia may be obtained by inhalation,
but great caution is necessary lest dangerous or even
fatal irritation of the air passages be set up by too
strong inhalation during complete or partial uncon-
sciousness. None of the pharmacopoeial ammoniacal
solutions should be applied close to the nostrils.
250
Ammonium Carbonate. — Upon subliming a mixtun
of chalk and ammonium chloride or sulphate, doubli
decomposition ensues, and a sublimate is obtained
which consists of acid ammonium carbonate and
ammonium carbamate, represented bv the svmhol
NILHCO3, NH 4 NH,C0 2 . This composite salt is oil,.
cial under the title Ammonii Carbonas, Ammonium
Carbonate. It occurs as "white, hard, translucent
striated masses, having a strongly ammoniacal odor
without empyreuma, and a sharp, saline taste. On
exposure to the air, the salt loses both ammi
and carbon dioxide, becoming opaque, and is finally
converted into friable, porous lumps, or a white
powder. Slowly but completely soluble in about four
parts of water at 25° C. (77° F.); decomposed by hoi
water with the elimination of carbon dioxide and
ammonia. By prolonged boiling with water the
is completely volatilized. Alcohol dissolves the car-
bamate [NH 4 NH 2 C0 2 ], and leaves the acid carbonate
(ammonium bicarbonate). When heated, ammonium
carbonate is completely volatilized, without charring
The aqueous solution possesses an alkaline reaction
and effervesces with acids." (U. S. P.) This salt
must be kept in well-stoppered bottles in a cool place.
Ammonium carbonate behaves, physiologically .
like ammonia itself, but is a little less rapid and
evanescent in operation. In concentrated solution it
is locally irritant, and taken internally, dangero
poisonous. The salt is used for the constitutional
stimulant and sustaining effects of ammonia, and
often for such purpose preferred to solutions ,,t
ammonia because of the slightly longer duration of the
action. It is given internally in frequently repeated
doses of gr. iv. (0.25) in aqueous solution, with the
acrimony disguised by gum arabic or sugar, or si
agreeably flavored aromatic addition. Large s :
doses should be avoided, since they easily overirritate
the stomach and may excite vomiting. Ammonium
carbonate is also much used to get an ammonia
effect by inhalation. For this purpose it is coarsely
bruised, treated with half its bulk of strong water of
ammonia, and flavored with a little oil of lavender or
bergamot, such mixture constituting what is knov
smelling salts.
Ammonium Acetate.— -This salt, CH 3 .COONH„ is
used only in the aqueous solution in which it results
from the procedure of neutralizing wit h ammonium car-
bonate the diluted acetic acid of the Pharmacopoeia.
Such solution, commonly called spirit of Minderi
is official as Liquor Ammonii Acetatis, Solution of
Ammonium Acetate. It is "a clear, colorless liq
free from empyreuma, of a mildly saline, acidulous
taste, and an acid reaction." (U. S. P.) The solution
contains five per cent, of the salt. It should be made
freshly for use, since like other solutions of alkaline
salts of the common organic acids it tends to sponta-
neous decomposition on keeping. Ammonium acetate
is a bland, mawkish salt, which upon absorption may
prove feebly diaphoretic or diuretic, according to
circumstances, and may to a slight degree exert the
characteristic effects of the ammonium compounds
generally. It is used to allay headache, especially the
headache of pyrexia, to quiet an uneasy stomach, or
to promote gentle diaphoresis or diuresis in fevr;
but it is at best a feeble medicine. One or two
tablespoonfuls may be given at a dose, clear or diluted,
sweetened and aromatized. The pharmacopceial dt
is oss. (16. C). If diluted, carbonic acid water mal
an excellent addition.
Toxicology of Ammonia. — Ammonia is met with
in commerce in a number of forms.
First, as anhydrous ammonia condensed in large
steel cylinders for use in ice machines. In these the
ammonia is under a pressure of several hundred pounds
and is in a liquid condition. When the pressun
removed, the liquid assumes a gaseous form and
issues from the opening as a colorless, irrespirable gas
intensely corrosive to organic tissues.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Ammonia and Ammonium
Salts
V number of fatal accidents have happened from
action of this gas, either through the bursting of
. cylinder when it has been highly heated, ur
h imperfect connection with the refrigerating
n'hine.
Vxt, as the Aqua Ammonia Fortior and the Aqua
of the pharmacist. Both of these are
ied above.
a solution of varying strength containing
number of impurities, sold under the name of
hold Vmmonia.
Poisoning from gaseous ammonia is always the
,| accident, and such cases occur only in plants
ie gas is stored or where it is used in quantity
refrigerating purposes. Poisoning by inhalation
the gas arising from its water solution has also
own as the result of accident.
When the gas is inhaled there is generally a sense of
ion and giddiness, followed at times by vomit-
i. The face is pale, and the pulse is faint and accel-
In some instances the mucous membrane of
e mouth becomes detached in the form of white
ds, leaving the surface beneath intensely reddened
v sure. The sense of taste is seriously im-
ired for some time and the contact of solids with
ch eroded surfaces is intensely painful. The
effects of the inhalation of the gas are said to
inflammation of the eyes and a diseased condition
-kin. There is also a general lowering of the
f the system with pronounced anemia.
\\ hen applied to the surface of the skin, a strong
lution of ammonia causes an intense smarting
-at ion and the skin may become rough and ex-
I through the corrosive action of the solution.
When a solution of ammonia is swallowed, the
tnptoms depend largely on the degree of concen-
ution of the solution. When it is concentrated. there
itly a strong smarting pain in the mouth and
mat, which extends very soon to the stomach and
".vels. The abdomen becomes distended, and the
ightest touch increases the pain. There is vomiting
stringy matter having the odor of ammonia and
metimes containing blood. The face is pale, the
ion anxious, the inspiration hurried and
linful. The pulse is feeble and rapid. The body
covered with a cold perspiration. The interior
the mouth is white or bright red, more or less
>vered with shreds of mucous membrane, and the
irte are greatly swollen. There is loss of voice and
icre is also difficulty in swallowing. The thirst is
tense and the mouth feels dry and parched. The
>\v of saliva is greatly increased, in one case reaching
ie amount of three liters in twenty-four hours. The
rine is scanty, slightly acid or even alkaline in rear-
on, and it may contain albumin and casts. The
owels are sometimes constipated and sometimes the
■verse, the liquid dejecta at times containing much
lood. If the patient dies from the immediate action
f the poison, it is usually from suffocation on account
f the swelling of the glottis. Some have died in a
ondition of coma and some in convulsions. In a few
:i". I
dermal « ing; ma, me
amnion; p.o.. region free from n
derm; p. s., primitive streak. (Aftet
Sehauinsland.)
252
REFERENCE IIAXDHOOK of THE MEDICAL SCIENCES
,ui. This band, known as the ectamnion, bends
iliquely backward on each side of the head, extending
■i point aboul opposite the middle of tin- heart.
the stage with twelve it thirteen somites, the head
to the ectamnion, anil, bending downward,
iks into the proamnion beneath it. At the same
\d fold of the amnion, with tin' ectamnion
rest, begins to grow backward over the head.
1 tir-t this is a fold of the proamnion, but by tin'
ae it lias reached the midbrain, it is invaded by
pc h ph pc
I. — Transverse Section of the Albatross Embryo shown in
ss, interior to the Liue ma. a, amnion; ao, aorta; ap t audi-
v pit; />, brain; h, heart; m, mesoderm; nc, notochord; ,.
-dium; ph. pharynx; 5, serosa; va, anterior vitelline vein. (After
aauinsland.)
Ida of somatic mesoderm from the amniocardiac
. and the endodermal layer is withdrawn,
bile the embryo is sinking gradually into the sub-
rminal space and the amnion is growing over the
ad, the ectamnion is extending backward along the
- ;,- the crests of two lateral folds of the amnion
igs. 91 and 92) which are continually being drawn in
tween the embryo and the vitelline membrane and
oieh fuse along the median line from in front
ickward, beginning at the edge of the head fold of the
anion.
ac'. pc
ph
Fig. 00. — Seetion through the Line ma of Fig. 88. a. amnion;
. amniotic cavity; c, ccelom; ea, ectamnion; ec, ectoderm: in,
loderm; >■>, somatic, and sp, splanchnic mesoderm; other let-
ring as in Fig. 89.
When the anterior half of the embryo lias been
ivered by the amnion, the outlines of the body are
mpleted by tin' appearance of the tail fold of the
pleure. Where the posterior limb of this fold
ins the general surface of the blastoderm, the tail
Id of the amnion arises. This grows forward over
ic embrvo and, at the sides, becomes continuous
ith the lateral folds.
The amnion of the chick is thus formed by folds of
ie somatopleure which meet and fuse over the
median lineol the embryo (ae, Fig. 90). At the line of
fu urn t lie ectoderm of each fold separates ami unites
with its fellow of the opposite side. Tin' sami
inn' of tin- mesoderm. In this way tin- exoccelom on
each side of the embryo beCO S confluent, separating
the two membrane I iei one i "■■ ei ing the
embryo is the ami ion; the outer one lining thevitel-
line membrane is the chorion, or membrana serosa
ig. 90). This process of amnion formation in the
chick continues to aboul the stage with thirty-one
somites, when the embryo is completely covered ex-
cepl for a very small opening called the arm
Fig. 91. — Section of Fig. 88 behind the Head-fold of the
Ainiu.m. a, amnion; ca, ectamnion; If, lateral fold; other letter-
ing as in Fig. 89.
umbilicus. This soon closes, but at this point the
amnion and the chorion remain united, funning the
\tic connection, which later becomes per-
forated allowing communication between the amni-
otic cavity and the albumen-sac.
Among the other Sauropsida the development
differs (1) in the relative time of beginning; (2) in
regard to the importance of the proamnion; and (3)
in the comparative size and form of the several folds.
The amnion, in time of appearance, is earlier in
reptiles and later in birds. It is earliest in the
chameleon and latest in the hen. The chameleon is
peculiar in that the amnion arises as a continuous
elliptical fold surrounding the area embryonalis when
the latter consists of but two germ layer-.
h ac pc nc
Fig. 92. — Longitudinal Section of an Embryo a little older
than Fig. 87. a, proamnion; hf, head fold of amnion; mc, medul-
lary canal; other lettering as in Figs. S8 to 91. After Schaninsland.)
In general, according to Schauinsland (1902) the
earlier the amnion appears, the greater the impor-
tance and the longer the duration of the proamnion.
In Sphenodon, a remarkable, primitive reptile of
New Zealand, in which the amnion appears earlier
than in any other reptile except the chameleon, the
entire anterior part of the embryo is enclosed in the
proamnion for a great part of the fetal life. The
embryo is bent nearly' at right angles into the yolk
and all of the amnion from the fore-limbs forward
is free from mesoderm.
253
Amnion
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
In Sphenodon, the turtles, and some birds where
the tail fold is wanting or poorly developed, the
amniotic umbilicus is prolonged as a tube, the amni-
otic duct, which extends backward over the blasto-
derm and finally opens on the surface of the chorion.
For the nourishment of the amnion, blood-vessels
grow into it from the ventral wall of the embryo,
about the eleventh day of the chick embryo. Some
of the mesodermal cells of the amnion become differ-
IV:. 93. — Section of the Blastocyst of a Hedgehog at the Stage
when the Amniotic Cavity is a Cleft Between the Trophoblast and
Formative Ectoderm, a, amniotic cavity; ec, ectoderm; en.endo-
derin; tr t trophoblast. (After Hubrecht.)
entiated into muscle fibers (beginning about the
sixth day in the chick) and these, by their rhythmic
contractions, are capable of rocking the infant bird at
about the rate of sixteen oscillations per minute.
Amnion Formation in Mammalia. — The Mam-
malia are divided into three main groups: Mono-
tremes, or Prototheria; Marsupials, or Metatheria;
and placental mammals, or Eutheria. These groups
differ in the character of their eggs and in their ontog-
eny as much as they do in their adult structure.
Fig, 94. — Section of the Blastocyst of a Hedgehog in which the
Amnion is Complete, a, amniotic cavity; Co, ccelom; en, endo-
derm; tr, trophoblast. (After Hubrecht..)
In the Monotremes, which are oviparous with rel-
atively large eggs (3.5-4 mm.) enclosed in a shell,
the formation of the amnion probably is similar to
what has been observed in the Sauropsida, but the
steps in this process are at present unknown. Semon
(ls'.M), however, has described the fully formed
amnion of Echidna. An extensive proamnion is
present, and a persistent seroamniotic connection
extends the whole length of the fetus.
The early stages in the development of the amnior
of Marsupials is also unknown, but the fully formed
fetal membranes of a number of species have beet
described. Semon (1894) divides them into twi
groups. In the one of which the opossum is a typi
there is a remarkable development of the proamnion
which envelopes all but the posterior extrerjQ
of tin' embryo. Later, this is converted into
amnion by the ingrowth of mesoderm from tin
Fig. 95. — Human Embryo. Diagram of a Longitudinal Section
a, Amnion; all, allantois; c, chorion; cs, connective stalk; c, area
embryonalis; ec, ectoderm of chorion; m, mesoderm; //, yolk Bac.
(After Spee, from Hertwig's Handbuch.)
sides and behind between the two primary germ
layers of the proamnion. In the other group the
amnion shows no remarkable characteristics.
The development of the amnion of the Eutheria i
complicated by the entypy of the embryonic area,
which in the new formed blastocyst is surrounded
by an extra embryonic membrane, tin' trophobla I
of Hubrecht. (See articles Area embryonalis and
Blaaimlt nn.j
Fig. 96. — Human Embryo "Gle." Dimension of blastocyat,
exclusion of villi, S. 5X10X6. 5 mm.; length of area embi
1.54 i. Reconstructed sagittal section. All, allantois; Am,
amnion; b.8, connective stalk; cho, chorion; Ec, ectoderm
endoderm; mes, mesoderm; Vi, villi; Yk, yolk-sac. (Aftei
from Minot.)
According to Hubrecht (1912) the most primitive
method of amnion-formation is that found in the
hedgehog. This begins with a cleft that separates
the trophoblast from the formative ectoderm of the
area embryonalis. Later, this is roofed over by :>
sheet of the extraembryonic ectoderm which, carry-
ing a fold of mesoderm with it, grows up on all sides
finally enclosing the cavity, which thus becomes the
254
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Amnion
amniotic cavity. The double layer of ectoderm and
mesoderm which now forms its roof, is, of course,
the amnion. The outer limb of the mesodermal
[old unites with the trophoblastic ectoderm to form
the diplotrophoblast, or chorion. (Figs. 93 and 94.)
In a number of mammals is found a very simple
type of amnion formation that Hubrecht regards
as an example of accelerated development. In
the ectodermal central cell-mass simply be-
hollow. The floor of this cavity is the em-
bryonal area, its roof is the amniotic ectoderm,
which subsequently receives a mesodermal covering.
! in- amnion is found in this way in the guinea-pig,
i in- hats, some insectivores, edentates, and probably
in most primates.
In the earliest, known human embryos, the Teacher-
Bryce and the Peters embryos, the amnion and the
yolk-sac are already formed. In both, the amnion
is a simple globular cavity lined by a layer of ecto-
dermal cells and surrounded by
a solid mass of mesoderm.
Spee's von Herff embryo (Fig.
95), which is somewhat ad-
vanced in its other structures,
has the amnion still in the ear-
liest known condition. Then-
is no evidence of any amniotic
folds. The amnion is probably
formed by the expansion of a
split in the ectoderm of the
inner cell-mass, as in the
guinea-pig and frugivorous
bats.
In mice, the central cell
mass is elongated, and he-
comes tubular with the lumen
closed at both ends; at the
outer end by the trophoblast,
at the inner end by the em-
bryonic area. The amnion is
formed by folds (a, Fig. 97)
which constrict this cavity near
the middle.
In the majority of mammals
the embryonic shield becomes
spread out upon the surface of
the blastocyst. This may fol-
low a rupture of the tropho-
blast over this area, as in Tar-
sius, in some insectivores, and
in the ungulates; or may be
accompanied by a stretching
of the trophoblast, as in the rabbit, where the tropho-
blast over the embryonal area becomes very thin and
finally disappears. In all of these mammals the
amnion is formed by a folding of the somatopleure,
very much as it is in the Sauropsida. The main differ-
ence is that in the mammals the tail fold is generally
more prominent, with the result that the point where
the amnion finally closes is farther forward.
In the cat, however, the head fold of the amnion
is the first to appear, while in the dog amnion forma-
tion begins with the tail fold (R. Bonnet, 1901).
In both the dog and the cat, the mesoderm at first is
continuous in front of the head region. But as the
head develops, the mesoderm disappears from
beneath it. In these animals, the proamnion is not
a primary structure as in the chick, but is formed
econdarily, and finally covers a considerable part of
the embryo as it does in the rabbit (Fig. 99).
Later, the mesoderm returns to the proamnion which
thus becomes uniform in structure with the rest of
the amnion.
Tin Phylogeny of the Amnion. — The origin of the
amnion and the history of its development in t lie
course of phylogeny of the vertebrates is unknown.
Paleontology furnishes no evidence, and we can only
Speculate as to the probable history of the amnion
Flo. 97. — Early Embryo
of Mus Sylvaticus. En,
lerm; c, cavity of
umbilical vesicle; ol, tro-
ist ; TV, proliferating
trophoblast; Ec, embry-
onal ectoderm; a, ecto-
dermal cavity, the lower
portion of which is after-
rard cut off to form the
amniotic cavity. (From
Minot, after Selenka.)
from such facts as may he gathered from embryology
and comparative anal omy.
First of all, I he writers on the history of the amnion
may In' divided into t«o classes: i 1 ) those who regard
the amnion as formed independently of the chorion,
and (2) those who regard the amnion and the chorion
as being due to the same process. (If the first group
Hubrecht is almost the sole representative. lie
regards the trophoblast which form- the outer layer
of the chorion as a larval envelope similar to what is
found in the echinoderms and -nine marine worms,
where the body of i he first larval stage forms an envel-
ope within which a small part of the body gives rise
to the definitive embryo that developsinto the adult
worm. Just as in certain groups of worm-, some
species undergo such a metamorphosis, while in others
the development is direct; so Hubrecht thinks that
I he ancestral group that gave rise to the vertebrates
early separated into two divisions. One of these
lost its larval envelope and gave rise to Amphioxus,
the cyclostomes and elasmobranchs, in which no
trace of trophoblast has been found; the other divi-
sion retained its larval envelope and its descendants
include the ganoids, dipnoi, teleosts, Sauropsida, and
Mammals, in all of which groups Hubrecht finds the
trophoblast to be more or less developed.
He regards the type of amnion as found in the
hedgehog as the most primative and as having
arisen in the holoblastic eggs (see Segmentation of the
ovum) of the viviparous quadruped (Prototetrapoda)
which first forsook aquatic life for the land and gave
rise to the terrestial vertebrates. The oviparous
habit, large yolk, and folded amnion of the Sauropsida,
are, according to Hubrecht, secondary acquisitions.
Although brilliantly expounded and supported by
a wealth of facts, Hubrecht's argument is not con-
vincing to the majority of zoologists, for several
reasons.
In t he first place, Hubrecht's hypothesis involves
the theory of the amphibian origin of mammals,
which is by no means universally accepted, although
supported by certain morphological comparisons;
as in the development of the heart, and ear bones,
and the anatomy of the epiglottis and the intestinal
arteries.
In the second place, if we accept Hubrecht's views,
we must believe that the Sauropsida have abandoned
the viviparous habit for the oviparous one and that
the yolk of these forms is not a gradual development
from the conditions found in the present representa-
tives of the amphibia, but has been acquired anew.
This seems highly improbable, because it would
seem to involve a loss of productive efficiency, and,
moreover, the other groups of the animal kingdom
present no analogy for such a course of evolution.
Those who believe that the Sauropsida and Mam-
malia have evolved independently from amphibian
ancestors, must believe in the independent origin of
the amnion in the two groups. This seems very
improbable on general biological principles, and
needs very strong support on morphological grounds,
especially in view of the important results recently
announced by Hill (1910). Without going into
details, (for which see articles Ovum and Blastoderm)
it may be said that Hill finds in the eggs of the Mono-
tremes and Marsupials progressive stages connecting
the Sauropsidian type of egg with that found in the
higher mammals (Eutheria).
Whatever views may be held regarding the morpho-
logical history of the amnion, from the physiological
point of view it must be regarded as an adaptation to
a terrestrial mode of life. In the Ichthiopsida
(fishes and amphibia), life is either wholly aquatic or
else generally so in the larval stage, and either the
whole egg is developed into the embryo, or else the
embryo is folded off from the general blastoderm,
which grows over the yolk forming a double layered
yolk sac, that is eventually absorbed. In this case
255
Amnion
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
the embryo projects from the upper surface of the
volk-sac, as is well seen in the catfish. (Jlinot, 1903,
Fig. 97.)
The embryos of the Amniota, on the other hand,
never project above the general surface of the blasto-
derm, but sink into it, or else are developed from the
first in a depressed area. In either case, the embryo
is soon enclosed in the amnion, which is filled with
a fluid. Thus, although on land, the young replilc,
bird, or mammal really leads an aquatic
life from conception until birth.
Several authors have sought mechan-
ical explanations of the origin of the
amnion. Balfour tried to explain the
amnion and chorion as formed by a
folding of the somatopleure which results
from the development of the allantois.
It has been objected that, the amnion
may be fully formed before there is any
trace of the allantois. This disproves
any direct mechanical effect; but, never-
theless, the two organs may be geneti-
cally related in tin' history of the race.
We have many examples of the develop-
ment of organs in ontogeny in anticipa-
tion of their use. A woman develops
breasts long before she has a child to
suckle, yet we must believe the evolu-
tion of mammas to have been genetically related to
the production of offspring.
Van Beneden and Julin sought for an explanation
of the amnion in the effect of gravity, causing the
embryo to sink into the fluid yolk. But Semon
(1894) has shown that the embryo at first has less
specific gravity than the yolk.
Selenka regards the amnion as the direct mechan-
ical effect of the development of the allantois and its
distention with embryonic urine, combined with a
bending of the embryo into the yolk that results from
the cephalic and cervical flexures.
Semon, on the other hand, has pointed out that
the amnion is a protective organ that has been d<\ el-
oped by natural selection in the course of evolution,
and that it is not to be regarded as purely the result
of the developmental processes of neighboring organs.
In order that an animal may bring forth young on
land, either the young must develop in the oviduct
until viable in air, or the egg must be provided with a
shell. The former is the primary condition according
to Hubrecht, the latter, acording to Hill (1910), who
makes the important suggestion that, "The acqui-
sition of a shell by the Proamniota conditioned I In'
appearance of the amnion. The loss of the shell in
the Eutheria conditioned the occurrence in their
ontogeny of entypy." Little reflection is needed to
make il appear that Hill is probably correct. Deane
has described the relation of the shell te the embryo
in the chimeras, but it would be interesting in view
of Hill's hypothesis to know what influence the shell
has upon ontogeny in other fishes that have egg shells,
as the skates, ami in what way the embryo is modified
in the terrestrial amphibia that do not lay eggs in
water but deposit in moist places eggs covered with a
leathery shell.
Anatomy and Histology of the Human Amnion.
— The amnion in the fully developed afterbirth is a
thin, smooth, translucent membrane lining the inner
or fetal surface of the placenta and membranes.
It rests upon the chorion, to which it is loosely at-
tached — so loosely that it has some play on the chorion
and can be easily stripped off. At the placental
insertion of the umbilical cord the amnion merges
into the integumentary covering of the cord, which,
while corresponding to the amnion, differs from the
latter in some important particulars.
The amnion is made up of two layers: (1) a super-
ficial ectodermal epithelial layer, and (2) a deeper
mesodermal connective-tissue layer.
1. The inner free surface of the amnion, that di
rected toward the fetus, is lined by a single layer o
epithelial cells of ectodermal origin. These cells a
an early period are thin, but later become thicker
low columnar or cuboidal in form. At times, however
in the mature state they appear thin and squamous
The measurements of the dimensions of these cell;
(diameters or diagonals) given by various obsen en
vary from 0.008 to 0.012 mm. (Dohrn), 0.011 to 0.01!
Fig. 9S. — Epithelial Cells Lining Inner Surface of the Amnion. Surface view.
Silver nitrate and hematoxylin. X 1,000.
mm. (Kolliker), 0.011 to 0.014 mm. (Lang.), 0.011
to 0.033 mm. (Nichols). The varying sizes of these
cells, as stated by different observers, probably
depend, partly at least, upon the degree to which
the membrane is stretched in the process of prep-
aration for microscopical examination. When hard-
ened by the usual reagents without taking any pre-
cautions, the membrane is apt to contract or shrink
in superficial extent and at the same time to become
* MM,
Fig. 99. — Surface View of Eoithelium of Amnion from 1 It-
Day Embryo, Showing Intercellular Bridges or 1' esses (pr)
pi, Protoplasm (cytoplasm): nu, nuclei. XI, 225. (Miuot.)
thicker, thus giving these cells an appearance of
greater thickness and less superficial area: while
when stretched on a cork and so hardened, the cells
may be unduly stretched and thinned.
Viewed from the surface, as after treatment by the
silver-nitrate method to bring out the cell boundaries,
these cells present the appearance of pavement
epithelium, uniting in a single layer edge to edge,
with often slightly wavy margins, and being in shape
polygonal (often pentagonal and hexagonal), elon-
256
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Amnion
gated, or irregular (Fin- 98). Some observers have
seen intercellular bridges uniting these cells (Fig. 99).
Viewed in vertical sections, the amniotic epithe-
lial colls appear as low columnar, cuboidal, or thinner
; the nuclei arc often situated near the free ends
f the cells, leaving a clearer protoplasmic none in the
per portions (Figs. 100, L03, 104).
Che nuclei of these cells are rounded or spherical,
about 0.004 mm. diameter. Most of the cells contain
g single nucleus each, hut cells containing two, three,
or four nuclei are common; these multinucleated cells
of larger size than the uninucleated. In the latter
part of pregnancy the epithelial cells sometimes un-
dergo a certain degree of degeneration. Among these
■*;■-,
v Mes
- Msth
Fir,. 100. — Section of Placental Portion of Amnion of Two-
months' Embryo. Ec, epithelial layer; Afcs, mesenchymal con-
ive-tissue layer; Msth, mesothelial or endothelial layer.
250. (Minot.)
cells are occasionally observed round clear spaces
or objects, which have been variously interpreted
as stomata, vesicles, or cells that have undergone
mucinous degeneration and burst.
2 Beneath the superficial epithelial layer is a con-
nective-tissue stratum of mesodermal origin. This
stratum can be divided into two layers: (a) a thick
connective-tissue layer (mesenchymatous), and (b)
in endothelioid (mesothelial) layer lining, par-
tially at least, the outer surface of the amnion, that
directed toward the chorion
(n) The connective-tissue layer of the amnion,
underlying the epithelial layer, makes up the larger
part of the thickness of the membrane, and corresponds
Fig. 101. — .Surface View of Nuclei of Cells of Amnion from Five-
Months' Fetus. X 1,225. (Minot.)
to that portion of the mesoderm which has been
termed the mesenchyma. This layer is somewhat em-
bryonic in character, and consists of connective-
li-Mie cells embedded in an abundant matrix. The
cells for the most part occupy the deepest plane of the
amnion, often leaving in the upper portion of this
connective-tissue layer, immediately beneath the
epithelial layer, a zone that is free from cells (Fig.
103). The nuclei of these cells are at first rounded
and oval, but later become irregular in form and
size. The cells are flat and thin, arranged parallel with
the surface. The shapes of these cells, especially in the
ire amnion, have not been well made out; one
specimen from a mature afterbirth in which the
amnion had remained permanently separate from
the chorion, presenting unusually favorable condi-
tions for observal ion, (Fig. 102) has been examined by
the writer (Nichols). In this instance the connect i ve-
t issue cells were mostly huge flat cells, very irregular in
form, giving off irregular processes and branches,
some broad, some fine and filamentary. The proc-
esses of neighboring cells were often directly con-
tinuous with one another. The general outlines of
the smaller of these cells were often roughly rounded;
of the larger, polygonal or altogether irregular.
These cells ranged in size from 0.025 to 0.100 nun.
in extreme dimensions, measuring between the e.x-
Fig. 102. — Connective-Tissue Colls from Mesenchymatous Layer
of the Amnion. Silver nitrate and hematoxylin. X500.
tremities of the processes (perhaps the specimen in
which these measurements were made was somewhat,
overstretched). Mingled with these larger cells were
smaller rounded or oval cells, not so well provided
with processes and ranging in size from about 0.008
to 0.016 mm.
The intercellular matrix in which the connective-
tissue cells of this layer are embedded is a homo-
geneous ground substance said to be of gelatinous
or mucinous character. At times, however, toward
the close of pregnancy, the deeper portion of the
layer (where the cells are mostly situated) becomes
Fig. 103. — Section of Placental Amnion from Eight-Months*
Embryo, ect, epithelial layer; mes, connective-tissue layer, show-
ing non-cellular subepithelial stratum and deeper fibrous stratum.
X340. (Minot.)
markedly fibrous in character (Fig. 103), the outer
subepithelial non-cellular stratum still retaining its
homogeneous mucinous nature. The amnion of man
is a non-vascular structure and contains no blood-
vessels; the presence of an extensive system of lymph
channels has not been definitely demonstrated, though
such vessels may be present. The amnion of the
chick is contractile, and is said to contain muscle
cells.
(b) The outermost surface of the amnion, that di-
rected toward the chorion, is lined, partially at least,
by a single layer of thin, flat endothelioid cells (Figs.
Vol. I.— 17
257
Amnion
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
100, 101). These are descendants and representatives
of the mesotheliai cells which line the coelom and
from which the endothelial cells of the pleura and
peritoneum are also derived. These cells are nat-
urally well marked in the early period of pregnancy,
while the amnion is still unattached to the chorion
and presents a free (.niter surface. A similar layer
of cells probably lines the innermost surface of the
chorion. After the amnion becomes united with the
chorion, these cells would probably be suppressed
at the points of union of the two membranes, though
even at full term such cells have been seen at a plane
corresponding to the deepest part of the amnion or
innermost part of the chorion, perhaps lining spaces
left between the membranes similar to lympn spaces
in the bodv lined with endothelium.
mes
Fig. 104. — Section of Placental Amnion, at Term, cct , Epithelial
layer; mes, mesenchyznatous connective-tissue layer; a, meso-
theliai endothelioid layer. X 340. (Minot.)
In the specimen of afterbirth above referred to, in
which the amnion remained permanently separate
from the chorion and presented a free outer surface,
this layer of cells was nicely demonstrated by the
silver-nitrate method (Fig. 105). On surface view
these cells were mostly of hexagonal shape (some
pentagonal and heptagonal), quite uniform and
regular in shape and size, with slightly rounded angles.
They were united to one another by their edges,
which were straight, not sinuous. Their size was
small, measuring 0.0055 to 0.007 mm. in diameter.
They did not form a complete lining over the entire
outer surface of the amnion, or at least they appeared
only in patches; perhaps many of them were lost
from degeneration. No nuclei were visible in them
■ — possibly another degenerative sign; if present, they
did not take the nuclear stains employed. Patches
of precisely similar cells
were also obsen ed on
the inner surface of the
chorion in this case.
The covering of the
umbilical cord, which is
continuous at the pla-
cental end with the
amnion and at the fetal
end with the skin,
differs in some marked
characters from the
amnion elsewhere.
This covering consists of a superficial layer of epithe-
lium, which rests directly upon the mucoflbrous tissue
composing the chief part of the cord. The integu-
ment of the cord is therefore intimately adherent
to, or an integral part of, the cord, and cannot be
stripped off as can the amnion elsewhere. The epi-
thelial covering is composed at first of a single layer
of cells, but later becomes stratified squamous in
character, consisting of two to four layers of len-
ticular cells.
Union of Amnion and Chorion. — In its origin and
early period the amnion is distinct from the chorion
and separated from it by a space, which is the extra-
embryonic part of the ccelom, and is homologous
and at first continuous with the pleural and peritoneal
cavities. After about the third month of pregnancy,
in man, the amnion comes into contact with the
Fig. 105. — Endothelioid Cells of
Outer Surface of Amnion (and
Inner Surface of Chorion). Silver
nitrate. X 1,000.
chorion, and the two membranes grow loosely together.
The precise character of the histological connection
between the amnion and chorion has not been well
made out.
Abxormalities of the Amnion. — Very rarely is
the amnion the seat of abnormal or pathological
conditions. Such abnormalities may arise in two
ways: from anomalies of development, or from
pathological processes.
Among conceivable anomalies of developmeni
the amnion might be: complete absence of the amnion;
incomplete development of the amnion from failure
of one of the amnion folds to grow; failure of tin
edges of the amnion folds to unite, leaving a hi
in the amnion and chorion; persistence of a coYd
or connection of tissue between the amnion and
chorion (the "amniotic cord"), such as normally
occurs in ruminants: incomplete expansion of ami
after closure, compressing the fetus. Some such
anomalies of development have been occasion;
observed in some animals, but in man they are
exceedingly rare.
A couple of human cases are recorded (Hamard)
in which there was a separate small amniotic pouch
around the abdominal insertion of the umbilical co
The reporter of one of these cases attributed the con-
dition to a rupture of the amnion (the chorion re-
maining intact) with retraction of the amniotic mem-
brane. Hamard, who reported tin- other case, con-
sidered the condition to be due in both cases to an
early anomaly in the development of the amnion.
It happens, rarely, that the primitive separation of
the amnion and chorion persists, in man, throughout
pregnancy, so that the fetus to the time of birth is
enveloped in two separate sacs, the amnion internally
and the chorion (united to the decidua) externally.
This constitutes a rare anomaly of the human after-
birth, of which the writer has reported one case and
cited seven other cases found recorded.
Small nodules or caruncles have been observed in
the human amnion, scattered about in considers
numbers, some flat and sessile, some more or less
pedunculated, and ranging in size from (hat of a pin-
head to that of a pea. Structurally, these are of two
kinds, one composed of epithelium, the other of con-
nective tissue. The epithelial nodules are commoner
and have little or no pathological significance; thy
are small aggregations of epithelial cells. The con-
nective-tissue nodules are composed of tissue like
that of the mesodermal portion of the amnion; they
are very rare, and have been observed in connection
with early fetal death.
Adhesions of the amnion to various parts of the
fetus, with resulting deformities of the latter, I
been observed. These adhesions have apparently
been due to inflammatory action.
Deficiency and excess in the quantity of the amniotic
fluid, with the resulting pathological consequences,
are considered in other articles.
Amniotic Fluid. — The amniotic sac is filled with a
serous fluid, the amniotic fluid or liquor amnii, in
which the fetus is immersed.
In quantity the amniotic fluid at full term in the hu-
man female may vary greatly, but ordinarily ranges
from about 500 to 1,000 c.c, averaging from 600 to
800 c.c. Abnormally there may be a deficiency (oligo-
hydramnios) or an excess (polyhydramnios) of
amniotic fluid, both conditions giving rise to certain
pathological conditions and dangers. The differences
in quantity at different periods of pregnancy are not
well determined; it is quite possible that the fluid
increases in amount during the earlier portion of
pregnancy, and diminishes in the later portion.
The liquor amnii is a serous or watery fluid, con-
taining in solution a small proportion of protein,
organic, and mineral substances. It is normally
clear, limpid, and transparent, colorless, alkaline in
reaction, and has a specific gravity of about 1.007 or
25S
REFER KM IE HANDBOOK OK THE MEDICAL SCIENCES
Amnion, Pathology
1.008. It contains from one to two per cent, of dry
solids, besides a small amount of adventitious epithe-
ligj cells, haii's, vernix caseosa, and occasionally
leucocytes. Proteins (albumin, globulin, mucin,
eto.) are present in the early part of pregnancy in
large amount (10.77 per cent, at four months, 7.67
per cent, at fix e months, (i.ti7 per cent, at six mont h ! ,
l, hi undergo a great decrease toward the end of preg-
cy, when there is only a small proportion present
(0.82 per cent.). The inorganic sails present are
those usually found in serous fluids, chiefly salts of
i, potassium, ammonium, and calcium. Urea
is present in slight proportion; t he aim unit is less early
in pregnancy and gradually increases, 0.03 or 0.045
per cent, being present at the ninth and tenth months.
(larked abnormalities in the physical and chemical
racteristics of the amniotic fluid have been rarely
encountered.
\- io the source from which the amniotic fluid
originates, there have been two opposing views: one
that it is derived (in mammals at least) from the
maternal tissues by transudation from the decidua
through the chorion and amnion; the other that it is
derived from the fetus, being the excretory products
of the urinary or sweat glands of the latter. The
view that the liquor amnii is of fetal origin has long
been held; but in opposition thereto and in support
of its maternal origin it has been urged by Minot that
the fluid in its composition does not resemble urine,
but is more of the nature of a serous fluid transuded
from the blood-vessels: that the fluid appears before
the urinary or other excretory glands of the embryo
are developed and while the urethral outlet of the
male is still imperforate; and that substances experi-
mentally administered to the mother have afterward
i found in the liquor amnii but not in the fetal
tissues. On the contrary, the fluid occurs in saurop-
sidan embryos which have lost their connection with
the maternal tissues; and as to the finding of dines
administered to the mother in the liquor amnii but
not in the fetus, it is possible that the substances
may have been entirely excreted and eliminated
from the fetus and discharged into the amniotic
fluid. Possibly in mammals the fluid is derived from
both the fetus and the mother — from the mother at
first and later from the urine of the fetus, but in
man, according to Grosser, the latter source is not
important.
The function of the amniotic fluid is largely to
ai end protection to the fetus in utero, by equalizing
the pressure on all parts of the fetal body and pre-
venting undue direct pressure of the uterine walls on
particular parts of the fetus. By maintaining a
symmetrical shape of the uterus, and protecting the
umbilical cord and uterine walls from excessive and
unequal local pressure, it obviates interference with
the umbilical, placental, and uterine circulation. The
amniotic fluid also permits the movement of the
fetus in the uterus, and prevents adhesions of the
fetus to the amnion or of parts of the fetus with one
another from taking place. The symmetrical dis-
tention of the womb by it facilitates and assists in
the dilatation of the os uteri during labor. It has
been also asserted that the amniotic fluid serves as a
source of water for the fetus; as the fluid contains only
a small proportion of solids, it could have little nutri-
tive value except as supplying water. It is well
settled that both mammalian and bird embryos
swallow amniotic fluid; but whether this is done as a
reflex act or for nutritive purposes, or whether the
placental circulation is incapable of furnishing suffi-
cient water to the fetus, is not known.
J. B. Nichols.
Revised by R. P. Bigelow.
Referexces.
Bonnet, R. (1901). Beitriige zur Embryologie des Hundes. 1.
Fortsetzung. Anat. Hefte, 51 (Bd. 16, Heft 2), p. 232-413.
Hill, J. P. (1910). The early development of the Marsupialia,
with pecial ace bo the native cal I ' i iru rivin
Q .1 Mir Sci., vol. hi., i>. I I ; i
Hubrechti A. V. W. (18 ESarly ontogenetic phei lena in
mammals and their bearing on ou pretal i ' I" phyli
"i the vertebrates. Quart. Jour. Mic Sci . '■"! liii . pp. I 181.
Hubrecht, V \. w 191 ! I ruhe I ntwicklungsstadien des
[gels und ihre Bedeutung fur die Vorgeschichte Phylogi
Amnions. Zool. Jahi b. Suppl 15 I estrchr
; , 19 771.
Keibel, I . 1 1910 a), "i oung human ova .'en I embryos up to the
formation ol the first primitive segment. Keibel and Mall's
Manual of human embryology, vi i . p 2] !_'
Keibel, F. (1910 6). The formation ol the germ layei md the
i. >n pri >l ilera. f.c, p 13
Lillie, !•'. It. il'.ins). The developmei thechick. Nen York:
Hell.
Minot, C. S. (1903). Laboratory texl "logy.
Phila Blakiston.
Schauinsland, If. (1902). Die I atwickelung der Eihaute der
Reptilien und der VogeL Hertwig's Handbuch, Bd. 1. Teil. 2,
p. 177-234.
Semen, Richard (1894). Die EmbryonalhtUlen der Monotre-
rnen mid Marsupialier. Zool. Forsch. im Australien, Bd. 2, J.fg.
1. (l)enk. .Med nat. Gessel. Jena), p. 17—74.
Si relit, II, (1902). Die EmbryonalhUllen der Siiuger und die
Placenta. Hertwig's Handbuch. Bd. 1, Teil 2, p. 235-270.
Amnion, Pathology. — The amnion is the inner-
most of the membranes inclosing the fetus. It is
continuous with the fetal epidermis at the umbilicus
and forms a sheath about the umbilical cord. The
exact manner of the development of the human am-
nion is as yet unknown, for in the earliest embryos
examined it forms a complete sac about the embryo.
It probably arises through the vacuolization of a por-
tion of the inner cell-mass, and is, therefore, a closed
cavity from the beginning. Morphologically, it is a
part of the body wall. It consists of two layers: an
epithelial one continuous with the ectoderm, and a
layer of embryonic connective tissue continuous with
the somatic mesoderm. The epithelial layer is on the
inside of the membrane, toward the fetus; the con-
nective-tissue layer on the outside, next to the chorion
and uterus wall.
The membrane is thin and translucent, containing
no blood-vessels, but is rich in large lymph spaces,
forming lacunae in which the mesodermic cells lie.
These spaces are connected by a system of very fine
lymphatics. In the earliest stage the tissue of the
.-minion consists of but two layers of cells (ectodermal
and mesodermal), between which lies a distinct space.
By the second month these layers have become united,
and the mesodermal portion has increased greatly in
thickness so that it is capable of being divided into
two parts, a thin mesothelial layer covering the cho-
rionic surface of the membrane, and the mesenchyma,
which makes up the greater part of the fully devel-
oped amnion. The tissues of the amnion do not
normally develop beyond an early embryonic stage;
the ectoderm preserves its one-layered structure, and
the mesodermal tissue remains embryonic in char-
acter. No blood-vessels or nerves have been found
in the human amnion. In the later months of
pregnancy, physiological degenerative changes occur
in both mesodermal and ectodermal nuclei.
The amniotic fluid (liquor amnii) is most probably,
for the greater part, a secretion of the amnion, but
the manner of this secretion or the source of supply
to the amnion is still unknown. In the later months
of pregnancy some portion of the fluid is undoubtedly
derived from the fetus. It is probable that the fluid
is secreted by the capillaries of the chorionic villi next
to the amnion, and is passed on through the amnion
by means of the activity of its cells. The fluid serves
as a source of water supply to the fetus; and, as a
mechanical protection against blows, shocks, pressure,
etc., it assists in maintaining a uniform temperature,
allows room for fetal movements, and aids in delivery.
The amniotic fluid has a specific gravity of about
1.003, and contains about one per cent, of solids, chiefly
259
Amnion, Pathology
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
albumin, urea, and grape sugar. It occurs in greatest
amount (J to % liter) at the beginning of the last
month of "pregnancy, but diminishes to about half
that amount at birth.
During the first two months there is a definite
space between the amnion and chorion, but in the
third month the amnion is gradually pressed against
the chorion, until an agglutination takes place be-
tween the two membranes through the formation of
a homogeneous fluid or gelatinous matrix containing
few cells. This union is always very slight, as the
amnion in all normal cases can be readily stripped
from the chorion. In the first three weeks the mem-
brane is somewhat removed from the embryo; in
the fourth week the rapid growth of the latter almost
entirely fills the amniotic cavity. During the second
month the membrane enlarges more rapidly, forming
a larger space for the amniotic fluid, but after the
fourth month it fits more closely about the fetus, from
which it is kept separated by the fluid.
The structure of the amnion is analogous to that
of the serous membranes, and there is consequently
a close analogy between the general pathology of the
fetal membrane and that of the latter. The tendency
toward plastic exudations with the formation of more
or less extensive adhesions, changes in the amount
and character of the secretion, etc., occur here as
upon other serous surfaces. The peculiar function of
the amnion and its close relations to the embryo lead,
however, to pathological processes peculiar to itself.
Hematoma. — An effusion of blood between the
chorion and the amnion may occur as the result of
accidental or voluntary trauma, or of diseased con-
ditions of the chorionic villi. Rupture of the umbili-
cal vessels may lead to the formation of a very large
blood clot between the two membranes. The small
extravasations from the capillaries of the chorionic villi
are relatively frequent and have little significance, but
large ones may strip the amnion from the chorion
over a large area, producing abnormal pressure upon
the embryo and alterations in the amniotic secretion.
Death of the embryo and abortion may result from
these causes, or the pressure upon the amnion may
produce adhesions between it and the fetus, leading
to disturbances of development. The small clots are
absorbed and replaced by new chorionic villi or fibrous
connective tissue, or they may become calcified.
Retrograde Changes. — The placenta and fetal
membranes at term must be regarded as senile struc-
tures, and certain retrograde changes must be
recognized as a part of their physiological decay.
These signs of age in the amnion begin as early as the
fourth month, and manifest themselves chiefly by
degenerative changes in the mesodermal nuclei, as
shown by diffusion of chromatin, hydropic and fatty
degeneration. Marked alterations in the shape of these
cells occur in the later months, but these changes
are probably dependent upon the tension of the
membrane.
Fatty Degeneration. — Minute fat droplets are very
frequently found in the mesodermal cells of the mature
amnion, and are to be regarded as physiological. In
retention of the membranes after abortion this change
may reach a pathological degree.
Hydropic Degeneration. — This may occur to a
limited extent in the mature amnion. In the rare
cases of edema of the chorion the cells of the amnion
become hydropic; and frequently, after death of the
fetus, both the cells and intercellular substance of the
mesenehyma undergo liquefaction.
Myxomatous Degeneration. — A myxomatous degen-
eration of tin' amnion may be associated with a similar
change in the chorion. The mesodermal cells be-
en branched, the intercellular substance more
gelatinous in character, and small mucin-containing
cysts may be formed in tin' mesenehyma. A hyper-
plasia of the mesodermal cells may precede this
change, and the amnion may be greatly thickened
throughout, or villous-like projections into the am-
niotic cavity may be formed. In very rare cases
these may acquire such size that they may be classed
as myxomata. These changes are of most frequent
occurrence in the earlier months of pregnancy and
usually follow the death of the fetus.
Colloid-like Change. — The mesoderm of the am-
nion not infrequently becomes homogenous and
hyaline, loses its cells and slight fibrillation, and
stains as colloid. The exact nature of this change is
not known. It occurs rather frequently after the
death of the fetus.
Hyaline Change. — Portions of the amnion may
undergo a proliferation of the connective-tissue cells,
leading to the formation of a more mature connective
tissue in which fibers are formed. The intercellular
substance acquires a true hyaline character and stains
rose red with Van Gieson's stain. This sclerosis in a
limited degree may be considered as a senile change,
but in the normal amnion it is never extensive, and
the membrane for the greater part preserves its
embryonic character. Any extensive hyaline change
must be regarded as pathological. The causes and
conditions of occurrence of this change are not known,
but it may occur after the death of the fetus or in
connection with syphilitic changes in the chorionic
villi.
Calcification. — Small plaques of calcification are not
infrequently found at full term upon the inner side of
the amnion, most frequently in the placental amnion.
These most probably are calcified masses of fibrinous
exudate or blood-clots. After the death of the fetus
lime salts may be deposited in the amniotic meso-
derm. This deposit may be preceded or accompanied
by fatty, myxomatous, or hyaline change. The
pathological significance of calcification, either of the
chorion or of the amnion, is probably very slight, and
the deposits of lime salts found in these structures
at delivery, unless very extensive, are to be regarded
as senile phenomena.
H ypcrplasia.— After the death of the fetus the amnion
may become much thickened from a hyperplasia of the
mesodermal cells. The new tissue formed usually un-
dergoes hyaline or myxomatous change or calcification.
Localized hyperplasias may appear as new growths.
The processes underlying these changes are practically
unknown, but hyperplasia of the amnion is associated,
at least in some cases, with syphilitic hyperplasia of
the chorionic villi.
Amniotitis. — Since the amnion contains no blood-
vessels, a primary inflammation in the ordinary
acceptance of the term cannot occur in the membrane.
But the tissues of theamnion may become involved in
changes which are so analogous in character and
sequelae to inflammatory processes that the use of the
term amniotitis may be accepted for practical reasons.
Edema and liquefaction of the intercellular substance
of the mesenehyma may occur; fibrinous exudates
may take place, leading to the formation of extensive
deposits of fibrin on the epithelial surface of the
membrane, and to the presence of strings and bands
of fibrin in the lymph spaces of the mesenehyma.
The gelatinous tissue connecting the amnion and
chorion may wholly or partially liquefy, its number of
wandering cells may be increased, and in very rare
cases pus may be formed between the two structures.
In these cases there is also present a small-celled in-
filtration of the chorionic villi. The umbilical cord
may show a similar infiltration. Purulent placentitis
is apparently very rare, and no well-studied ca es
have been reported. I have seen two cases of pla-
cental abscess resulting from infection of the placi
through attempted abortion. In these the space
b tween the chorion and amnion contained masses of
fibrin and collections of leucocytes; the amnion "as
swollen and colloid-like, containing fibrin strings and
large numbers of leucocytes.
In both of these cases the amnion was involved oy
260
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Amnion, Pathology
extension from the chorion ; and il is probable thai the
fibrinous exudates, which are rather frequently found
i,, ; , n , i upon the amnion, are the result of primarj
pathological changes in the chorion or decidua. The
existence of a primary amniotitis is yet to be proved.
Ii has been stated that in cases in which the am-
,n itic fluid is absent or greatly reduced in quantity,
the friction of the fetus upon the membrane Leads to the
formation of plastic exudates and adhesions. It yel
remains to be proved that such exudates are the
direct result of changes in the amniotic cells.
Iliai fibrinous exudates do occur has been con-
firmed by numerous observers, but we are as yet at a
to explain either their etiology or the manner of
occurrence. Through the organization of
fibrinous adhesions between the fetus and the amnion,
• us bands may be formed which may lead to the
production of marked abnormalities in the fetus.
These adhesions may also be formed between the
of the umbilical cord or between it and the body
of the let us. Amniotitis is also regarded as one of the
causes of hydramnion, the overproduction of the
amniotic fluid being explained as of the nature
ni acute serous inflammation. The proof of
this remains to be established, but the fact that hy-
dramnion and the formation of adhesions between
fetus and amnion have followed traumatic injuries to
mother may be taken as support of this theory.
The amnion is not a perfect protection in so far as
the entrance of bacteria is concerned. A number of
■ il amniotic infection have been reported. The
pyogenic cocci, the tubercle bacillus, and other organ-
isms are reported as having gained entrance through
this membrane. The amnion must be regarded,
therefore, as a possible portal of entrance for patho-
genic microorganisms.
In the later months of pregnancy the epithelium of
the fetal surface of the amnion may be torn away in
snips. According to Ahlfeld, this is the result of
fetal movements, the epithelium being scratched by
the finger and toe nails of the fetus. The amnion
may burst in the last months of pregnancy, the
ovum being preserved by the chorion. Through the
movements of the fetus, the torn membrane may be
mlled up into bands, which may become entangled with
the umbilical cord and constrict it even to the extent
of shutting off the fetal blood supply. Inflamma-
tory changes have not been shown to follow these
conditions.
Amniotic Bands and Adhesions. — During the early
stages of development of the membrane there may
occur total or partial union of the amnion with the
developing skin of the embryo. This union may be
the result of an imperfect development of the mem-
brane, in that it does not become differentiated from
the ectoderm, or fits too closely about the embryo,
BO that the amount of secretion is not sufficient to
separate the amnion from the surface of the embryo.
At the points of contact, union through direct fusion
or intergrowth may take place; or a plastic exudate
may be thrown out which unites the surfaces and
later becomes organized after the manner of plastic
exudates on any serous surface. It is still an unsettled
Question as to how far these adhesions between
the amnion and the fetus are to be referred to a pri-
mary failure of separation and fusion, or to inflamma-
t iry processes; but it is probable that in the majority
of cases they are primary defects of development.
Amniotic bands may also be produced by the rupture
of the membrane, and the rolling up of the torn
portions into bands or strings. In a case reported by
Tetzer a rupture of the amnion had evidently occurred
at an early month, with the rolling up of one portion
into a fold, while from the other portion complete
regeneration of the membrane occurred.
rhese adhesions play a great part in the formation
of monsters and malformations, and their teratologi-
cs! inportance can hardly be overestimated. Bam Is
and strings of union uol infrequently per i t at full
term, and their connection with the mi shapen por-
tion of the child leaves no doubt thai they bear a
direct causal relation to the malformation. The
structure of these hands ii uallj resembles that of the
amnion, containing no blood-vessels; and they may
be covered with epithelium. In other eases they
in be regarded as prolongations and outgrowths of
the fetal dermis, and con lain blood- vessels which arise
from those in the fetal skin. Very frequently the only
remnants of these bands al birth are short tags in the
skin of the child. These have a tructure similar to
thai of normal skin. Stretching of the adhesions
through increase of the amniotic fluid may lead to
their atrophy or to the formation of fibrous bands,
which contain few cells and no blood-vessels and
po i - no epithelial covering.
A total adhesion of the membrane to the embryo
causes marked disturbances of development of the
head and extremities. Partial adhesions occur most
frequently al the extremities of the embryo. An
abnormal tightness of the cephalic cap may lead to
marked malformations of the cranium, brain, Or face
(acrania, anencephalia, exencephalia, cephalocele,
cyclopia, arrhinencephalia, etc.) ; while abnormal tight-
ness of the caudal cap produces a deficient develop-
ment of the lower ext remities (amelia, phocomelia, etc).
Clefts of the thoracic and abdominal walls, failures
of closure of the dorsal and genital furrows, etc., are
aNo associated with deficient growth of the amnion.
Jt is impossible to say to what extent this association
is one of cause and effect or merely a coincidence.
If the amniotic fluid increases greatly in amount at
an early period, portions of the adhesions may be
separated and torn loose, floating in the fluid: or
remaining attached at the ends, they may become
stretched into fine threads and bands. These may
entangle the extremities of the fetus and affect, their
development through pressure and disturbance of
blood-supply, or even cause intrauterine amputations.
The variety of malformations produced in this way is
very great. Larger bands of adhesions may divide
the amniotic cavity into several chambers, and an
over-accumulation of fluid in one or several of these
cavities may result in the production of pressure
malformations (club-foot, flat-foot, etc.).
Hydramnion. — The pathology of an abnormal
increase of the amniotic fluid remains unsettled.
No constant pathological changes have been found
in the membrane in hydramnion. It is evident that
a number of factors may underlie this condition. It
may be acute or chronic. The latter may be due to
pathological changes in the mother (edema and
dropsy from nephritis, cardiac disease, etc.), hyper-
trophy of placenta and decidua, placental tumors, per-
sistence of chorionic vessels which normally undergo
obliteration, abnormalities of the umbilical vessels;
or to pathological changes in the fetus (increased
blood pressure, cardiac hypertrophy, obstruction of
the ductus Botalli, syphilitic cirrhosis, fetal tumors,
oversecretion of urine, as in the case of unioval twins,
especially when one is an acardius and the other a
maerocardius, ichthyosis and lymphangiomatous con-
ditions of the fetal skin, etc.). Deficient absorption
of the fluid may also lead to an overproduction of the
fluid. In some instances, as in syphilis, disease of
both the mother and child may contribute to an exces-
sive formation of the fluid. Chronic amniotitis is a
hypothetical cause. Acute cases following trauma to
the mother have been ascribed to the occurrence of an
acute serous amniotitis. Other cases of acute hy-
dramnion arise without apparent cause. These cases
are most common during the fourth and sixth months
of pregnancy.
OKgohydramnion. — A deficient formation of the
amniotic fluid may occur, but the pathology of the
condition is as obscure as that of hydramnion. It is
commonly found in cases in which extensive adhesions
261
Amnion. Pathology
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
exist between the fetus and the amnion, and in the case
of twins in which one sac may present a deficiency of
the fluid, the other an excess. Imperfect develop] unit
of the urinary apparatus (cystic kidney, imperforate
urethra, etc) has been regarded as a probable cause.
Abnormalities. — A large number of varieties of
abnormal development of the amnion have been
described. The most important of these, the bands
and adhesions, have been mentioned above. Defects
of the membrane, total or partial reduplication, for-
mation of multiple cavities, etc., may occur. The
etiology and the manner of production of these are
unknown. A very rare anomaly is monoamniotic
twin pregnancy. It is usually associated with acute
hydramnion.
Tuberculosis. — Primary tuberculosis of the amnion
has not yit been reported. In one case of placenta]
tuberculosis which I have seen, miliary tubercles
found in the chorion just beneath the amnion,
which was thickened and adherent, showing small-
celled infiltration and signs of connective-tis ne
proliferation. Tubercle bacilli have been demon-
strated in the armniotic fluid and on the surface of the
amnion. The rupture of chorionic tubercles through
tin- amnion has been reported by Schmorl.
Syphilis. — In syphilis of the fetus and fetal placenta
a hyperplasia of the amnion similar to that of the
chorion may take place. This may lead to a general
or localized thickening of the membrane, and i- asso-
ciated with various degenerative processes (fatty,
colloid-like, hyaline).
New Growths. — Cysts of the amnion have been
described. These were small and without clinical
significance. They were most probably due to a
myxomatous degeneration of the mesenchyma. Der-
moid cysts of the amnion have also been described.
They may be single or multiple and may contain
daughter cysts. They are most probablj- the result
of errors of development and not to be regarded as
true neoplasms. Small myxomatous projections into
the amniotic cavity occur rarely. They are either
localized hyperplasias or remains of adhesions which
have undergone a myxomatous change. The exist-
ence of true amniotic neoplasms is as yet doubtful.
Extrauterine Pregnancy. — In extrauterine pregnan-
cies, either before or after the death of the embi yo,
the tissue of the amnion may undergo extensive hyper-
plasia, ami become greatly thickened. It may con-
tain new blood-vessels, which penetrate it from the
external cyst wall. After the death of the fetus the
entire amnion may become calcified, forming a cal-
careous cyst wall, from which the mummified fetus
may be easily shelled out (lithokelyphos) ; or if
adhesions exisi between the fetus and the membrane,
these may also become calcified, while the remaining
portion of the fetus undergoes mummification
(lithokelyphopedion). Aldred Scott YVarthix.
Amoeba. — Ameba. A genus of simple protozoans
of the class Rhizopoda, order Gymnamaebida, which
have blunt or lobose pseudopodia and are without a
shell or test. Tlii- genus i< non-pathogenic, but some
nearly related forms like Entamoeba, Paramoeba, etc.,
are more or less important in connection witli cer-
tain intestinal and other diseases. See Protozoa.
A. S. P.
Amok. — A Malay word meaning "an impulse to
murder.*' .More commonly spelled annul.. Thi i
pression "running amuck" is used to describe the
action of a .Malay who suddenly and apparently with-
out reason rushes into the street armed with a kris,
bolo, or other cutting weapon and slashes or kills the
f i i — t person he meets and as many more as possible
until he is killed himself or put under restraint.
The motive for this performance and the mental stati
of the performer are QOl always clear to the white
man in the East. The cases seem to fall into several
categories.
1. In many cases it appears to be a genuine psycho-
sis, a form of epileptoid seizure, or of manic-depres-
insanity, the murderous outbreak being preceded and
followed by marked emotional depression.
2. In other cases the action appears to be a form of
religious frenzy carried out in pursuance of a vow.
3. In some instances it appears to be merely ar,
of desperation resolved upon by the native in i
sequence of domestic jealousy, gambling losses, or
other misfortune or disgrace. In this form it is said
to be an intentional mode of committing suicide,
indirect mode taking the place among the Malays thai
hara kiri has among the Japanese.
Each case must be dealt with on its merits.
W. \Y. Skeat says, "The act of running amuck is
probably due to causes over which the culprit
3ome amount of control, as the custom has now died
out in the British possessions in the Peninsula, the
offenders probably objecting to being caught and
tried in cold blood." J. F. Leys.
Amphistomum. — A synonym for Gastrodiscua, a
genus of flukes belonging to the order Malacoi
family Amphistomidos. G. hominis has been four
the colon and cecum of cholera victims. It i- an
occasional parasite in man. See Trematoda.
A. S. P.
Amputation. — Amputation (Latin, nmputare. to
cut away) is a term generally used to designate tin-
removal by surgical operation of a portion or the
whole of an extremity. In a wider application tin-
word is still used with reference to separations of
other prominent or projecting portions of the body,
-u«h as the mamma, penis, and cervix uteri. In this
article amputations of the extremities alone will be
considered. Older writers, and many of the pn
time in Germany and France, still further res
tin- term amputation to the operative removal of a
limb in its continuity, as in amputation through
forearm or thigh, while they designate a- "disarticu-
lations," "enucleations," the removal of a member
in its contiguity {i. e. through the joint),
tinction is properly ignored by English and Amei
writer-, since many operations present combinations
of the two procedures (Syme, Pirogoff).
Historical Sketch. — The helplessness of sui
of ancient times to cope with profuse hemo
ally accepted as the sole admissible explanation
of the fact that, for nearly two thousand years, from
the time of Hippocrates to that of Pan'-, amputal
were practically limited to the removal by cutting
through the dead tissues of gangrenous extremities.
The only reference to amputations in the Hippocratic
writings is as follows: "In case of fractun
bones, when strangulation and blackening of the parts
lake place, at first the separation of the d
living parts quickly occurs, and the parts speedily
drop off, as the bones have already given way ;
when the blackening (mortification) takes place .
the bones are entire, the fleshy parts in this can
quickly die, but the bones are slow in separating ai
the boundary of the blackening and where the b<
are laid bare. Those parts of the body which arc
below the boundaries of the blackening ate to be
removed at the joint as soon as they are fairly d
and have lost their sensibility, care being taken not
to wound any living part: for if the part which i-
cut off give pain, and if it should prove to lie
quite dead, there is gnat danger lest the pal
swoon away from the pain, and such swoonings are
often immediatelv fatal/' 1
The anatomical labors of the Alexandrian school
could not have been without influence on the status
of surgery. This we see illustrated in the surgical
262
REFERENCE BANDBOOK OF THE MEDICAL SCIENCES
Amputation
writings of Celsus, who unquestionably was the first
to suggest amputations in the living tissues above the
line thai separates them from the sphacelus. While
lie admits that patients frequently succumb during
the operation from hemorrhage, there can be no
ition I .ut that Celsus was acquainted with the
■ usefulness of the ligature. In Ids chapter
on wound-, he advises that "if these [plugging the
wound, compression, and mild caustics] do not pre-
vail against the hemorrhage, the vessels which dis-
charge the blood arc to he taken hold <>f and tied in
places, aboul the wounded part, and cut through,
they may both unite together and neverthele
have their orifices closed."
1 1 seems scarcely possible that the theory, if not the
practice, of surgery could have developed to the
ion designated, unless a less difficult procedure
for the ligation of a bleeding vessel in an open wound
had been likewise perfected, particularly in view of
the facts that Archigenes had introduced the tourni-
quet, that every writer of the Greek and Arabian
schools makes repeated reference to the use of the
ligature for the relief of hemorrhage, and that torsion
of bleeding vessels was advised under certain circum-
jtances by Galen, Rhazes, and Paulus ^Egineta. It
is quite certain, therefore, that the proper mam
incnt of hemorrhage was not entirely lost sight of
in the darkest period of the. history of medicine.
Indeed, the indications for amputation seem to have
a more elucidated fcr a time after the labors of
is. Thus Archigenes enumerates, among the
circumstances which require amputation, "the
presence of intractable disease, such as gangrene,
necrosis, putrefaction, cancer, certain callous tumor-,
and sometimes wounds inflicted by 'weapon-."
Nevertheless, the advanced position occupied by this
writer was soon receded from. For a thousand
years from the time of the latter authority retro-
sion was the fate of amputations as of surgery
in general. Where recourse to amputations was
unavoidable, the most barbarous methods wi i
i ted to. The Arabians operated with red-hot
knives. Throughout the dark ages the actual cautery
applied to the bleeding stump, or this was covered
with boiling oil, or molten pitch, or sulphur. More
cruel than any other was the practice of Guy de
Chauliac, who in the fourteenth century bound a
cord with sufficient force around a limb to insure its
ival by gangrene. While amputations were
dreaded, until within the last three centuries,
alike by surgeons and patients, it is certain that this
operation was not called for so frequently as it is
now. Lacerations as terrible as those produced by
machinery and firearms, which for the most part
e the amputating knife into the surgeon's hands.
could hardly have been often encountered prior to
the discovery of gunpowder and steam.
While Gersdorff of Strasburg probably had used
the ligature in amputation wounds for some year-, it
remained for the genius of Pare to give to amputations
a comparatively firm position among surgical opera-
tions. After nearly thirty years of experimentation
and practical test of the ligature, he published results
which should at onfee have revolutionized the surgical
practice of the time. With the retraction of the skin
and soft parts above the site of operation, to insure
sufficient tissue to cover the divided bone, and the
of a constricting band, Pare had adopted all the
preliminary means which are deemed necessary
to-day by many for making a circular amputation.
Grasping the open mouths of the arteries with curved
forceps, he closed them with a double thread, and the
wound with three or four sutures. Likewise was
Pare the first who clearly taught the value of the
ligature en masse in refractory hemorrhages. "In-
1 by God with this good work," it would seem
that Pare should have speedily moulded the prac
of his contemporaries. That this was not the case
is evident from the great opposition encountered
by him, and that it required nearly two centuries for
the ligature to supplant the actual cautery as a hemo-
static measure. Although Fabricius Hildanu
Germany, Dionys in France, and Richard Wiseman
in England (last half of seventeenth century) make
mention of the ligature, they in nowise recommend
it. It is not remarkable, therefore, thai in the seven-
teenth century, Botal did not hesitate to perf
amputation by means of two hatchet-, one placed
immediately below the member and the othi r loaded
with leads let fall upon it ( \ elpeau), and that even as
late as 1 70 1 W. Sharp saw cause for complaint at the
restricted practice of ligaturing blei -el-.
Indeed, it is questionable whether the ligature of
Is in amputation wounds could even then have
obtained a firm foothold without the assistance given
to it by the tourniquet. The origin of the latter is
enshrouded in mystery. There can be no doubt
that II. \iiii < lersdorff made use of constricting bands.
It appears that the idea of provisional compression
of the artery, as now practised, was introduced inde-
pendently by two surgeons of diffi i o mtries at
about the same time. Morel, in France, and Young,
in England, each devised a tourniquet for the arrest
of the circulation. It remained, however, for the
great J. L. Petit (1718) to elaborate the principles of
arterial compression and to construct an instrument
from which those now in use differ but little. Finally,
with the introduction of digital compression and the
use of the Esmarch bandage, the appliances for the
control of hemorrhage appear as perfect as human
ingenuity can make them.
The most dangerous feature of an amputation being
controlled, attention could be directed toward the
securing of a more rapid cure and a useful stump.
When, in ancient and medieval times, an amputation
terminated well, a year elapsed before the wound had
healed, and a conical stump usually resulted. In
1678 a friend of Thomas Young expressed his great
surprise that larger extremities could be removed
in such a manner that the wound was firmly cica-
trized by first intention in three weeks. The circular
incision for amputations being the one most quickly
implished and intuitively resorted to by the
earlier operators, was the one generally adopted.
Although Celsus clearly indicates the necessity of
completely covering the ends of the bone with the
soft parts by dividing it upon a higher level, yet it
was but rarely accomplished. This will not appear
remarkable when we consider how the operation
was described a- late a- the -ixteenth century by Hans
von Gersdorff, the meat barber-surgeon of Strasburg:
"And when you will cut him, order some one to draw
the -kin hard up, and then bind the skin with your
bleeding tape tight. Next tie a simple tape in front
of the other tape in such a way that a space is left
between the two tapes of one finger's breadth, so
that you may cut with the razor between them. In
this way the cut is quite reliable, goes easily, and
makes a perfect stump. Now- when you have done
the cut, take a saw and separate the bone, and after
that undo again the bleeding tape and order your
assistant to draw the skin over the bone and the
flesh, and to hold it hard in front. You should have
a bandage ready of two fingers' breadth; it should be
moistened beforehand, so as to be wet through, then
bind the thigh from above downward to the cut. that
the flesh may protrude in front of the bone, and then
bandage this too." Amputation by a single circular
incision down to the bone has since been revived by
Louis and Brunninghausen in the beginning of our
century, and has been advised by Esmarch recently
in emaciated and exhausted subjects.
Early in the last century J. L. Petit originated the
first decided improvement upon the ancient method
of practising the circular incision. With the I
circular incision he divided the skin and subcutane-
263
Amputation
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
ous cellular tissue alone, and after reflecting them
divided the muscles upon a higher level by a second
circular sweep of his concave knife. Cheselden and
Sharp in England, and Heister in German}-, independ-
ently devised and became adherents of this improved
operation, by which the end of the bone could be
completely covered. To still further improve the
stump Edward Alanson, after the customary circu-
lar incision through the skin, sought to give the wound
a funnel shape by applying the knife obliquely and
dividing the muscles in the form of a hollow cone.
Subsequent operators finding, however, that the
wound thus made was not conical, but spiral, and
that it entailed conditions unfavorable to primary
union, this modification failed to get a permanent
foothold among recognized operations. A better and
simpler means to produce a conical wound was pro-
duced by Desault, who, after division of the skin,
divided the superficial and deep muscles on different
levels by two separate sweeps of the knife.
Meanwhile flap operations had been devised. Al-
though, according to Yelpeau anil Lacauchie, Helio-
dorus had described amputation of superfluous fingers
by the double flap operation, the knowledge of this
method was entirely forgotten. R. Lowdham of
Exeter in 1(579, introduced the flap operation for
amputation of the leg by making a lateral flap on one
side, a semicircular incision on the opposite side com-
pleting the operation. The incision was made from
without, and included the skin and muscles of the
calf of the leg. Although, as already indicated,
Young (currus triumphalis) most highly lauded the
results achieved by the new method, it was ignored
until Peter A. Verduyn of Amsterdam (1696),
practised a similar amputation, transfixing the soft
parts with a double-edged knife. Sabourin and Gar-
engeot adopted the method by transfixion. Other
modifications rapidly followed the first steps of the
new method. H. Ravaton (1750) and Vermale (1767),
surgeons of the Palatinate, recommended the for-
mation of double flaps, while Charles Bell (1807) and
the elder Langenbeck (Gottingen) again practically
returned to the older operation of Lowdham. ( )n
the other hand, Sedillot, in 1841, and Teale, in 1858,
greatly improved the double-flap operation. Sedillot
formed two musculocutaneous flaps, in which only
a small part of the flesh was included, and divided
the remaining soft parts by a circular incision. A
number of operators advised that the flaps be of
unequal size, lest the cicatrix become adherent to
the divided end of the bone. Finally, Thomas
Teale of Leeds (185S), devised the anteroposterior
rectangular musculocutaneous flaps. Scoutetten
of Metz in 1827, combined into what is termed the
oval method a number of operations which had been
previously employed by the elder Langenbeck,
Larrey, Guthrie, and others. According to Scoutet-
ten, this method, which is best adapted to disarticu-
lations, is supposed to possess the advantages of both
flap and circular operations. While, on the Conti-
nent, this operation has found a small band of fol-
lowers, it has never met with general favor.
Indications. — Amputation has been termed the
"last resource" and the "opprobrium" of the sur-
geon. Recourse to this radical measure signifies the
surgeon's unbelief in his efforts to restore to useful-
ness an injured limb; it is his confession that, in the
combat with disease, he has been conquered, or that
his ability to rectify a congenital deformity is limited.
To recognize the limits of his powers to save a part
requires the keenest judgment of the surgeon, and
it is remarkable how, in the history of amputations,
this has swayed between the extremes of radicalism
and conservatism. It is, of course, not remarkable
that, prior to the introduction of the ligature, ampu-
tations were, for the most part, confined to the re-
moval of pails which were all but removed by an
accident itself, or were already the seat of gangrene.
On the other hand, the multiplication of methods
of amputation, during the eighteenth and the early
part of the nineteenth century, went hand-in-hand
with the most reckless condemnation of limbs. The
voices of Gervaise and Boucher, which were raised
in defence of conservatism, were unheard, and even
the remarkable reports of Bilguer were unable to
stay the useless sacrifice of limbs. Bilguer, the fal
of conservative surgery, and surgeon to Frederick
the Great, could report, in 1763, 169 compound
fractures successfully treated by conservative meth-
ods. Among these were nine of the femur, forty-
two of the leg, nineteen of the ankle, nine of the head
of the humerus, sixteen of its shaft, twenty-two of
the elbow, nine of the forearm, three of the wrist,
and three of the hand. The distinction which these
statistics brought to Bilguer was materially dimmed
by the fact that he published his successes alone, and
that for a while he denied amputations a place among
justifiable operations. The incredulity of surgeons
in these results and extreme views was one of the
causes which prevented them for many decades from
resl ricting the indications for an amputation. Faulty
methods of treating wounds and an insufficient
appreciation of the dangers attending major amputa-
tions were likewise potent factors in so frequently
forcing the amputating knife into the hand of the
surgeon. The introduction of immovable dress-
ings, the startling statistics of Malgaigne, published
in 1842 and 1848, the favor with which excisions
were received, and, above all, the advantage of anti-
septic and later of aseptic wound treatment in the
widest sense, were the chief causes in finally deter-
mining the indications for amputations as they are
now generally accepted.
In general terms, it is proper to resort to amputa-
tion when the sacrifice of a part, which is hope!
diseased, is necessary to the preservation of life or the
enjoyment of its various functions and duties. It
is well to remember that " the vast majority of people
would prefer living with three extremities to being
buried with four." While in each individual case
the danger and advantages of an operation are to be
carefully balanced, conditions may arise which may
make an operation imperative which but a few clay-
before seemed uncalled for.
Contraindications to amputation, either tempo-
rary or permanent, should also be clearly recognized.
Among the former, particularly as to amputations
for injury, should be considered extreme shock and
exhaustion from excessive hemorrhage. As perma-
nent contraindications, such conditions should be
recognized as will preclude the possibility of attain-
ing the object of all operative procedure, viz., the
restoration of the patient to health. Such indica-
tions are, first, so extensive an involvement, by
disease, of a limb and contiguous parts that ampu
tation will not suffice for its complete removal
and, second, complications on the part of important
internal organs from injury or disease, under
which circumstances an amputation would not on!.
be useless, but would probably curtail life.
While it is an axiom that amputation should be re-
sorted to only under circumstance's in which no other
means will avail, there is no little difficulty in deter-
mining the conditions that call for this extreme
measure. They may be most readily investigated by
considering them under the three general headings of
injuries, non-traumatic lesions, and deformities.
Injuries. — (a) When, from accident of any kind, B
limb is entirely severed from its connection, or the
soft parts are so mutilated that it is attached by skin
alone, or by it and pulpified flesh, an amputation is
absolutely indicated. Wounds from circular sai
railroad accidents, extensive gunshot lacerati
afford numerous instances in which the amputal
consists in nothing more than trimming off the
ged edges of the wound, leveling the inequalities of
264
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Amputation
the protruding fleshy masses, and placing the stump
in tin' best condition for speedy repair. To thi^
class of injuries belong those cases, caused by rail-
iad trains, heavily loaded wagons, entanglement
in machinery, etc., in which the soft parts are exten-
sively torn from the bone, the muscles being pulpi-
fied, the blood-vessels and nerves lacerated. It is
remarkable that in instances of this character the
skin itself may remain unbroken, while all that it
ers has been practically crushed. The shock
i ading the tearing off of a leg or an arm is usually
: scessive thai a formal operation with attendant
of blood must be dispensed with,
i In the other hand, it is a well-established fact that
fingers, portions of the nose and ear which had been
almost completely and even totally separated by an
incised wound uncomplicated by contusion, have
been permanently replaced by the careful use of
sutures. In amputating crushed parts of the hand
ervatism is particularly desirable. Every part,
e\ en of a finger, that can be sewed may be sen iceable.
When a doubt exists as to the viability of a crushed
part of a hand, an effort to save it should be made.
In the event of death or uselessness of the part if saved
a secondary amputation can be made. For this
reason amputations for crushed wounds of the fingers
and hand should in most cases be atypical.
(b) Extensive hums and circumferential lacerations
of only the skin and subcutaneous cellular layers
may, in rare cases, require the sacrifice of a limb.
When, from the depth of a burn, it becomes evident
that the reparative process must be suppurative in
character, and continue for many months, and when
finally ended leave a disfigured and practically use-
less member, it is usually better at once to amputate
than to expose the life of the sufferer to the dangers
of septic infection or exhaustion. Extensive strip-
ping of the integument from a member may likewise
impel the surgeon to operative interference. A most
interesting case of this character is recorded by M.
Schede, 3 in which an entire arm was caught in a cog-
wheel and stripped of its integument, the muscles
of the arm and forearm being laid bare as in a care-
ful dissection. Although amputation at the shoulder
was successfully resorted to and the acromion re-
moved, the integument was insufficient for the closure
of the wound.
(c) The simultaneous injury of the main artery and vi in
of an extremity has usually been considered an indi-
cation for amputation, since it almost invariably
results in its mortification if conservatism is practised.
This has applied particularly to wounds of the femoral
artery and vein. The advisability of an operation in
all such cases must, however, be seriously questioned,
since instances are multiplying in which with neo-
plasms, several inches of the main vessels of the limb
nave been removed without resulting in its death.
When the vein alone is slightly injured, it is far pref-
erable to trust to a properly applied lateral ligature,
or if it is completely divided, an attempt to save the
limb should be made by ligation of the accompanying
artery. Quite recently a case has been recorded by
Pilcher in which an incised wound of both femoral
artery and vein was successfully treated by double liga-
tion of both vessels. On the other hand, amputation
may be required for the relief of traumatic aneurysms
or those of spontaneous origin which have become
diffused. Particularly may ablation of the thigh
be preferable to other plans of treatment of aneurysm
of the popliteal and of the deep arteries of the leg in
persons of advanced years. In cases of subclavian
aneurysm exartieulation at the shoulder has likewise
been successfully performed as a modified distal liga-
tion. Finally, secondary hemorrhage after injuries
from whatever cause, when other measures have
failed, can be relieved alone by the sacrifice of the
limb. Since, after ligation in continuity of an artery,
the secondary hemorrhage most frequently comes
from the distal end of the vessel, it is apparent why
amputation is often successfully practised. Rei
advances in the surgery of the blood-vessels has made
mi ervatism in these injuries practicable. Arterior-
rhaphy and aneurysmonhaphy have in many ca
done away with the necessity for primary amputation
for injury Of eil her artery, vein, or both.
() Inflammatory conditions of the bones and
joints which cannot be relieved by less radical meas-
ures may rarely make an amputation imperative.
Acute osteomyelitis, when unrelieved by trephining,
when affecting only a single bone, must be con-
sidered a condition requiring this radical interference.
Necrosis which involves the entire thickness of the
shaft of the bone, as for example a part of the
humerus, or the femur, and especially when repeated
necrotomies have proved to be unavailing, occasionally
requires the sacrifice of a limb. In extensive tuber-
culosis of the articular ends of the long bones, or of the
carpus and tarsus, when from the depraved condition
of the patient excision is unfeasible, amputation is
compulsory. The improved methods of dealing with
suppurative and destructive affections of joints by
immobilization, by the injection of formalin or, if
need be, by resection, have happily reduced the
number of cases calling for amputation from these
causes to a minimum.
(c) Extensive circumferential ulcerations of the
leg, which sap the strength of the patient through
hemorrhage or profuse suppuration, or which unfit
him for the vocations of life, not unfrequently render
amputation advisable. This also applies to cases of
true and spurious elephantiasis, in which milder
measures have proven of no avail.
(d) Tumors of benign and malignant character,
when from their size they destroy the usefulness of a
limb or endanger life, are well-recognized indications
for amputation. The neoplasms most frequently
demanding the latter are carcinomatous degenerations
of chronic ulcers or epitheliomata developing around
a sequestrum, or an osteosarcoma of the articular
ends of the long bones. Under all these conditions
amputation offers a better chance for permanent
recovery than does excision. For the central giant-
celled sarcomata, curett ng or excision should be
tried repeatedly before amputation is resorted to.
The rule which applies to the management of neo-
plasms generally, that an operation must lie refrained
from unless all of the diseased tissue can be removed,
is particularly to be remembered before an amputa-
tion is determined upon for the relief of a tumor of an
extremity. The bearing of amputation upon certain
traumatic affections of the blood-vessels and upon
special spontaneous aneurysms has already been
referred to. Congenital telangiectases likewi e exacl
amputation when rapidity of growth endangers life
or when other plans of treatment have been unsuc-
cessful.
Deformities. — (a) Supernumerary fingers and toes
are proper cases for removal, and the operation may
be safely practised six months after birth. This
early removal assures a better form of hand or foot
and a diminutive scar. Cases of club-foot which
have been altogether neglected or badly managed,
and which, from extensive ulceration or infli id
bursa-, entail great suffering upon the patient, not
infrequently can be relieved by amputation only.
But in early life no case of talipes is of sufficient
severity to warrant the removal of the foot.
(6) Cicatricial contractions of tin- joints, associated
with great wasting of the muscles, from extensive
burns; great deformity and uselessness of a limb
from neglected dislocation (foot or ankle), may call
for an amputation. For these and similar ca < .
amputations of expediency may occasionally be
required, but the surgeon should carefully weigh all
factors in the case before subjecting his patient to
the risks of an operation for the relief of a condition
which in itself is only a burden and not a source of
danger. To this category belong limbs useless
In low the knee from infantile paralysis. Such legs
are often burdensome from one cause or another
(sensation of cold, proneness to superficial ulceration,
etc.) and, since they are useless, it is probably better
to amputate them and substitute an artificial Hint).
The paralysis alone is not an indication for amputa-
tion, since marvelous results may lie obtained from
tendon grafting and its various modifications.
Time fob Amputation. — When, in consequence of
an injury, an amputation is indicated, the proper
time for performing it must be considered. While
the patient is still suffering from collapse, or even
exhaustion from excessive hemorrhage, it would be
sealing his fate to resort to an operation. At least
moderate reaction may ordinarily be awaited, and
hastened by the use of morphine, transfusion of salt
solution with adrenalin, and possibly the strapping
of the abdomen to raise the blood pressure. A
moderate degree of shock is no contraindication to
immediate amputation. Indeed, this may put an
end to the shock by removing the afferent painful
impulses from the dragging of the mangled limb, the
added pain of the tourniquet, and the oozing.
Wil h ether, or preferably gas-oxygen anesthesia com-
bined witli cocainization of the larger nerve trunks,
the amputation does not increase the shock but tends
to end it. For from twelve to seventy-two hours,
rarely more, an injured part may appear to remain
unchanged, after which the evidences of infection
or of tissue necrosis (gangrene) may become manifest.
Primary. — All amputations practised prior to the
advent of these changes are designated primary.
Since the time when these changes supervene varies
from one to three or four days, according to a multi-
tude of circumstances, foremost of wTiich is the
character of the wound and the extent to which it
can be maintained aseptic, no absolute limit can be
fixed to the time when an amputation should no
longer be classed among the primary amputations.
With very few exceptions, surgeons of the present
day recognize the necessity for immediate amputation
in every instance in which conservatism cannot be
practised. The diversity of opinion which has pre-
vailed on this subject has been great. Among the
advocates of primary amputation may be enumer-
ated Du Chesne, Wiseman, Pott, Percy, J. Bell,
Larrey, and Guthrie; among its opponents, Faure,
Hunter, and, in the last quarter of the last century,
.1. NeudOrffer. Paul, and Cross. The extensive ex-
periences of Guthrie and Larrey have finally con-
vinced surgeons of the advantages of early, as com-
pared with late, amputations. Of 291 primary
267
Amputation
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
amputations, 107 recovered, twenty-four died, and
160 remained under observation. Of 551 secondary
operations, 170 recovered, 265 died, while 116 re-
mained under treatment (Guthrie). The accumu-
lated experiences of the Crimean and Franco-Prussian
wars, and the vast statistics of our Civil War, indorse
the prevailing practice of resorting to early ampu-
tations. In the statistics of Otis, there were in
3,259 primary amputations of the arm, 602 deaths,
IS. 4 per cent, mortality; in 902 intermediary ampu-
tations of the arm, 302 deaths, 33.4 per cent, mor-
tality; in 411 secondary amputations of the arm,
114 deaths, 27.7 per cent", mortality; in 1,914 primary
amputations of the lower third of the thigh, 927
deaths, 48.7 percent, mortality; in 676 intermediary
amputations of the lower third of the thigh, 459
deaths, 67.9 per cent, mortality; in 207 secondary
amputations of the lower third of the thigh, 100
deaths, 48.3 per cent, mortality. The obvious rea-
sons for tin' better results which follow early opera-
tions are that they are made at a time when the con-
stitution has not yet been exhausted by protracted
suppuration and high temperatures, and that they
leave wounds which can be kept free from septic
infection.
Intermediary. — The second date at which an amputa-
tion might be forced upon the surgeon is that during
which the severest local and general signs of inflam-
mation are present. The damaged limb has become
red, edematous, and painful. From the wound there
issues a sanious, malodorous fluid, and a more or less
extensive sloughing of the tissues adjacent to the
wound ensues. Associated with these local conditions
are an acceleration of the pulse, elevation of the
temperature, often to a dangerous degree, headache,
dry tongue, scanty urine, and muttering delirium.
Unless the patient succumbs to the paralyzing influ-
ences of excessive temperatures, his condition be-
comes gradually ameliorated in from five to fifteen
days. As the discharge of scanty serum is followed
by a free secretion of pus, the gangrenous parts are
exfoliated, and the swelling largely subsides; the
fever and acceleration of pulse are reduced; the
tongue regains its normal moisture and color, and a
comparative degree of comfort is enjoyed. Ampu-
tations practised during this stormy period of the
clinical history of an accident have, after the desig-
nations of Boucher and Alcock, been called inter-
mediary. Since they are made at a time when the
damaged part and the system at large are in the very
worst condition for operations, it is not remarkable
that such amputations offer the worst prospects for
recovery. Although the mortality following such
amputations must, therefore, be very much greater
than that following primary or late amputations,
cases will arise in which the very gravity of the local
and general phenomena, such as recurrent hemor-
rhage, impending gangrene, or septicemia, will neces-
sitate the speedy removal of the limb, as the last hope
of deliverance. With improved methods of avoiding
wound infection, in patients who are already septic,
the terrors of so-called intermediary operations
have been largely laid, although no statistics are
available in proof. As an illustration may be cited
the frequency with which success attends high ampu-
tations for rapidly spreading diabetic gangrene and
that in the presence of a high degree of acidosis.
Secondary. — With the subsidence of the grave con-
stitutional symptoms and the advent of profuse sup-
puration begins that period when, if amputations are
performed, they are termed secondary. It has already
been seen that the prospects for recovery after amputa-
tions in this period are less promising than after those
of an earlier period. An equally strong objection to
waiting for this period is that more of a limb must
generally be sacrificed than by an early operation.
Thus Guthrie observes that " When an amputation is
delayed from any cause to the secondary period, a
joint is most frequently lost: for instance, if a leg be
shattered four inches below the knee, it can fre-
quently be taken off on the field of battle and the
joint saved. Three or four weeks after, the joint will in
all probability be so much concerned in the disease
that the operation must be performed in the thigh;
the same in regard to the forearm and hand, and the
upper part of the arm with the shoulder." Notwith-
standing the drawbacks attending secondary ampu-
tations, certain circumstances frequently make them
imperative. Continued fever, impending exhaustion
from excessive and protracted suppuration, and
evident uselessness of the limb, even if saved, may
force the knife into the hand of the surgeon, after
much valuable time has been lost through an error of
judgmenl on his part, or a procrastination on the
part of friends.
Anesthesia. — Many minor amputations of the
fingers, of the toes, and parts of the hand and foot
can very easily be performed under local anesthesia
with cocaine, tropococaine, or novocain. In the
same way by nerve blocking with cocaine, a badly
lacerated limb can be removed by trimming the parts
without resorting to an immediate formal amputa-
tion. In almost all major amputations, however, a
general anesthesia must be induced, and the choice is
an important one. Chloroform should practically
never be given, ether being preferable because it is
a cardiac stimulant. In cases of severe shock, which
so often attends the mutilations of the extremities
caused by machinery, the anesthetic should be of
gas-oxygen. Unfortunately it is a method that
cannot be used outside of well
A equipped hospitals and is a dan-
gerous one, except in the hands
of an expert anesthetist.
Preparations. — Before begin-
ning an amputation it is essential
to make such preparations for it
as are required for every major
operation. If possible, the ampu-
tation should be made in the early
part of the day, in order that if
there be much hemorrhage subse-
quent to the operation its source
may be looked for without artifi-
cial illumination. It can be most
satisfactorily performed on any
operating table, or, in the absence
of this, on two kitchen tables
placed end to end. The instru-
ments necessary for major ampu-
tations are: 1. An Esmarch elastic
bandage and strap for the produc-
tion of anemia of the part to be
removed. 2. A suitable tourni-
quet. 3. Amputating knives of
various lengths and widths, with
at least one double-edged blade
(catlin) (Fig. 106). 4. One large
and one metacarpal amputating
saw. 5. From six to twelve hemo-
static forceps. 6. A bone-cutting
forceps, and a lion-jawed forceps.
7. Ligature and sewing materials,
drainage tubes, needles, and an
abundance of hot water.
Fig. 106. — Catlins. The preparations which are to
be made for the after-treatment,
although they are necessarily a preliminary to the
operation itself, will vary according to the plan to
be adopted, and will be considered at some length
hereafter.
While a finger or toe can be removed by a surgeon
with only such aid as a layman can give, at least
three assistants are required for every larger amputa-
tion. The duties of these should be first clearly
defined by the operator, lest valuable time be lost
•jes
REFERENCE HANDBOOK OF Till-: MEDICAL SCIENCES
Amputation
during the operation. The undivided attention of
one must be given to inducing and maintaining anes-
thesia. The second is to support the part to In-
removed, after which he can be entrusted with the
ligation of the vessels. The duly of the third should
be confined to controlling the circulation of the limb
above the seat of operation, and eventually to retract
the flaps. These details arranged, the patient is
anesthetized and brought into such a position that
the limb to be removed is everywhere accessible. Tin-
part to be removed must now be carefully wrapped
in towels, the entire limb thoroughly cleansed with
soap and brush, and the hair removed from the part
wln-re the incision is to be made. The skin is then
sterilized with tincture of iodine or a ten per cent,
solution of iodine in benzine. The surgeon is then
ready to take the final and most important prelimi-
nary measure for the amputation, that by which he
intends to control the circulation of the limb and
reduce the loss of blood to a minimum.
Prevention of Hemorrhage. — There are various
methods by which the circulation may be more or
less controlled during an amputation, and they are
of sufficient importance to
justify a detailed considera-
tion. To prevent hemorrhage
the surgeon can choose be-
tween tourniquets, digital
compression, and the Es-
march elastic bandage, or
combine the latter with one
of the other two.
T ourniquet.— From the time
of Morel the ingenuity of sur-
geons has been taxed to devise
an instrument which will
safely compress the main
artery of a limb above the
point where an amputation is
to be practised. Of the many
instruments introduced, only
a few have been able to gain
general recognition. The
oldest of these is the Spanish
windlass or garrote of Morele,
which consists of nothing
Fig.107.— Morel's Tourniquet. more than a wide band (Fig _
107, g) of an unyielding ma-
terial (muslin or linen), firmly drawn around the
limb and tied. Over the main artery and at a point
diametrically opposite, there are inserted under-
neath it compresses of linen, a piece either of
thick leather or of pasteboard (p). At a point
opposite the artery a firm rod (s, s) is introduced
underneath the encircling band and is then turned in
such a manner as to shorten the latter, and thus the
compression of the main artery is effected. Owing to
the simplicity of its construction, the garrote of Morel
stands without a peer in cases of emergency in civil
as well as military practice. It has, however, one
very objectionable feature which renders its use a
matter of necessity rather than of choice. Not-
withstanding the use of the pads of linen or leather
already referred to, veins, arteries, and soft parts are
compressed to an almost uniform degree; hence exten-
sive venous hemorrhage and insufficient retraction
of the muscles follow. A great improvement on the
windlass is the tourniquet of Petit which was in gen-
eral use until the Esmarch strap was introduced. It
consists of two metal plates, the distance between
which can be regulated by a screw, and which are con-
nected by a strong linen band supplied with a buckle,
by which the limb is encircled (Fig. 108). To apply
it properly, the limb should be surrounded by a few-
turns of a roller, while the body of the bandage (p)
is placed over the artery (a). Over this bandage
the lower metallic plate is then placed, and the band
and buckle are fastened, when, by turning the screw 7 ,
compression of the main vessel can be regulated at
pleasure. The objection has been raised to the
tourniquet of Petit that it compresses not only the
artery, but also its accompanying vein, and thus
induces venous stasis, and enhances the dangers of
thrombosis. While this is doubtless true, it is an
insurmountable defect com-
mon to all tourniquets, and
based more on theoretical
t nan on clinical data. \\ hen
properly applied the tourni-
quet of Petit is not apt to
slip or yield, and its safety
i< such that in case of emer-
gency the management of
the screw might be en-
trusted even to a layman.
In order to limit the com-
pression to the main vessel
alone, complete or incom-
plete metallic rings have
been devised which, while
they surround the limb
more or less completely,
make compression at only
two points, i.e. over the Fig. 108.— Petit 's Tourniquet,
artery and at a point dia-
metrically opposite. The best known tourniquets con-
structed on this principle are the horseshoe tourniquet
of Signorini and Dupuytren, the arterial compressor of
the late Professor Gross, and the abdominal tourniquet
of Pancoast and Lister (Fig. 109). While with these
the compression can be limited to the main vessels
of the limb, and the circumferential constriction of
the latter is thus avoided, they are more liable to slip
than the tourniquet of Petit, and are far less reliable
than digital compression. For certain amputations,
however (of the hip and shoulder), the instrument
of Petit is inapplicable; it is then that one or other
of the horse-shoe tourniquets or digital compression
will be found indispensable. The tourniquets above
described have for the most part only an historical
value, they having been almost altogether supple-
mented by the Esmarch apparatus.
Digital compression, when made by trustworthy
hands, is admirably suited to control temporarily
the circulation. If compression of the artery alone
is anatomically possible, it can be best accomplished
by the finger. To be practicable, the vessel must be
contiguous to a bone against which it can be pressed,
as the femoral upon the os innominatum, the brachial
upon the humerus, the subclavian against the first
rib, or the abdominal aorta
against the vertebra. Since
only a few minutes are re-
quired for the amputation
of a limb and the ligation
of the larger arteries, the
endurance of the assistant
entrusted with the duty is
not severely taxed. In
digital compression asso-
ciated w-ith the use of the
elastic bandage we have a
combination by which the
circulation of a limb can be
completely controlled, and
by which certain parts, the
compression of which would
be useless or even harmful, are protected. Notwith-
standing the advantages of this method, the surgeon
should never resort to it unless he can absolutely rely
upon the ability and skill of Iris assistant. For ampu-
tations' at the hip or shoulder direct compression of
the common iliac through a laparotomy wound, or of
the subclavian through an incision above the clavicle
is justifiable. With unreliable assistance temporary
ligation of these vessels would be an absolute safe-
269
Fig. 109.
-Horseshoe Tourni-
quet.
Amputation
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Fig. 110. — Esmarch's Apparatus.
(Bandage not shown in cut.)
guard against excessive bleeding. Digital compres-
n >n is especially indicated in amputations for senile
gangrene when the diseased condition of the main
artery is likely to be made worse by the prolonged
pressure of a tourniquet.
Elastic Compression. — Notwithstanding the pre-
cautions against hemorrhage after amputations, these
were invariably associated with very great loss of
blood until twenty years ago. The blood thus lost
was venous in character and came from the veins
of the amputated member. Through the practices
of Grandesso Silvestri,
an Italian surgeon,
and particularly of
1 }smarch of Kiel, the
blood contained in
the part to be re-
moved is saved, and
that this is not an in-
considerable quantity
has been demon-
strated by experi-
ment. The apparatus
of Esmarch consists
of an elastic bandage
and an elastic tube or
flat band with chain
or clasp attachment.
Commencing at the
fingers or toes, the
bandage is applied by
spiral turns until the
limb is covered to a
line at least four
inches above the point
u here the bone is to
be divided. Above
the last turn of the
bandage, the elastic band or tube is rather firmly
and repeatedly wound around the limb, and secured
by clasp or hook and chain (Fig. 110). When the
bandage is then removed, a condition of ischemia
is observed in the limb, which will permit its ampu-
tation without a more than appreciable loss of
blood during the operation proper. In recent years
the elastic bandage is used less and less, because of
the danger of disseminating the infective or malig-
nant process for which the amputation is to be
done. By elevating the limb for five minutes be-
fore applying the strap, complete ischemia can
always be induced. When the elastic strap is re-
moved, the integument of the stump rapidly assumes
a bright-red color, and in the wound there appears
free, persistent, and often embarrassing, capillary
oozing. It is generally accepted now that the source
of this hemorrhage is from the dilated capillaries,
the walls of which have been paralyzed in conse-
quence of the pressure exerted by the strap on
the vasomotor nerves. When in from twenty to
thirty minutes the vessel walls regain their tonicity,
the hemorrhage ceases. To check this capillary
oozing, a number of remedies have been suggested.
That of Riedinger, to apply the faradic current,
while very serviceable, is not always practicable. Es-
march relies upon closure of the wound and elevation
of the stump before the strap is entirely removed.
Hot water (150° to 180° F.), applied with sponges,
often acts admirably in these cases. Since compres-
sion of the vasomotor nerves caused by the bandage
is the cause of this parenchymatous hemorrhage,
this can best be obviated by completely substitut-
ing digital compression for the elastic strap, or, if
the latter be used, by preventing the ingress of blood
by the use of a tourniquet until the vessels have re-
gained their natural tone. The latter plan, as practised
bj Ashhurst, is "to place a tourniquet in position,
but not screwed down over the main artery of the
limb, and then to apply the Esmarch tube a few
inches above the point at which it is intended to am-
putate. As soon as the principal vessels have been
secured, the tourniquet plate is screwed down and
the tube removed. No bleeding follows, and by the
time that the remaining arteries requiring ligatures
have been tied, the vessels will have regained their
tone, and the tourniquet can be removed without
any risk of bleeding following." In amputations
near the trunk the elastic strap or tube should not
be used in the ordinary manner (see Special Amputa-
tions). In an amputation of the shoulder, and in
another of the hip, I have seen it loosen or slip over
the stump immediately after the disarticulation
effected, and in both instances (lie hemorrhage was
most alarming. In amputation at the shoulder,
when, by the use of the bandage, the blood in the
extremity has been returned to the economv, it is
better to rely upon compression of the main artery
against the first rib with the finger or a padded key.
In amputations of the hip, the main artery cat
compressed against the pubic bone, or even the cir-
culation in the aorta can be controlled by one of the
many compressors already referred to. In consider-
ing amputations of the shoulder, of the hip, or of I he
ilium special methods of controlling hemorrha
applicable to them will be discussed.
Methods of Amputation. — Every amputation
consists of three steps: (1) Division of the soft pa
(2) division of the bone, or disarticulation; (3) 1
tion of t lie vessels and closure of the wound.
According to the method adopted for the division
of the soft parts, amputations are classified as cir-
cular or flap operations, and in the choice of tin-
method the surgeon must be guided by the condition
of the soft parts about the bone, the ease with which
the joint can be opened in a disarticulation, the prob-
able position of the cicatrix and form of the slump,
and, above all, the desire to save as much of the limb
as possible. Of the circular and flap operations, all
methods of amputation may be said to be but modifi-
cations. By the circular method it is attempted
to give to the stump the form of an inverted cone or
funnel, the apex of which is occupied by the divided
end of the bone, the base or margin of which is rep-
resented by the cutaneous margin of the wound. In
the flap operation the soft parts are so divided as to
make one or more flaps, the bases of which are on a
level with the divided bone, and the free margins of
FlQ. Ill
which are so adapted to each other as completely to
cover the bone and admit of the ready closure of the
wound. Whatever plan of operation is adopted, the
surgeon should stand in such a position that he
grasps the stump with his left hand, so that the
amputated part falls toward his right side.
Circular Method. — All modifications of the circu-
lar method call for a similar incision through the skin
and subcutaneous cellular layer, this incision being
made around the entire circumference of the limb ami
at a right angle to its axis. According to the depth
to which the incision is carried, the method is sub-
270
REFERENCE HANDBOOK OF THE MEDICAL SI 1ENCES
Amputation
divided into that by single incision and that by double
incision. .
Single Incision.— This, as already remarked (see
History), is the oldest method of amputation, and is
generally known as the Celsian operation. Alter
tction of the soft pari-, a long amputating knife
is -wept around the limb, and all of the soft parts are
divided down to the In. no. This is then divided on a
slightly higher level by the retraction of the soft parts.
Wnile'this operation yields the smallest wound, and
i< the most rapid in it's execution, its manifest disad-
vantage is in the insufficient covering which it affords
for the bone. It is
admissible only in
greatly emaciated
subjects. Brunning-
hausen, in the begin-
ning of the century,
reintroduced this
method, but, after
Fia. 112. the amputation of the
limb was completed,
made a second section of the bone several inches
above the point at which it was first divided.
Double Incision. — This operation of which those of
Petit, Cheselden, B. Bell, Desault, and Alanson are
but unimportant modifications, has received its name
from the fact that the skin, underlying fascia, and
muscles are divided upon different levels, and there-
fore by at least two circular incisions. It i< made as
follows: The surgeon, securely holding the limb with
the left hand, carries his right hand, in which he
firmly holds a large amputating knife, underneath
and around the limb until the heel of the cutting
Fig. 113.
edge is over the uppermost part of the line of the
proposed incision. Giving the knife this position
forces the operator into a more or less stooping pos-
ture, from which he raises himself as the incision is
completed. This is commenced with the heel of the
knife, winch, by a single sweep is carried around the
entire circumference of the limb, severing the skin
and adipose layer down to the deep fascia (Fig. 111).
Two incisions, the ends of which meet, will answer as
well as the division by a single sweep of the knife.
As soon as the integument is divided the wound gapes.
The upper margin is raised by the thumb and finger
of the left hand, and gradually detached from the
fascia by repeated long incisions carried perpen-
dicularly to the axis of the limb. This operation of
detachment is continued until the skin and adipose
Fig. 11 1.
layer can be reflected like a cuff, the length of which
should be equal to half the diameter of the limb (Fig.
112). When the latter rapidly increa e in circum-
ference, or there is a thick subcutaneous layer, oi this
has been infiltrated, the reflection of a cuff is often
impract icable. 'I ben
two longitudinal inci-
sions, diametrically op-
posite each other will
materially facilitate
this part of the opera-
tion, although by this
means the amputation
is in a manner con-
verted into a Hap oper-
al ion. The integument
having been reflected
to the required extent,
the muscles are next
divided close to the line of reflection by one steady
circular sweep of the knife, which should cut through
everything down to the bone (Fig. 113) or rather to the
periosteum. Before using the saw, the bone should
be stripped of its muscle and a periosteal cuff made,
which after the division of the bone falls natur-
ally over its raw surface, and applies itself to the open
medullary canal. Where there is no oozing it may
even be sewed in place advantageously with catgut
sutures. In dividing the muscles it is often desirable
to do so on different levels whereby
the wound naturally assumes a
cone-shape and is more easily
closed.
Where there is but one bone to
be divided, the surgeon is now
prepared to use the saw. Where
there are two bones, the interos-
seous tissues re-
main to be divided.
Whereas this can
be accomplished
with an ordinary
amputating knife,
it is safer to use a
double-edged in-
strument (catlin)
for this purpose.
By using it in the fig. us.
manner indicated
in Fig. 114, there is no danger of cutting the blood-
vessels twice, and thus one danger of troublesome
hemorrhage is avoided. To protect the soft parts
from injury by the saw they must be well retracted
by the hands of an assistant, or by the use of a band
of muslin (retractor) divided into two or three slips
according to the absence or presence of an interosse-
ous space (Fig. 115).
The movements of the saw can be greatly facilitated
by guiding them with the nail of the left thumb
(Fig. 116). The to-and-fro movements of the saw
Fig. 116.
should be slow, lest the heat developed by its too
rapid use endanger the vitality of the bone. Where
there are two bones of the same diameter (forearm),
they should be divided simultaneously. In the leg,
271
Amputation
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Fig. 117.
the tibia is to be almost entirely divided before the
section of the fibula is commenced. Unless this
precaution is adopted, splintering of the bone is not
easily avoided. For the same reason, the assistant in
charge of the part to be amputated should hold it
horizontally,
allowing it xaW
neither to , J-Jft
drag by its L*J MWmi
weight nor to
be raised in a
manner to in-
terfere with
the move-
ments of the
saw. Should
splintering of
t h e bone
neve rtheless
occur, the
splinters and
sharp margin
of the latter
must be re-
moved with
the cutting
bone forceps.
Oval Method.
— Holding an
i n t ermediate
position be-
tween the cir-
cular and flap
operations is
the oval method, which, although practised by the
older Langenbeck and others, was first generalized
by Scoutetten (1827). The essential feature of this
amputation in the continuity of the limb is that the
incision, instead of being made perpendicnlar to its
long axis, is carried at an angle of forty-five degrees,
and in such a way that the soft parts in front of the
bone are divided upon a higher level than those on its
posterior aspect. At the same time the upper portion
of the wound is converted into an acute angle, whereas
its lower portion is given an oval outline. The upper
extremity of the wound is placed at the point where
the bone is to be divided. The operation is com-
menced by two incisions in the form of an inverted
V, the lower
ends of which
are united by
a transverse
cut on the
posterior sur-
face of the
limb(Blasius).
Here, as in the
circular am-
putation, by
a single inci-
sion all the
soft parts are
divided at
once on each
side of the
bone, and
then those on
its posterior
aspect. This
operation has
been generally
discarded for
amputations in the continuity, although for disarticu-
lations at certain joints it presents advantages which
an 1 worthy of consideration (see Fig. 117).
Flap Method. — As already indicated, this consists
in the formation of one or more flaps, comprising
integument and muscular tissue, or integument alone,
and designed in a manner completely to cover the
divided extremity of the bone or its exposed articular
surface. According to the anatomical components
of the flaps, they can therefore be called tegumentary
and musculotegumentary.
Tegumentary Flaps. — This operation is generally
practised by making two semilunar incisions, the
ends of which meet on opposite sides of the part,
down to the deep fascia, and dissecting up the skin
and subcutaneous cellular layer to an extent sufficient
Fig. 119.
to cover the stump (Fig. 118). When it is practicable,
the flap should be taken from the anterior and pos-
terior aspects of the limb in the forearm, thigh, and
leg, and they should not be of equal lengths, the
anterior flap usually being made longer, to fall like a
curtain over the divided end of the bone, where it
comes in contact with the posterior (shorter) flap.
In recent years the tegumentary method, with only
one cutaneous flap, made from the anterior surface
of the limb, has been most highly advocated (Garden,
Bruns). When, from choice or necessity, a single
tegumentary flap is to be made, the incision should
be commenced on a level with the point where the
division of the bone is contemplated, and carried for
a varying distance down one aspect of the limb,
parallel to its axis, and then by a wide curve on the
opposite side to a point on a level with its commence-
ment (see Fig. 118). In this manner the base of the
Fig. 120.
cutaneous flap extends over half the circumference
of the limb, while its length should be greater than
its anteroposterior diameter at the level of the
amputation. After separation of this flap from the
deep fascia (it may be made to include this) it is
reflected and the ends of the incision are united by
a posterior incision carried perpendicularly to the
axis of the limb as in the circular operation (Fig. 119).
Whether one or more cutaneous flaps be made, the
division of the remaining soft parts is practised by a
single sweep of the knife, carried perpendicularly
around the limb at the base of the flap, as in the
circular operation. Owing to this division of the
272
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Amputation
muscles, amputations by the tegumentary flap
method are not infrequently called "modified circular
operal ions."
Musculotegumentary Flaps. — Here, as in the tegu-
mentary method, one or more Haps may be made to
rever the stump. They may be formed by transfixion
of the limb and cutting from within outward, or by
cutting from without inward, or by making one flap
by the former and the other by the latter mentioned
method. Where there is but a single bone (thigh,
arm), it was the custom of the older surgeons to make
at least one flap by transfixion. The integument
being well retracted, and the soft parts raised from
the bone with the left hand, a sharp-pointed and
large amputating knife is passed through the limb
from side to side, the knife being made to graze the
surface of the bone (Fig. 120). By a sawing move-
ment the instrument is gradually carried downward
and forward, and then obliquely outward, thus form-
ing a wide flap with convex margin. The danger of
making a flap too narrow is best avoided by not
cutting outward too soon. The knife is then entered
at the angle of the wound on one side, passed around
the bone on the side where the soft parts are still
adherent, and out at the opposite end of the wound.
The second flap is then made by cutting outward as
before. The flaps being now retracted, the knife is
rapidly carried around the bone, as high as possible,
to divide the muscular tissue still adhering to it.
The application of the saw then follows. In order
to make sufficient allowance for shrinkage, the flaps
should have a length at least equal to three-fourths
the diameter of the limb. Redundance of the flap
is always preferable to insufficiency, since the excess
of muscular tissue can easily be removed with a few
strokes of the knife. In flap operations, owing to
unequal retraction of the soft parts, tendons and
nerves are particularly apt to protrude above the
surface of the wound, thus giving it an irregular
appearance, and interfering with its ready union.
After ligation of the blood-vessels, these protruding
masses are to be carefully removed with the scissors.
The protrusion of the muscular tissue of the flap
and the irregularity of the latter
can be totally avoided by cut-
ting from without inward. This
plan, generally known as that of
Langenbeck (Fig. 121), insures
perfect symmetry of the flaps,
Fig. 121.
and permits the ligation of the vessels as they are
exposed or divided. It is also practicable to cut
through the skin and subcutaneous tissue from with-
out inward, and complete the operation by transfixion.
Although already practised by Dupuytren, this plan
was advocated later by Agnew.* Most surgeons who
prefer accuracy to speed will fashion their flaps by
cm ting them from without.
Rectangular Flap. — In 1S55 Mr. Teale of Leeds
practised the formation of one long and one short
rectangular flap, each of which comprised one-half
the circumference of the limb and all the tissues
down to the bone. The operation is made as follows:
A rectangular anterior flap (posterior in the forearm),
equal in length and breadth to half the circumference
of the limb at the base of the flap, is marked out by
one transverse and two parallel longitudinal incisions,
the latter involving only the skin and superficial
fascia, and the former being carried down to the bone.
Vol. I.— IS
Fig. 122.
The longitudinal incisions should be so placed that
the posterior obtains one-fourth the length of the
anterior Hap. The two flaps are then turned up
from the bone from below upward, and the saw is
applied. To insure equal width of the Haps at their
bases and their extremities it is besl to map out the
Haps by actual measurement before tin- incisions are
made. In closing the wound, the long Hap is doubled
upon itself so that the square ends of the two flaps
are brought into apposition, where they are retained
by a number of sutures (Fig. 122).
Comparison of Methods. — The surgeon who
would obtain the 1 best results after amputul ions should
be familiar with all the different methods without
becoming too partial to any, since the condition of the
part to be ampu-
tated, the thick-
ness and vitality
of the subcutane-
ous cellular tissue,
the position of the
wound, and many
other circum-
stances should
guide him in the
selection of a
m e t h od ra t her
than individual
preference. To
save as much of a
limb as possible
must be the first
aim of the opera-
tor, and this can
be accomplished
only by resorting
to various methods
according to the exigencies of individual cases. If
one method of operating deserves a preference, it is
that by tegumentary flaps with circular division of
the remaining soft parts. By this method the posi-
tion of the angles of the wound for favorable drainage
and that of the cicatrix can be readily determined,
and when two oval cutaneous flaps are made no
anxiety for their vitality need ordinarily be enter-
tained. When the subcutaneous cellular layer is very
thin, there is a manifest advantage in dissecting up
with the integument some of the superficial muscular
fibers. The marked advantage of the tegumentary
flap over the circular method lies in the fact that by it,
when the disease extends higher on one side of the
limb than on the other, it often enables us to ampu-
tate several inches lower than we could by the circular
method. While during the early part of this century
the musculocutaneous method by transfixion was
very extensively practised, on account of the rapidity
with which it could be executed and the muscularity
of the stump which it left, it is gradually being dis-
carded for two reasons chiefly. In the first place, the
general use of anesthetics has removed the necessity
for unusual haste, and in the second place, the muscu-
lar tissue left in the stump generally undergoes
atrophic changes from disuse during the first year.
A most decided disadvantage of the musculotegumen-
tary flaps exists in the oblique division of the blood-
vessels, on account of which they are often difficult
to find and to ligate. It is for this reason that sec-
ondary hemorrhages are more prone to follow ampu-
tations made by this method, although by proper care
in the act of ligation and with sufficient compression
of the stump with the dressing this can usually be
avoided. The circular operation commends itself,
owing to the facility with which it can be executed,
even by a novice in the operative art, and by its
special applicability for amputations in certain parts,
as in the forearm and lower part of the leg. Where
the operator can choose his method, amputations
may be made with good results as follows: In the
273
Amputation
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
arm and forearm, by circular method or rectangular
flaps; in the upper part of the leg, by tegumentary
and rectangular flaps (lateral or anteroposterior) ;
in the lower part of the thigh, by anteroposterior
muscular flaps; in the middle of the thigh, by one
tegumentary flap raised from the anterior surface of
the limb. The oval method will be found particularly
applicable to amputations at certain articulations,
while the method of Teale, which has not been exten-
sively practised in this country, will give good results
in amputations of the leg and forearm where the
injury or disease has invaded a limb more extensively
on one side than on the other.
Ligation of Vessels. — When the amputation
proper is completed, the entire attention of the
operator must at once be directed toward permanently
controlling the hemorrhage. For this purpose it is
best to grasp the divided blood-vessels, one after
another, as they are seen, with hemostatic forceps,
which are allowed to remain in the wound until all
the vessels are thus held. This accomplished, the
vessels are separately tied with catgut. The ligatures
are then cut short. Veins should be tied to avert the
development of a general infection out of a possible
local infection. As a rule, not more than from four
to six arteries will require ligation in all amputations,
except those of the hip and shoulder, although long-
standing disease (large neoplasms or preexisting
occlusion of the main artery) may have multiplied
the number of vessels requiring ligation. Here, as in
ordinary wounds, at least the larger arteries should be
carefully exposed before the ligature is applied. In
the smaller vessels, where their exposure would entail
an unnecessary loss of time, portions of the tissues in
which they are embedded may safely be included in
the ligature by passing this with a needle behind the
bleeding vessel. The question has for a long time
been discussed as to whether the veins should be tied.
There can be no question but that the ligature of the
divided veins removes a common source of secondary
hemorrhage, and materially reduces that immediately
following the removal of the Esmarch bandage. The
opposition to the ligation of veins in amputations has
been mainly based upon the fear of exciting an as-
cending phlebitis and of giving rise to embolic proc-
esses. That these fears are utterly groundless has
been conclusively demonstrated. " Of forty cases of
ligation of the internal jugular vein, death was fairly
ascribable to the ligature in only four, all due to
secondary hemorrhage coming on about the time of
the separation of the thread. In not a single instance
was diffused phlebitis excited. In twenty cases of
ligation of the external jugular vein, and fifteen of the
axillary, additional evidence of the safety of ligation
of veins is recorded." The most troublesome hemor-
rhage is the parenchymatous oozing which supervenes
when the Esmarch bandage is removed. How- to
contend against this has already been discussed
(see above). It is proper to add, however, that in
every case the application of an abundance of hot
water is of unquestionable value. When the oozing
from the divided end of the bone is not checked by
this, the medullary canal may be temporarily plugged
with clean white wax, or with sterile gauze. The
accurate closure of the wound and pressure upon it by
a well-applied bandage are among the best means of
checking the capillary hemorrhage. When it is
necessary to resort to this means, a large gauze pad
is firmly pressed against the wound and retained until
the sutures are passed. As the sutures are tightened
the pad is gradually withdrawn while an assistant
tightly presses the wound surfaces against each other.
In large amputation wounds, the size can be greatly
reduced by buried continuous catgut sutures which
bring the divided muscles close together. Sutures
thus applied in purse-string fashion or in tiers help
to cover the bone and to prevent the formation of
dead intermuscular spares.
After-Treatment. — It is beyond the scope of this
article to enter into an extended discussion of the
various methods of treatment of wounds, although in
hardly any other class of wounds are the good or evil
results so clearly attributable to the manner of treat-
ment adopted. The question at once presents itself
whether the surgeon will pursue a course which will
reasonably assure a total, or at least partial primary
agglutination of the wound, or whether he will avoid
the dangers of retention and decomposition of the
secretion of the wound by treating this openly, thus
expecting its closure by the slower process of granula-
tion. The latter plan, which is now known as the
"open method," was first enunciated by Vezin.
Bartscher, and Burow 5 in Germany and disseminated
in this country by the late Dr. James R. Wood.
When this method of treatment is adopted, sutures
adhesive straps, etc., are entirely dispensed with, the
stump being comfortably placed on a pillow or pad,
and the wound freely exposed to the air. A mass of
absorbent cotton is placed underneath the stump to
catch the discharges from it. Twice daily the wound
is irrigated with an antiseptic solution, usually of
carbolic acid, until at the termination of the first
week, when the process of granulation has been thor-
oughly established, the edges of the wound are ap-
proximated by adhesive strips, care being taken that
retention does not occur. The manifest advantage of
the "open method" of treating amputation wounds
is in the ready outlet which is given to the secretions.
Their decomposition in the wound is thoroughly
prevented, and the chief factor of septic absorption
is thus avoided. However admirable the results
which have been obtained from it, the length of time
required for the closure of the wound (six to twelve
weeks) militates against its general adoption. While
incomparably better than the older methods of
tightly closing the wound regardless of proper drain-
age, the open treatment of wounds has subserved its
purpose, and has yielded to the superior advantages
of the aseptic method, which strives to obtain the
ideal of the surgeon in the treatment of wounds, viz.,
primary union. The open treatment of amputation
wounds has been therefore properly relegated to those
cases in which the surgeon is convinced that, from the
condition of the parts in which the operation has
been made, or from the general condition of the
patient, primary union cannot, take place.
When a doubt exists as to the certainty of primary
union, sutures should be passed both deeply and
superficially and left untied. The wound itself is
packed lightly with sterile gauze. If, at the end of
forty-eight or seventy-two hours, there is no evidence
of septic infection, the gauze may be removed and
the sutures closed with prospect of securing union
without suppuration. When, on the other hand,
primary union is aimed for, all drainage is to be
dispensed with unless there is considerable oozing.
The rubber drainage tube formerly extensively used
is gradually being replaced by a narrow wick of
sterile gauze drain in rubber tissue, or a strand of
silkworm gut passed through the angle of the wound
from the immediate vicinity of the divided bone.
This can be removed on the third or fourth day, or, if
there is no evidence of infection, may be allowed to
remain until the first dressing is changed, after a week
or ten days. When, as in the case of amputation of I he
heel (Syme), there is danger of the formation of a
dead space, one of the flaps can be perforated in such
a manner as to prevent pocketing of wound secret ion.
Although an advocate of limiting drainage as far OS
possible, the writer believes it should be resorted to
in every case in which oozing has not been entirely
stopped by the time the sutures are read}' to be tied.
Primary union is often prevented by the accummula-
tion of bloody serum, which mechanically separates
surfaces which ought to be held in apposition.
An amputation wound is to be closed by three or
274
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Amputation
four deep sutures, which should include the entire
thickness of the muscles on each side of the divided
bone, they should be of fine cupper wire or silk-
worm put. The superficial sutures or skin clamps
should he placed al distances of about one-third of an
inch from one another.
The dressing of the wound follows. The amount
of material used should be ample and it should be so
applied that pressure will tend to keep the wound sur-
s in apposition. Unless a moist dressing is
ued advisable because a doubt as to the asepsis
-. a dry dressing should always be used with
pulous attention to surgical cleanliness. Even
amputation wounds, as those of the thigh, hip,
or shoulder, will generally heal under one or two
dressings. As in other operations, the dressing should
kllowed to remain for at least a week or ten days.
Should there be a slight oozing, a change of dressing
i~ imperative. The stump should always be main-
tained in an easy position on a pillow or a well-padded
posterior splint. It is usually advisable to elevate
this to a degree sufficient to faciliate the return of
blood through the veins. Postoperative oozing can
thereby be best prevented.
After amputations in which the asepsis has been suc-
cessfully carried out, even the largest wounds will
heal entirely by first intention. The dissimilarity of
tissues which are often brought in contact with
one another in an amputation wound, and which
were formerly supposed to preclude the possi-
bility of immediate union, is no obstacle to the
achievement of this result. Of greater importance
are the novel relations of the blood-vessels to one
another. The circulation in the veins of the stump
has lost the vis a tergo so essential to the proper per-
formance of their function, while the smaller arteries
are distended with blood in consequence of the in-
terrupted circulation in the main vessel. It is for
this reason that a marked edema and congestion will
often manifest themselves in the stump. Unless
infection has occurred, these manifestations will
disappear in three or four days.
In whatever manner the wound heals, certain
marked changes will occur in the stump. The
muscular tissue undergoes atrophic changes, its
fibrous elements becoming firmly adherent to the
end of the bone. This itself gradually decreases in
size, the end becoming rounded off and often covered
by a rounded osteophyte formed from the periosteum
or from the granulations springing from the medullary
canal. Where two bones are present, an irregular
osseous bridge not infrequently unites them (Gueter-
bock 6 ). As a rule, the end of the bone is intimately
united to the soft parts covering it, although at times
a bursa is developed between them. The ligated vessels
are converted into firm fibrous cords for a varying dis-
tance and are reduced in size, not only in the stump but
also in the entire limb. Thus, in amputations of the
leg, the artery and vein are reduced over one-half in
size as high as the inferior vena cava and the bifurcation
of the aorta. The divided nerves lose their nervous
elements by atrophy, while their connective-tissue
components increase in number until their extremities
"ften expanded and bulbous, thus forming false
neuromata.
Complications. — Pain and muscular spasm maybe
said to be present to a greater or less degree after every
major amputation. They usually supervene soon
after the patient regains consciousness, and may
develop to a distressing severity, particularly in
persons of a nervous and irritable disposition. For
the relief of these symptoms hypodermatic injections
of morphine act most promptly. The jactitations of
the -tump are most successfully overcome by lightly
fastening the stump with a few turns of a bandage to
a well-padded posterior splint.
A very slight reaction may be said to be necessary
to the process of repair. When infection has taken
place, the evidences air speedily seen in the wound.
It may lead to more or less extensive suppuration,
to a limited sloughing, or to gangrene of the -lump.
When such severe inflammation attacks the wound,
the stump becomes exquisitely sensitive and hot, and
i Lines a dusky red and glistening appearance.
The discharges from the wound arc scant and offen-
sive, while the elevated temperature aid hard and
rapid pulse sufficiently indicate 'lie constitutional
dist urbancc. When the inflammatory proci
along the intermuscular spaces the limb becomes
sensitive to the touch, and swollen for a considerable
distance above the seat of operation. When suppu-
ration ensues all may yet be well, (in the other
hand, the exudation into the tissues may develop in
proportions incompatible with the vitality of the
parts, when extensive sloughing, and even gangrene
..t i he entire stump, may result.
The treatment of these conditions must be con-
ducted upon established principles. Locally nothing
answers so excellent a purpose as measures which
relieve the tension. Stitches, when too tight, mii-i
be removed, and as soon as a suspicion of purulent
accumulation is aroused, free incisions are to be made.
When such extensive suppuration has supervened
it is advisable to remove all constricting dressing,
and to treat the wound by the open method, removing
sloughs as fast as they are formed. Frequent irri-
gations with sublimate solutions and hydrogen di-
oxide are now indicated. As a dressing the balsam
of Peru (ten per cent.) in castor oil applied on strips
of gauze will do away with the necessity of drainage.
As an especially dangerous seat of inflammation the
medullary canal of the bone must be referred to.
Periostitis and osteomyelitis are particularly prone
to follow amputations made for gunshot injuries.
It usually manifests itself during the first week after
the operation by a brownish or greenish appearance
of the medulla, the bone appearing dull and devi-
talized, while the periosteum is detached from its
surface. The pain is usually very severe, and
associated with it are the well-known symptoms of
systemic infection, i.e. rigors elevated and irregular
temperatures, diminished secretion of the kidneys,
and a dry and thickly coated tongue. Not only does
this condition lead to extensive necrosis when
recovery ensues, but death may result from general-
ized sepsis. The only measures that offer any hope
for this condition are to scoop out the bone cavity
with a sharp spoon, and if this prove unavailing, to
resort to a second amputation at the nearest joint.
However desperate this procedure may be, a very-
large number of cases have been reported in which
lives have been saved which, without it, would have
been inevitably lost.
As a sequel of moderate inflammation of bone,
necrosis of its extremity is not infrequently encoun-
tered. This may result from devitalizing of the bone
from excessive heat generated by the improper use
of the saw. If the necrosis be limited to the divided
end, this condition does not interfere with the primary
union of the greater part of the wound. The exis-
tence of such a superficial sequestrum can be deemed
probable when, after the permanent closure of the
wound, a fistulous tract continues to discharge. Its
actual presence can always be recognized by the
cautious use of a probe or by the x-ray. When the
sequestrum is of larger proportions, numerous fistu-
lous openings will usually be found in the soft parts,
which are then more or less adherent everywhere to
the bone. The treatment of this condition must In-
palliative until nature has completely separated the
sequestrum, when it can ordinarily be removed with
little difficulty by laying the fistulse freely open.
When the sequestrum is large, it occasionally becomes
necessary to resort to a formal sequestrotomy for its
removal. In a very small proportion of cases the irri-
tation consequent upon the long-standing discharges
275
Amputation
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
from the necrosis of the bone gives rise to epithelioma
for the relief of which a second amputation is usually
necessary.
One of the most dreaded complications of an ampu-
tation is hemorrhage. It may supervene within a few
hours after the completion of the dressing, or as late as
the third or fourth week. The sources of early and
late hemorrhages after amputations differ materially.
The former arise from small arteries or veins that
have escaped ligation, from arteries divided above the
ligature, or from the divided capillaries of the muscles.
This condition is readily recognized by the staining of
the dressing, the distended appearance of the stump,
and the flowing of blood from a number of places
where the edges of the wound have been separated.
The rapid distention of the stump and the bright
hue of the blood which is discharged at once indicate
the arterial source of the hemorrhage. The darker
appearance of the blood and its appearance in a
sluggish stream sufficiently indicate its venous origin.
Blood oozing from a hematoma is always dark.
When the hemorrhage is slight, and particularly if
it can be recognized as venous, elevation of the limb
and the application of ice may suffice for its control.
When it becomes evident that such simple measures
are futile, the wound must be reopened, the coagula
removed, and the bleeding vessel found and ligated.
\\ hen it is found that the hemorrhage has come from
the medullary canal, this must be treated in the
manner already described. The hemorrhages which
supervene during the second week, or even later,
usually result from the erosion of a vessel wall weak
from sclerotic changes at the time of operation, or
from wound infection and softening of the thrombus.
By cutting short both ends of the ligature the neces-
sity for the "cutting through" of the latter is done
away with, and at least one important factor in the
causation of late hemorrhages is thus removed. For
the relief of late hemorrhages, compression of the
artery by a compress and firm bandage should first
be tried. When this proves unsuccessful, pressure
should be made at different points of the main artery
to determine the point nearest the stump where the
hemorrhage can be controlled. Here the artery is
to be exposed and ligated, or, what seems to be
preferred by most recent writers, it may be included
in the pressure of an acupressure needle. Reopening
of the wound and direct treatment of the bleeding
vessel is usually successful although in rare cases it
may become necessary to resort to reamputation.
A peculiar and very rare condition of the stump is
the development in it of a dilatation of the blood-
vessels, commonly in the form of an aneurysmal varix.
Cases of this nature have been recorded by Cadge of
Norwich, England, by Gross, and by Agnew. Whereas,
in some cases of this kind, operative treatment
would not be called for, in others it may become
directly indicated. Thus, in the case of Gross, 7
ligation of the femoral was deemed necessary. The
operation resulted fatally, from secondary hemor-
rhage, on the sixth day.
The form of the stump very frequently gives rise to
considerable annoyance and suffering. A healthy
stump should present a nicely rounded outline, with
tin- bones hidden beneath and away from the cicatrix.
From a variety of causes this normal appearance of
the stump may give place to prominence of the bone,
retraction and ulceration of the soft parts covering it,
and uselessness of the part for locomotion. Such an
abnormal condition is commonly known as the
"conical" or "sugar-loaf" stump. It may result
from an insufficiency of flap, from inordinate retrac-
tion of the soft parte, or from gangrene of the integu-
ment alone. It is a condition which is more likely
to follow the circular and tegumentary flap ampu-
tations, although with ordinary precautions it would
seem that amputations in healthy tissues should not
result in a badly formed stump. When this condition
276
does result, nevertheless, its treatment must vary
according to the extent of the deformity. When
from an insufficiency of flap or excessive retraction of
the soft parts, the end of the bone assumes a too
prominent position, the flaps can be drawn down by
appropriate bandaging, from above downward; or,
by the aid of adhesive straps and weights, extension
may be made in such a way as to cover the end of the
prominent bone with integument (Fig. 123). When,
notwithstanding these measures, the proper relation
between bone and soft parts cannot be brought
about, nothing remains but to enlarge the wound,
remove the periosteum from the bone, and divide
this several inches above the level of the first section.
It is unnecessary to defer this until the first wound
has cicatrized. In extreme cases of conical stump
reamputation will be indicated. It can be more
highly recommended since reamputation is not often
followed by bad results. Mr. Bryant refers to a very
interesting condition of amputation stumps in
children, in whom the development of conical stumps
Fig. 123.
may be in a measure expected, since, in the process
of growth, the bone appears to develop more rapidly.
In the case of a boy whose leg was amputated, he
found it necessary on two occasions, at intervals of
three years, to remove two pieces of bone at least an
inch long.
Neuroses of the stump are among the most intract-
able of its diseases. They may appear in the form of
severe neuralgias, or in the form of spasmodic muscu-
lar contractions. The former condition usually
depends upon an adherence of the divided nerves to
the bone or the cicatrix, while in exceptional cases it
results from the bulbous enlargement of the extrem-
ities of the nerve. For the relief of the former
condition, subcutaneous division of the adherent
cicatrix must be practised. Where neuromata can
be felt, these are to be removed; when, from the
number of these enlargements or from their deep
positions, this procedure is impracticable, nothing
short of a reamputation will give relief. Continuous
jactitations, or "chorea" of the stump, as it might
be termed (Gross), is very rarely encountered. It
is more prone to develop in the thigh than elsewhere.
The stump, when thus affected, is the seat of a
constant tremor, often sufficiently active to be
noticed when the limb is covered. In a case of this
character which I saw two years ago, and which
involved the thigh in an otherwise healthy subject,
the spasms continued, notwithstanding all efforts to
allay them. The most efficient measure was the
deep injection of ether, which would relieve the
spasm for about two weeks at a time, when the
injection had to be repeated.
Prognosis and Mortality. — In estimating the
inherent dangers of the operation, we must take into
consideration only those cases in which the individuals
operated on were — aside from the lesion which neces-
sitated the operation — in the enjoyment of compara-
tively good health. As it is incorrect to attribute
the immense mortality of tracheotomy for diphther-
itic croup to an operation which, if performed for the
removal of foreign bodies, is almost alwaj's successful,
so it is manifestly improper to attribute most deaths
after amputation to the operation itself. A compila-
reference handbook of the medical sciences
Amputation
tioii of the amputations of "expediency," made in
Guy's Hospital, indicates a mortality of 26.8 per
criii. If we remember, however, thai these statistics
of Bryant and Golding Bird include amputations
made for neoplasms, and that the most valuable
methods of after-treatment were at that time not
employed in the hospital in question, tliis percentage
must be misleading as to the inherent dangers of
amputations. That the mortality of the operation
under favorable circumstances can be greatly reduced
front the percen age aBovo given can be easily
demonstrated. Thus, of 716 late and pathological
amputations collected by Sir James V. Simpson from
smaller hospitals and private practitioners of Scotland
and England, only seventy-four, or 10.3 per cent.,
died. Of 100 amputations (including thirty-nine of
the thigh) made by Brims, only twelve terminated
fatally. According to the latest statistics of Bruns,
of 204 major amputations two per cent, only died.
Finally, of 187 amputations made by Volkmann for
onlj seven succumbed (three per cent.).
This number includes seventy-four amputations of
the thigh with only two deaths.
statistics can hardly be improved upon,
although we are in need of carefully compiled data of
amputations performed with modern aseptic pre-
■ion. Except for the amputations near or at
tin- hip, or of a limb and part of the shoulder girdle
or ilium, the mortality uf amputations is practically
nil. One must exclude, of course, such cases as
diabetic gangrene or acute septic invasions.
Unhappily these statistics are largely at variance
with those gathered either from large hospital- or
from the battlefield. Thus, of 500 larger amputations
for all causes collected by Malgaigne in the hospitals
of Paris, 299 ended fatally, the mortality being fifty-
three per cent. The fatality attending amputations
by English surgeons in the Crimean campaign is
represented by 420 operations, with 169 deaths
(39.6 per cent.), while the figures of the French
surgeons during that war are 4,390 amputations,
with 3,218 deaths, giving the appalling mortality of
seventy-three per cent. Compared with such results
those obtained during the War of the Rebellion show
a most decided improvement. Of 29,980 ampu-
> is, the result was determined in 28,261; of these,
20,802 recovered. There were 7,4.59 deaths, tints
yielding a mortality of 26.3 per cent. The most
complete recent statistics of amputations for gunshot
injur}' show only a moderate improvement over
those obtained by the older methods. Thus the
irt of Surgeon General Stevenson on the South
African War shows that of 134 major amputations,
only seventy per cent, recovered. This was largely-
due to the fact that at the time of the operation, the
patients were already septic.
John F. Erdmann, 8 in 1S9.5, tabulated the statistics
of amputation performed in the leading hospitals in
York, done during the decade preceding. Of
709 major amputations 109, or fifteen per cent., died.
Page,* in 1S95, collected 712 major amputations from
the infirmary, Newcastle-upon-Tyne, of which sixty-
one died, giving a mortality of 8.5 per cent. In
thirty of the fatal cases death resulted from shock
and loss of blood. Forty years before, Fenwick had
tabulated 225 amputations done in the same infirmary
with a mortality of fifty-four, or twenty-four per cent.
Of 163 amputations done in the Cincinnati Hospital
during the decade preceding January 1, 1000, nineteen
terminated fatally. The gross mortality of the
series was 12.7 per cent. From the clinic of Bruns 10
comes the remarkable record of eighty-one ampu-
tations of the leg without a death. An examination
of all statistics will show that the mortality of major
amputations is gradually being reduced. If the
cases are subtracted in which death resulted from
shock and the loss of blood, the mortality of all
major amputations will be reduced to about four
per eeni., as has been the case with the statistics
published By Estes.
It is not the least important achievement of Mal-
gaigne to have directed the attention of -urge. ins to
the chief causes which modify the; prognosis in indi-
vidual cases of amputation, and how, therefore,
statistics must vary according to certain now well-
known conditions under which they are collated.
In a somewhat similar direction were the investiga-
tions of Simpson. The conditions which influence the
prognosis of amputations will now be considered in
the order of their importance.
Age. — The mortalitj of amputations is determined
more By age than By any other one factor, since they
betterborne in childhood and adolescence than
later in life. Malgaigne was the first to point this out
By the tabulation of 560 i :a es in which the mortality
steadily increased with the age of the patients.
Amputations between the ages of five and fifteen
years yielded a mortality of thirty-three per cent.,
those Between fifty and sixty-five one of , 1.1 per nut.
Similar investigations have Been made By Callender,
Holmes, Bryant, and Golding Bird in England, and
By Morton and Ashhursf in this country. The last-
mentioned author combined the statistics from various
sources, and, after the manner of Mr. Holmes, he
divided life into three periods of twenty years each.
The total number of cases thus tabulated is sum-
marized as follows:
Table I. — Percentage of Mortality at Different Ages.
Whole
number of
Mortality
below 20
years.
Mortality
between 20
and 40.
Mortality
over 40
years.
General
death
rate.
2,619 16.7 30.1
43.4
29.4
Table II. — Percentage of Mortalitt Before and After
Thirty Years of Age.
Whole number
of ca-ts.
Mortality Mortality General death
below 30 years, above 30 years. rate.
1,805
19.2 37.4
26.7
The comparatively excellent results after amputa-
tions in children must Be attributed to the rapidity
with which even large wounds unite in them, to the
resistance which their ordinarily unvitiated constitu-
tions offer to septic processes, and to their freedom
from visceral complications. The ease with which
even large amputations are supported in childhood
was particularly impressed on the mind of the writer
By the case of a lad of seven, in whom he had ampu-
tated Below the shoulder for railway injury. Because
he was not given the freedom of the ward, the boy
escaped from the hospital (Good Samaritan, in
Cincinnati) on the eighth day after the operation.
The wound had healed per primam.
The very unfavorable results which follow amputa-
tions in advanced life are readily- accounted for by the
reduced vitality of the system at large. By the imper-
fect nutrition of the stump from impaired integrity
of the blood-vessels, and By the rapidity with which
these patients succumb to septic infection, or post-
operative pneumonia. It is extremely probable that
if the latter could be prevented the marked influence
of advanced life on the results of amputations would
be materially lessened. Thus of sixty-one uncompli-
cated amputations made by Volkmann. in persons
over fifty, only 4.S per cent. died. Among these was
a successful amputation of the thigh for injury in a
man eighty-four years of age.
277
Amputation
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Seat of Operation. — The danger of an amputation
always increases with the size of the wound and its
proximity to the trunk — amputations of the lower
extremity yielding a greater mortality than those of
the upper. Since about thirty-two per cent, of the
deaths following amputations are directly attributable
to the combined shock and hemorrhage consequent
upon the injury and the operation, it is easily under-
stood why the mortality varies in the manner indi-
cated. The dangers of septic infection also increase
with the size of the wound, and when amputation
wounds fail to unite by primary union, death often
results from the exhaustion consequent upon pro-
tracted suppuration. The situation at which the bone
is divided also materially influences the result.
The opening of the medullary cavity of a large bone
like the femur or tibia is more apt to be followed by
osteomyelitis and its consequences than is the division
of the bone through its articular end. This is well
shown by a comparison of the results of amputation
through the lower third of the thigh and through the
femoral condyles, the former operation yielding a
mortality of thirty-nine per cent, against twenty-nine
per cent, of the latter.
The ratio of deaths following amputations for
injury and disease in different parts of the body is
well illustrated in a subjoined table which is based
upon large hospital reports issued from 1S64 to Ins I.
For exceptional operations (hip-joint and elbow)
reports of cases from private practice were included.
This doubtless explains the apparently greater mor-
tality of amputation of the thigh than of the hip,
since relatively more successful than unsuccessful
cases are thus recorded.
Nature of Lesions. — Very potent in its influence on
the results of amputations are the causes for which
they are made. When the operation is resorted to in
an individual who, while in perfect health, has received
a severe injury from which he has probably lost a
considerable amount of blood, the prognosis is much
less favorable than when it is made for disease.
This applies particularly to amputations after railway
injuries and traumata inflicted by heavy machinery.
The shock and hemorrhage are very often so severe
Table III. (From Max Schede).
Amputations for
Amputations for
lnjury.
disease.
o
:•> j
o
=■>.!
— . t. .
$ 2 S
z - r.
H go
S j=
3 -O
1 i
o S
B2 %
Si 3 2
3-B
£ 05
Z
z
Z
z
Amputation —
55
39
70.9
153
65
42.6
of thigh, upper
73
57
78.0
42
15
35.7
third.
of thigh, middle
67
50
74.6
137
55
10.1
third.
of thigh, lower
149
71
50.0
205
64
31.0
third.
of thigh, through
136
44
32.3
79
20
25.4
condyles.
of thigh, locality
1.3S4
664
48.0
2,494
S17
32.7
not specified.
314
130
103
54
32.8,
41.5
123
17S
30
44
24.4
of leg, upper and
24.7
middle third.
of leg, lower third.
33
3
9.1
128
19
14.0
of leg, locality not
1,956
785
40.0
1,695
215
12.7
specified.
of foot, partial.. .
223
45
20.2
562
70
12.4
at shoulder- joint.
271
116
42.3
IIS
33
28
1,167
23
364
6
31.2
26.0
441
8
SI
1
18.4
at elbow-joint. . . .
12.5
1,316
143
10.8
506
62
12.2
199
337
5
6
L> . 5
1.8
27
329
of fingers and
6
1.8
toes.
It will be seen from the table given below that the
statistics indicate with remarkable uniformity the
greater mortality of amputations when made for
injury than when made for disease. The explanation
generally offered for this feature of the prognosis of
amputations is that patients who have for a long time
been subjected to suppurative processes (necrosis,
TABLE IV.
Amputations for
injury.
Amputations for disease.
Total Amputations.
Authority.
Number
of cases.
Number of
deaths.
Mortality,
per cent.
Number
of cases.
Number of
deaths.
Mortality,
per cent.
Number
of cases.
Number of
deaths.
Mortality,
per cent.
1S2
4 17
846
106
1 1 1
28
130
72
1S6
388
355
159
115
117
201
202
57
58
21
24
24
77
126
84
72
33
64
45
24
54
40
75
19
33
41
32
2 1
46
29
378
679
524
58
94
52
1S7
2S
371
338
305
409
424
1S2
147
102
IS
32
25
7
4
73
40
48
99
55
48
2°
19
31
33
4S
3
14
19
12
16
24
13
560
1.126
1,370
164
238
SO
317
100
557
726
660
568
539
299
34S
304
75
90
46
31
28
150
166
132
171
88
53
31
22
Billroth (1860-67) . .
46
38
57
9 +
28
27
23
20
30
16
Total.. .
3.158
1,096
34.7
3,847
832
21.6
7,005
1,928
27.5
that death results within a few hours after the opera-
tion. The prejudicial effect of a trauma on the
results "f amputations is still further enhanced if the
subject is addicted to intemperate habits. This was
well illustrated in the Cincinnati riots in 1SS4. Those
injured were for the timst part more or less under the
influence id' alcohol when wounded, and four-fifths of
those on whom amputations were made succumbed.
caries, etc.), are so inured to suffering that they bear
the shock of an operation comparatively well, and
that they are less prone to septic infections which are
so often the immediate cause of death titter amputa-
tions for trauma. The correctness of this view is
substantiated by the fact that about seventy-five
per cent, of so-called pathological amputations are
made for chronic inflammatory conditions of either
278
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Amputation
bones or joints, and that under these circumstances
tin' soft parts are usually more or less atrophied, and
yel at the same time densely infiltrated with a connec-
tive-tissue growth which, when divided in an opera-
tion, presents a barrier to the absorption of deleterious
elements. It is noteworthy, as Mr. Bryant has pointed
out, that this infiltration of the soft parts does not
necessarily interfere with the ready union of the
wound. While amputations for chronic affections of
the nature indicated terminate fatally in only four-
teen per cent, of the cases, those made for deformity
and neoplasms present a mortality of 26. S per cent,
and forty-six per cent, respectively (Golding Bird and
S pence).
Tables V. and VI., while they show the great
reduction in the mortality of amputations in general,
Mill demonstrate the greater mortality of operations
done for trauma. That the difference is not so marked
in my own table (V.) is due to the fact that many
of the pathological amputations were made for senile
gangrene.
Tadle V. — Major Amputations Done at the Cincinnati Hos-
pital from January 1, 1890, to January 1, 1900.
Injury.
Disease.
•6
u
o
>
o
a
-3
3
O
H
c
Hi
o
u
a
•6
>
a
Ci
~6
0)
s
o
o
o
Leg
54
4
11
3
5
57
4
16
5.2
31.3
22
2
17
1
2
1
3
24
3
20
1
8.3
3.3
nigh
Hip
1.5
Wrist
2
11
1
2
12
Elbow
S.3
3
*3
11
2
4
11
6
3
1
3
1
Total
95
13
108
13.7
19
6
55
10.9
* One multiple injury.
Table VI. — Amputations Done During Twelve Years Prior
to 1895, Newcastle-on-Tyne. (Page.)
ta
3
>
o
s
u
1)
s
3
>
o
5
fc
Ph
55
0)
Ph
13
7
6
46
tation,
Hip-joint
6
3
3
50
23
14
9
3.9
Thigh
52
39
13
25
1.31
141
10
6.4
7
76
7
69
2
70
2
67
7
9.2
3
4.2
26
2.".
1
3.8
[22
120
2
1.6
Shoulder
17
16
1
5.8
15
14
1
6.6
37
31
3
8.1
IS
17
1
5.5
36
7
35
7
1
2.S
31
31
Total
277
212
35
12.6
435
109
26.
5.9
Multiple Amputations. — While it is comparatively
rare that disease or injury affects more than one
extremity in a degree sufficient to warrant double
amputations, these are nevertheless occasionally re-
quired. It is self-evident that they are of the gravest
importance and present a most unfavorable prognosis,
on account of the shock associated with the injury.
Of twenty-eight double amputations made in the West-
ern Pennsylvania Hospital, twenty-seven were for rail-
road accidents and fifteen of the patients died. The
fact that eleven of the deaths occurred in the first forty-
eight hours shows that they were due rather to the in-
juries than to the amputations. Of thirteen multiple
amputations done for injury at the .Newcastle
Infirmary six, or forty-six per cent., died. When
multiple amputations are made for disease, which is
in about ten per cent, of all cases, they are usually for
frost-bite.
Table VII. — Multiple Amputations in
Military Practice.
"5
| i
EJ
>
o
~. 8
*D .5
2j
si
3 "
a
U ~
* 2
„° a
Ph
Both amputations in the
17
31
16
34
upper extremity.
One amputation in upper,
43
21
21
1
50
one in lower extremity.
Both amputations in lower
S2
31
50
1
61.7
extremity.
Total
172
83
87
2
50.5
Tarle VIII. — Multiple Amputations in Civil Practice.
Number
of
.■uses.
Recovered.
Died.
.Mortality,
per cent.
Thighs
18
21
5
7
42
11
12
9
15
3
9
2
4
20
6
10
6
11
15
12
3
3
22
5
2
3
4
83
Thigh and forearm.. . .
57
60
43
52
45
Foot and foot
Forearm and forearm.
16
33
27
Total
140
71
69
49
The mortality attending multiple amputations, it
will be seen from the preceding tables, is about fifty
per cent., amputations through the lower extremities
presenting a greater fatality than those of the upper.
The first table illustrates the mortality of these am-
putations in military practice. The second table,
made up from German, English, and American re-
ports, shows the relative frequency and fatality of
multiple amputations as they are made in different
parts of the body.
When the necessity for multiple amputations arises,
the question must be considered whether they shall be
made at the same time, when they are called syn-
chronous amputations, or whether a longer or shorter
interval shall intervene between them. In these
cases, as in amputations generally, no definite rules
can be formulated. In cases of trauma it is generally
advisable to make both amputations at the same
time, removing the larger member first, but deferring
the closure of the wound until both amputations are
completed. If, after the first operation, the condition
of the patient is such as to preclude the possibility of
recovery if the second is performed at once, the less
injured member must bo treated as if the injury
sustained by it were of a less degree of severity and
justified an attempt at conservatism. In cases of
disease affecting several extremities (frost-bite, white
swelling, etc.), it is generally better to observe a,
sufficient interval between the operations to permit
the constitution to rally from the first before the
second amputation is made. In these cases the
danger of septic infection from the limb that is spared
is not as great as in cases of traumatic origin.
279
Amputation
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Even triple and quadruple amputations are
occasionally performed with success. In a case of
railway accident, Dr. G. Koehler, of Schuylkill Haven,
Pa., in 1S67, removed simultaneously both legs and
one arm from a lad thirteen years of age, recovery
taking place. Professor Stone, of New Orleans, had a
similar case in a man of thirty, the subject of a railway
accident. According to Professor Agnew, successful
triple amputations were made in York, Pa., in 1868,
and Rochard reported to the Academy the case of
DeLeseleuc of Brest, who had successfully amputated
a thigh, leg, and arm in a man the subject of trauma.
Quadruple amputations, usually made for frost-bite,
have been successful in the cases of Muller, of the
United States army, Begg, of Dundee, and Cham-
penois, of the French army. Other cases are referred
to by Morand, Longmore, and Southam. Larrey
mentions two cases, one of which, the case of a soldier
who had all his extremities removed by heavy ord-
nance, he had seen in the "Invalides." The other
case, which he had seen in Algiers, was that of an Arab
twelve j'ears of age who had intentionally placed
himself on the track in such a position that a passing
train mangled both hands and both feet. Still another
successful quadruple amputation for frost-bite has
recently been recorded by Tremaine.
Individual Amputations.
Amputation op the Fingers. — When the pha-
langes of the fingers or thumbs are the seat of incur-
able disease or of severe injury, amputation often
becomes necessary. It is well to remember that if
the bone of the distal phalanx alone is affected, its
natural exfoliation should be awaited, when the soft
parts can often be preserved, to the great advantage
of the patient. Particularly in the thumb and index
finger is it necessary to save as much as possible.
In the third and fourth fingers amputation should
not be practised at the second joint, since the pres-
ervation of the proximal phalanx leaves a part that
is ungainly and does not add to the usefulness of the
hand. When a portion of a finger requires removal
the operation may be practised either at a joint or in
the continuity of a phalanx. In both cases it is
important to remember that when the finger is flexed
the articulations are below the prominences made by
the knuckles, the distal, middle, and proximal articu-
lations being respectively one-sixth, one-fourth, and
one-third of an inch below the most prominent lines
of the joints. It must also be borne in mind that
strong lateral ligaments prevent, until they are
divided, the complete exposure of articular surfaces
(Fig. 124). When the amputation is to be made at
the joint, it can be most ex-
peditiously executed in the
following manner: The
hand being held in the prone
position, the tip of the finger
encased in a piece of gauze
is firmly seized by the oper-
ator and flexed. With a
long and narrow knife an
incision is made from side
to side over the dorsal sur-
face. By this the joint is
at once opened. With two rapid strokes of the
point of the knife the lateral ligaments are next
severed. The blade of the knife, with edge directed
downward, is then placed behind the flexor surface of
the phalanx to be removed, from the soft parts of
which a well-rounded flap, is to be cut from within
outward by a sawing movement. The wound pre-
sents the appearance shown in Fig. 125. Only when
there is an insufficiency of flap is it proper to remove
the head of the proximal bone. The disarticulation
of a phalanx can also be effected by transfixion: the
Fig. 124.
hand being held in a supine position and the finger
extended, the latter is transfixed on the palmar side
of the bone, just below the fold of the joint; a palmar
flap of sufficient length is then made. The flap being
held out of the way, the joint is made prominent by
hyperextension and opened. The soft parts on the
dorsal surface of the joint are then divided by a
single sweep of the knife. In amputations of the
fingers, the soft parts of the palmar aspect are always
preferable for a flap, since the cicatrix is then pro-
tected from pressure.
Where they cannot be
utilized, a dorsal flap
can be made, either
by transfixion or,
what is preferable, by
cutting from without.
Lateral flaps, single
or double, can like-
wise be utilized in this
amputation. In amputations in the continuity of a
phalanx the flap may be cut from the palmar aspect
by a transfixion, the dorsal surface being divided by a
transverse incision, or a second flap may be formed.
The circular operation, with longitudinal lateral cuts,
may likewise be successfully practised in this position.
After the division of the soft parts, the bone must be
divided with a metacarpal saw or the cutting forceps.
In all amputations of the fingers two digital arteries
usually "spirt." Their ligation is unnecessary;
the approximation of the wound surfaces generally
suffices for their closure.
Amputation of an entire finger at the metacarpo-
phalangeal joint can be readily accomplished as
follows: The adjacent fingers being held aside by an
assistant, the operator with his back to the patient
grasps the finger to be removed with the left hand and
extends it sufficiently to see its palmar surface. A
narrow knife being introduced from the right side
divides the soft parts on the palmar surface on a level
with the extended interdigital web. The incision is
then carried around the right side of the finger (Fig.
120, Esmarch) in a slight curve into the dorsal surface
Fig. 126.
of the head of the metacarpal bone. The knife is then
carried around the left side of the finger in the same
manner, the ends of the first incision being thus
joined. The tendons, lateral ligaments, and capsule
being successively divided, the disarticulation ia
completed and a heart-shaped wound left. The
margins of this wound come accurately into contact,
when the remaining fingers are approximated to one
another. When comeliness of the hand is valued
more than strength, it is best to remove the head of
the metacarpal bone with cutting forceps (Fig. 127),
since its preservation usually leaves an unsightly
prominence. In persons who do manual labor its
280
reffkexcf handbook of tiik medical sciences
Amputation
removal should be avoided, since it would materially
lessen the strength of the hand.
The incisions for disarticulations of the thumb,
index and little fingers may often l>e advantageously
modified in such a manner as to make two lateral
llaps, the longer of which is on the free side of the
tiger, the shorter being made on the side of the
tnterdigital web. To preserve the symmetry of the
hand, t he heads of the Second
and fifth metacarpal bones
should always be removed by
an oblique section when the
index and little fingers are
amputated. \\ hen I no or more
fingers are to be removed, it
can easily be done by making
two convex flaps, one on the
dorsal and the other on the
palmar aspect of the hand,
the latter being given the
greater length. A flap may
likewise be taken
from the side of
one finger, or
reel angular flaps
from the opposite
surfaces of the
fingers that are
farthest from
each other. In
amputations of a
number of finger-
it is generally
best to remove
Fia. 127. each finger sepa-
rately, since un-
issary sacrifices for thesakeof brilliancy will thereby
be avoided and a better result be obtained. When,
in consequence of accident or disease, the metacarpal
bone must be removed with the finger, the incisions
are like those for the removal of an entire finger, only
that the dorsal cut must be continued upward toward
the wrist for a varying distance, and that the incision
around the root of a finger is to be made above the
interdigital web. The extensor tendons being divided
as high as possible, and the bone separated from its
muscular attachments, this is divided with cutting
forceps near its articular extremity or entirely enucle-
ated. When the surgeon has the option, the former
practice should be preferred, to avoid
opening the articulations of the wrist.
Exceptions can be made in the first
and fifth metacarpal bones, which,
having individual synovial sacs, may
be removed without the danger of
producing extensive inflammation of
the wrist. Amputation of the entire
thumb should rarely be practised, for
every portion of it that can be saved
is of value for opposition to the fin-
gers. When it becomes necessary
to remove the thumb with its meta-
carpal bone, it is best accomplished
by the oval method. The point of a
knife should be entered above its
articulation with the carpus, and a
triangular incision (Fig. 12S) made
along its radial aspect, the sides of
the triangle diverging from each
other as they approach the head of Fig. 128
the metacarpal bone and becoming
continuous with each other in the web and index
finger. The muscles being detached and the extensor
tendons divided, disarticulation is readily effected
by forcibly' extending the thumb toward the radial
side and severing the ligaments. In disarticulating,
the edge of the knife should be kept close to the base
of the bone, lest the joint between the second meta-
carpal and trapezium, and through it the remaining
Carpal joints, be opened. After this operation a
linear cicatrix remains. The most expeditious
method <>i amputating the thumb yet devised is that
of Walther, and is admirably suited to cases in which
an a nes i he tie is not used. The thumb being abducted,
the knife is made to cut its way between the lir-1 and
econd metacarpal bones until the base of the former
is reached (Fig. 11".)). The thumb being greatly ab-
Fia. 129.
ducted, the joint between its metacarpal bone and
trapezium is opened and traversed. The knife is
then carried downward upon the radial side of the
bone, where, by cutting outward to the level of the
interdigital web, a radial flap is made. Amputations
of the little finger with its metacarpal bone can be
made in the same manner, either by the oval or by the
flap method.
Injuries of the palm of the hand are generally of
such a nature that by a little ingenuity on the part
of the surgeon part of it can be preserved. "\\ hen in
rare cases disarticulation of the last four metacarpal
bones becomes necessary, the thumb being left, it
may be done as follows: The hand being grasped
and held in supine position, a long, narrow blade is
passed through the palm from the base of the fifth
metacarpal bone to the web of the thumb. By cut-
ting outward, a broad semilunar flap is made (Fig.
130). An incision is next made on the back of the
hand, beginning at the web of the thumb and carried
obliquely upward to the upper third of the second
metacarpal bone,
whence it is continued
transversely over the
three last metacarpal
bones until it meets the
palmar flap at the ul-
nar border of the hand.
Both flaps are thus re-
flected to the carpo-
metacarpal joints, and
disarticulation is ef-
fected from the ulnar
side, the hand being
forcibly abducted.
Amputation at the
Wrist. — In amputa-
tions at the wrist the
surgeon has the choice of the circular and the tegu-
mentary flap methods, both of which leave an excel-
lent stump.
Circular Method. — Retracting the skin of the fore-
arm with his left hand, the operator carries the knife
in a circular sweep around the hand one inch below
the styloid processes. The skin and subcutaneous
layers, being liberated by incisions perpendicular
to the axis of the limb as far as the styloid processes,
should be reflected like a cuff. The hand being then
pronated and forcibly flexed, the tendons are divided
and the joint opened by an incision over the dorsum
from one styloid process to the other. In making this
Fig. 130.
2S1
Amputation
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
incision the convexity of the upper surface of the
carpus must be remembered. The lateral ligaments
being next severed, the anterior part of the capsule
and all the flexor tendons are cut through with one
stroke of the knife (Fig. 131).
Fig. 131.
Anteroposterior Flap. — The operator seizes the
lower part of the pronated hand, and after flexing it
makes a semilunar incision over the middle of the
back of the hand from one styloid process to the other
(Fig. 132). After reflection of the flap the joint is
opened as in the circular operation, and the operation
is completed by cutting a short palmar flap from
within outward (Fig. 133). The projection of the
pisiform bone often renders this part of the operation
embarrassing.
Method of Dubreuil. — A very excellent result can be
obtained by making a single lateral flap, either from
the radial sur-
face of the
thumb or from
the soft parts
covering the
fifth metacar-
pal bone, the
former being
preferable. As
will be seen
from Fig. 134,
the operation
c onsis ts in
making a semi-
lunar flap with
broad base,
from the integ-
ument which
covers the first
me tacarpa 1
bone, the point
of the flap
reaching the
base of the
first phalanx. A transverse incision around the wrist
is then made and disarticulation is completed as in
the other operations.
Amputation of the Forearm maybe practised
by the circular, tegumentary, or musculotegu-
mentary flap method. The lower third of the
forearm, containing a large number of tendons, is
ill suited for the latter method, the circular oper-
ation being preferable (Fig. 135). When the in-
tegument is greatly infiltrated and the reflection
of a cuff is thereby rendered impracticable, tegument-
ary flaps can be made, the tendons being divided by
a circular incision (Fig. 130). The presence of a large
number of synovial sheaths, and the danger of inflam-
282
Fig. 133.
mation in them when they are opened should not
militate against the value of operations in the lower
third of the forearm, since, by operating below the
insertion of the pronator radii teres, movements of
pronation and supination will be preserved.
A number of surgeons prefer the flap operation in
all amputations of the forearm, making both flaps by
transfixion in fleshy subjects. Under opposite cir-
cumstances the anterior flap can be made in this
manner, and the posterior by cutting from within
outward. When
this method is
resorted to, the
bones must be
divided as high
up as possible,
to overcome
their tendency
to protrude at
the angles of
the wound.
Muse ulotegu-
mentary flaps
should be used
only in the
fleshy part of
the forearm.
In all amputa-
tions in this
part the catlin
is to be used, in
t lie man n er
al ready de-
scribed. The divided tendons and nerves must
be drawn from the wound and cut as short as
possible. The arteries requiring ligation are the
radial, ulnar, and interosseous. It is particularly
essential that the latter should be divided but once,
and carefully secured. When secondary hemorrhage
occurs after amputation of the forearm, it is almost
always the result of faulty ligation of this vessel.
Amputation at the Elbow. — The removal of
the forearm at its articulation with the humerus is
generally acknowl-
edged to have been
first performed by
Ambrose Pare, in
1536, in the case of a
soldier who had re-
ceived a gunshot
wound of the fore-
arm, which was fol-
lowed by gangrene.
The operation did not
meet with much favor
by surgeons generally, until it w r as again advised and
practised in the second quarter of this century by
Textor of Wtirzburg, by Dupuytren, and by Liston.
With the exception of Chenu's statistics, the results
of amputation at the elbow have been very favorable,
the death rate not exceeding fourteen per cent.
(Agnew). The last-named writer, however, gives a
mortality of sixty-five per cent, as that which attended
disarticulations of the forearm during the Crimea.
On the other hand, of thirty-nine amputations at the
elbow, made during the War of the Rebellion, in which
Fig. 134.
Fig. 135.
the result was determined, only three succumbed; the
mortality being less than eight per cent.
The operations generally resorted to in amputations
at the elbow are the circular and musculotegumentary
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Amputation
flap methods. When the former is practised, a circu-
lar incision should divide the skin and subcutaneous
cellular layer of the forearm ui least two inches below
the humeral condyles. When a cuff of sufficient
length has been reflected, the anterior surface of the
joint is made prominent by hyperextension, and
divided by a transverse cut with the end of the knife.
When the lateral ligaments are next divided, the
joint surfaces are sufficiently separated from each
other to permit the knife to be passed behind the
ranon, where the tendon of the triceps is to he
divided. The latter step of the operation is some-
times attended with such difficulty that many sur-
preserve the olecranon process by sawing the
transversely after disarticulation of the radius
has been effected. The advantages which are to he
nned by it.-- preservation, on account of the in-
fluence which the triceps will have over the artificial
limb, are more than balanced by the increased
dangers of retention of secretion in the wound and
i >>is.
Excellent results can also be obtained by tegumen-
tary flaps. As represented in Fig. 148 (Esmarch), a
curved incision is made over the flexor surface of the
forearm, beginning and ending about one inch below
the condyles. The large semilunar flap thus made is
reflected to its base. A second, but shorter convex
flap is made posteriorly, which, when reflected,
exposes the olecranon. The operation is then com-
pleted by disarticulation, as in that by the circular
method. The most brilliant operation, and at the
same time a very satisfactory one, is that by which a
long anterior flap is made
by transfixion. The
knife, being introduced
a little less than an inch
below the external con-
dyle (for the right arm)
of the humerus, is pushed
directly across the front
of the articulation to a
point on the same level
on the opposite side.
The arm being held in a
supine position, a broad,
almost rectangular flap,
from four to five inches
in length, is made by
cutting outward. The
ends of the wound should then be united by a slightly
convex incision carried across the posterior aspect of
the joint. Disarticulation is then effected as in the
previous operations.
When the soft parts of the anterior portion of the
forearm cannot be utilized, the integument of the
posterior surface can be shaped into an admirable
covering for the end of the bone. Ashhurst thus
describes the elliptical incision by which this is ac-
complished: " The arm being semiflexed, the point of
the knife is entered nearly an inch below the internal
condyle of the humerus, curved upward over the
front of the forearm nearly to the line of the joint, and
downward again to a point an inch and a half below
the external condyle; the arm being then forcibly
flexed, the ellipse is completed on the back of the
forearm by a curved incision passing nearly three
inches below the tip of the olecranon. The cuff thus
marked out is rapidly dissected upward as far as
necessary, when the muscles of the front of the forearm
are cut about half an inch below, and the ulnar nerve
as far above the joint, and disarticulation is effected
from the outer side. The wound is closed transversely,
forming a small curved cicatrix in front of the bone!"
It is probably always advisable, except in eases of
disease, to preserve the articular surface of the hu-
merus intact, although Sir William Ferguson believed
that a section above the condyles leaves a preferable
stump, and one more likely- to heal promptly. In all
\ %w ~ T~ ~~^— —
Fig. 136.
amputations at the elbow, the radial, ulnar, and
interosseous arteries require ligation. When the in-
ci~i. ui through the soft parts anteriorly is made on a
higher level than is ordinarily necessary, the brachial
may be divided and require ligation.
Amputation of the Asm. — This may be perform-
ed at any point below the axillary- folds, and all the
methods of amputation may he used with advam
in different cases, since the choice of methods often
permits the operator to save a considerable portion of
Fig. 137.
the arm. On account of the central position of the
humerus, the arm is properly considered the typical
position for the double musculotegumentary flap
operation by transfixion, and many surgeons prefer
this method in this situation. The objection to be
urged against it is the unequal retraction of the in-
tegument and underlying muscles, the latter gener-
ally protruding a varying distance over the cutaneous
margins of the wound. Agnew properly advises that.
to overcome this unequal retraction, anteroposterior
oval skin flaps should be raised of sufficient length to
compensate for the difference in muscular and cutane-
ous retraction; after these are made, the muscular
flaps are formed either by transfixion or by cutting
from within outward. The latter plan of operating,
although less brilliant than that by transfixion, should
always be preferred in amputations of the arm in
Fig. 138.
very fleshy subjects. In making the flaps, the
posterior should always be made first, the anterior,
containing the important vessels and nerves, being
made last. According to the dimensions of the limb,
the flaps should be made from two to three inches in
length.
In slender subjects, the circular operation answers
admirably. In exceptionally thin arms, the integu-
ment can be retracted sufficiently to make the opera-
tion by a single circular incision. As a rule, however,
283
Amputation
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
it is best formally to reflect a cuff (Fig. 137), or to
make rectangular cutaneous flaps by slitting the
cuff on each side. In dividing the muscles by a
circular incision, the biceps generally retracts more
than the remaining muscles. The wound is often
so irregular in consequence that a second division of
the muscles becomes necessary (Fig. 138). In cases
of injury attended with great destruction of the soft
parts on the dorsal aspect of the arm, the Teale
method, by rectangular flaps, offers particular advan-
tages. The incisions for making the long anterior
flap must be made in such a manner that the inner
one shall be without the brachial artery, which should
be contained in the short posterior flap.
In amputations through the middle and lower
thirds of the arm, the circulation can be controlled in
the ordinary manner by the Esmarch tube or tourni-
quet. In amputations higher up, where the tourni-
quet would be in the way of the operator, and liable
to slip, the main artery can be compressed against
the head of the bone by an assistant, or against the
first rib above the clavicle. When a tourniquet is
used in amputations in the upper part of the arm, it
should be so applied that a roller covers the axillary
artery in the arm-pit, while the plate of the tourni-
quet can be fixed against the acromial process of the
scapula. The arteries requiring ligation after ampu-
tation of the arm are the brachial, superior or in-
ferior profunda, occasionally the anastomotica, and
four or five muscular branches. It should be remem-
bered, likewise, that in every fifth subject, according
to Quain, there is a high division of the brachial into
radial and ulnar.
In 5,273 cases of amputation of the arm for gunshot
injury, 1,246, or 23.6 per cent., terminated fatally.
The gravity of amputation of the arm does not
increa-e with the extent of the limb removed, am-
putations through the lower third presenting a
mortality of thirty-five per cent, against nineteen
per cent, for amputations in the middle and twenty-
two per cent, for those of the upper third. In the
statistics of Gorman, derived from civil practice, this
remarkable feature in the prognosis of amputations
of the arm is even more pronounced, the mortality
following amputations in the upper, middle and
lower thirds being twenty-three per cent, twenty-one
per cent, and forty-four per cent, respectively. Of
fourteen amputations of the arm in the Cincinnati
Hospital all recovered. Of 157 amputations of the
arm collected from the recent statistics of Erdmann.
Page, and my own, twenty, or 12. S per cent., died.
Fur the comparative mortality after amputations of
the arm for injury and for disease the reader is re-
ferred to Tables III., IV., and V.
Amputation- at the Shoulder. — Although this
operation was referred to by ancient writers on
medicine, it was not performed as a formal operation
till 1710, when the elder Morand performed it with a
fatal result in a case of caries. The case was not
recorded until some years later, by the younger
Morand. The second operation, which was success-
284
ful, was made in 1715 by the elder Le Dran, likewise
for caries. That the arm had previously been re-
moved at the shoulder in a case of gangrene appears
in the Jour, de Med. de M. Dc la Roque, 1686. "The
surgeon took a small saw to remove the bone of the
arm, but perceiving that it was loose in the joint, he
gave it several slight 'jerks', when the bone was
readily drawn from the socket." Ravaton, La Faye,
Heister, and Bromfield repeated the operation from
time to time on the Continent and in England, but it
remained for the distinguished Larrey to give it a
Fig. 140. — Showing Wyeth's Pins and the Rubber Tubing in
Place. A piece of black court plaster indicates the tip of the
acromion. (Taken, by permission, from Keen's article on shoul-
der amputations, in the Transactions of the American Su:
Association for 1S94.)
firm footing among surgical procedures. Of 111
amputations made by him at this part, ninety-seven
recovered.
In all amputations of the shoulder, the circulation
in the axillary artery must be controlled. This can
be accomplished by the use of the rubber tube of the
Esmarch bandage firmly wound around the axilla
and shoulder, and held by an assistant or cL
toward the neck of the patient (Fig. 139). To prevent
the slipping of the strap, which is likely to occur \\ hen
the head of the humerus leaves the socket, two long
transfixion pins may be used, the one in front of and
the other behind the acromion. The anterior pin is
introduced through the middle of the anterior axillary
fold near the trunk line. It is made to emerge an
inch above the shoulder, one inch to the inner side of
the acromial tip. The second pin transfixes the
posterior axillary fold in the same manner, emerging
behind the acromion (Fig. 140). In all amputations
of the shoulder the joint
should be approached
from the outer side, so
that the artery shall not
be divided until disartic-
ulation has been effected.
In this manner an assis-
tant can, if necessary,
pass his thumb into the
wound above the knife
(Fig. 141) and compress
I he vessel before it is cut.
Two pairs of pedicle
clamp forceps with
blades three inches long
applied above the line
of division of the inner
flap, the one from in front
and the other from be-
hind, will perfectly con-
trol the artery while the operation is being completed.
Thereby skilled assistance, and even the Esmarch
strap, can be dispensed with. The hemorrhage is
from the smaller vessels only and is slight. When
the axilla is invaded so high that this plan of
Fig. 141.
REFERENCE BANDBOOK OF THE MEDICAL SCIENCES
Amputation
hemostasis is impracticable, the axillary shouUl In-
tied by dividing the pectoral muscle as suggested by
Delpech, or the subclavian should be tied in its third
part, as a preliminary step to the amputation. When
such precautions as have been described can be taken,
it is not necessary to make a preliminary ligation of
the artery in the axilla. Amputations at the shoulder
joint can be made by the oval or flap method, and
likewise by a circular operation with external longi-
tudinal incision.
Oval Method. — This operation, generally designated
rey's operation (as shown in Fig. 139), is per-
formed as follows: The patient being placed in a
semi recumbent position, with the part to be amputated
projecting over the edge of the operating table, the
point of the knife is introduced just beneath the point
of the acromion process, and carried down over the
external surface for a distance of from two and one-
half to four inches, according to the dimensions of the
part. This incision should divide all the tissues down
to the bone. From the center of this incision an oval
cut is carried around the arm, passing a little below
the axillary folds, but involving only the skin and
superficial fascia. The flaps thus outlined are
carefully liberated from the bone. The capsule is
then freely opened by a transverse cut over the head
of the humerus, and the arm is rotated inward and
outward to facilitate the diyision of the tendons of
the articular muscles; in this part of the operation,
the edge of the knife must be kept in close contact
with the bone. The operation is completed by
dividing the soft parts on the internal surface of the
arm on a level with the cutaneous incision already
made. "While it is not essential, in this operation, to
cany the oval incision completely- around the arm
before beginning the dissection of the flaps, it is
preferable, since, without it, the lower part of the
oval wound is very apt to be ragged and uneven. The
wound following this
operation is united
so as to leave a linear
cicatrix parallel
to the axis of the
body (Fig. 142, from a
photograph of one of
Ashhurst's patients).
Circular Method. —
In cases in which the
humerus is shattered
to such a degree that
it cannot easily be
used in the manipula-
tions necessary for
effecting disarticula-
tion, the following
modification of the
circular incision will
answer admirably:
The arm being ab-
ducted, a circular in-
cision at the lower
border of, or through,
the deltoid divides all
the soft parts down to
the bone. This, if necessary, is divided on the same
level, and all the gaping vessels are Iigated. When
the amputation of the arm is thus completed, a long
incision, dividing all the soft parts, is made from the
tip of the acromion over the external surface of the
shoulder to the circular wound. The remaining stumd
of the humerus is then seized with a strong pair of
forceps, and liberated from its muscular attachments
and from the joint by short incisions directed well
against the bone (Esmarch).
Flap Method. — Amputation at the shoulder by the
flap method can be made either by transfixion or by
cutting from without inward. The latter method,
while less brilliant, is preferable in every way. It
Fig. 14_\
Fiq. 143.
should be performed in the following maimer: In
amputation of the left arm the operator begin- his
incision at the coracoid process, and carries it down
over the anterior surface of the shoulder to the level
of the insertion of the deltoid, across which it i~ carried
in a wide curve; it is then prolonged upward on the
posterior surface of the shoulder to the junction of
the acromion with the spine of the scapula 1 1 it:. 143).
This broad flap, including a great part of the deltoid,
is then raised by rapid strokes of the knife and reflected
over the acromion in order that the joint may be
exposed. This is made prominent by pushing the
head of the humerus
upward, and is to be
i ipened by a trans-
cut upon the latter.
The head of the bone is
now easily dislocated.
The knife is then car-
ried behind the hu-
merus (as shown in
Fig. 141) and down its
inner surface to a point
one or two inches below
the axillary fold, when,
by rapidly cutting out-
ward, all the soft parts
on the inner side are
divided.
In making this oper-
ation by transfixion
(Dupuytren's method)
the arm must be held
at a right angle with
the body, while the
surgeon grasps and raises the fleshy part of the
shoulder with the left hand. The knife is entered one
or two inches behind the acromion and pushed directly
across the front of the joint, emerging just outside the
coracoid process of the scapula. Transfixion being
effected, a broad flap is cut from within outward.
The further steps of the operation are similar to those
above detailed.
Both of the operations described leave a wound
that, from its position, is more readily drained than
that which is left by the oval method. The cica-
trix which remains is transverse in direction and
curvilinear.
A wound closely resembling that left by Larrey's
oval operation remains after the formation of postero-
external and antero-internal flaps by Lisfranc's
method. In practising this method, when the left
arm is to be removed, a long and narrow amputating
knife is introduced at the margin of the posterior
axillary fold. The blade is then pushed along the
posterior surface of the humerus until the head of the
bone has been cleared, when the counter-puncture can
readily be made an inch beneath the clavicle and on
the outer side of the coracoid process. A broad
postero-external flap must then be shaped by cutting
from within outward. The capsule is then opened as
in other operations, and an antero-internal flap cut
likewise from within outward. In operations on the
right side the posterior flap is also made first; the
surgeon, standing behind the patient, inserts the
point of the knife from above and lets it emerge from
the posterior axillary fold.
Professor Spence of Edinburgh introduced a method
of amputating which is but a modification of the ova]
operation, in which the perpendicular incision is made
upon the head of the humerus, nearer to its
inner than its outer surface. This incision is com-
menced just beneath and outside of the coracoid pro-
cess and carried through the clavicular fillers of the
pectoralis major and deltoid muscles until the hu-
meral attachment of the former is reached. From the
lower end of this incision the external and internal
curvilinear incisions are almost the same as those of
285
Amputation
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
the oval operation as generally practised. The ad-
vantages claimed by Professor Spence for this modi-
fication are the facility with which the disarticulation
can be effected, the avoidance of injury to the main
trunk of the posterior circumflex artery, and the better
shape of the stump.
The prognosis of amputation of the shoulder has
been very greatly improved. For example, from
Estes's statistics from the South Bethlehem, Pa.,
Hospital, of twenty-two amputations at the shoulder
joint done during twenty years only one died. This
is in contrast to the amputations done on the battle
field or in military hospitals. Of seven cases re-
ported by Col. Stevenson, two or twenty-eight per
cent. died. Most of these cases were septic when
operated on.
IxTEKSCAPULO-THORACTC AMPUTATION. In the
first edition of this work fourteen cases of avulsion
of the entire upper extremity were referred to, which
ended favorably. In Ashhurst's "Surgery," seven-
teen cases are recorded of such avulsion which ended
favorably. Here also are recorded eighty-nine cases,
in which the entire upper extremity including the
Fig. 144. — Interscapulo-Thoracic Amputation. (After Treves.)
scapula and part of the clavicle was removed by
operation, with sixty-seven recoveries and twenty-
two deaths. Bergmann has put on record fourteen
amputations of the entire upper extremity, with only
one death. Favorable cases have likewise been
recorded by Chavasse, Ochsner, Keen, Doll, and
Heddaens. Barling" collected nineteen cases operated
on within five years without a death. Jeanbrau
Riche collected 188 observations from sixty surgeons.
The mortality was 11.1 per cent. But, while the
operations performed before 1S87 or when the tech-
nique was imperfectly developed, showed a mortality of
29. 16 per cent. ; those performed after 1887 showed one
of only 7.84 per cent. If cases in which intervention
was contraindicated are left out, the figures could
be reduced to 5.2 per cent. Of 125 cases in which
the nature of the new growth had been determined
by a microscopic examination, recovery followed in
105. Of the twenty others, ten died from operation,
and reports about another ten could not be obtained
(Rodman). The operation is indicated in cases of
severe crush of the upper extremity when exarticula-
tion at the shoulder would not suffice, and in neo-
plasms of the upper extremity when it is essential to
get as far as possible from the disease. The first opera-
tion was done by Gumming, in 1808, for gunshot
injury; the second, in 1830, by Gaetaui for a severe
trauma from an explosion. In 1887 Paul Berger
tabulated all of the cases recorded up to that time, and
submitted the most comprehensive monograph upon
tin- subject.
As in amputations at the shoulder joint, the control
of hemorrhage is the essential point of the operation.
It is now the consensus of opinion that the first step
of the operation should be the resection of the middle
third of the clavicle as a preliminary step to the
tying of the subclavian artery and vein. It is
essential to tie the latter as well as the artery, in order
to prevent the ingress of air. According to the
publication by Nasse of Bergmann's cases, the Berlin
surgeon begins his operation with the typical ligation
of the subclavian artery to the outer side of the ante-
rior scalenus muscle. This is followed by division of
the clavicle. The arm is then elevated and the sub-
clavian vein tied. The brachial plexus is at once
divided. Ochsner has called attention to the fact
that this plexus ought to be divided with a sharp
knife rather than with scissors, since the shock is
thereby greatly lessened. Le Conte has wisely
suggested the complete excision of the clavicle in
place of resection of its outer portion. In malignant
disease it is preferable, and when once accomplished
simplifies the control of the vessels. The cutaneous
incision must vary somewhat according to the degree
to which the soft parts about the shoulder are in-
volved. Bergmann makes an anterior incision,
through the skin only, from the incision made for the
division of the clavicle straight through the axilla to
the lower angle of the scapula. The posterior in-
cision is made over the dorsal aspect of the scapula
from the resection line of the clavicle to the end of the
anterior incision. The illustration will indicate the
lines of incisions recommended by Treves. That for
the antero-inferior flap extends outward from the
incision made for the division of the clavicle to the
outer and lower border of the axilla, which it crosses
directly from before backward, whence it passes
downward to the lower tip of the scapula posteriorly.
The posterior incision extends across the upper sur-
face of the shoulder, from which it inclines over the
scapula to its lower angle, as seen in the illustration.
After the lifting of the cutaneous flaps, the muscles
are divided and the small vessels tied as they are
encountered. In one of Kern's cases, owing to the
involvement of the parts about the acromion, an oval
incision was made beginning three inches above the
acromion, each limb passing in front of and behind
the shoulder respectively, and meeting in front of the
inferior angle of the scapula. In the cases of recovery,
the wounds heal within the course of ten days or two
weeks. In operations for malignant disease, the prog-
nosis is far more favorable when it is done for myeloid
sarcoma than for periosteal sarcoma. The prognosis
is more favorable in those cases in which the soft parts
about the shoulder are not involved. Thus in all the
cases of Heddaens recurrence rapidly took place.
Amputation of the Toes. — It is occasionally
necessary to remove the toes in consequence of
accident, disease, or deformity. While in cases of
accident, it may occasionally be well to save a part of
one of the smaller phalanges, it is generally best that
the amputation be made at the metatarso-phalangeal
joint. In amputations of the phalanges, a flap
operation, like that for the fingers, must be made,
care being taken, as in all amputations of the foot,
that the cicatrix is placed on the dorsal aspect of the
stump. In amputations of an entire toe, the in-
cision should be commenced on the dorsal surface of
the metatarsal bone, a little above the joint, but
considerably above the web, and carried directly
down an inch or more. It is then carried obliquely
around the web on each side, in such a manner as to
preserve as much of the soft parts as possible. This
preservation of tissue is necessary for a sufficient
covering for the large head of the metatarsal bone.
When the operation is performed in this manner, the
cicatrix is linear and entirely removed from pressure.
No part of the metatarsal bone should be removed,
lest the strength of the foot be deteriorated. Dis-
articulation of the great toe may be effected by the
oval method just described, or by the formation of
286
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Amputation
an internal flap. In 1 ho latter case, an incision is
begun on the outer side of the extensor tendon, just
below the joint, and carried longitudinally to the head
,,i the first phalanx, from its lower end an incision
j- carried transversely around the inner side, to the
flexor tendon, along the outer side of which it is
continued backward to the plantar fold, whence it is
again given a transverse direction around the outer
siTle of the toe until it meets the first incision near its
center (Stimson). The rectangular flap thus marked
out. is dissected up, the tendons are divided, and
disarticulation is effected. Although it is s times
ommended, the head of the lirst. metatarsal bone
should never be re ved unless it is implicated in the
lesion, since it tonus one of t ho most important points
of support in the foot.
Amputation of all the toes at the metatarso-
phalangeal joints may be made by carrying a curved
incision along the groove between the base of the toes
and sole of the foot from one margin of the latter to the
other. The toes being forcibly flexed, a similar
incision is made along the dorsum, which joins the
ends of the plantar wound. The semilunar flaps
thus formed are dissected back as far as the meta-
tarso-phalangeal joints, when disarticulation of the
individual toes can be made. It certainly _ cannot
be often that a formal operation of this nature is called
into requisition.
Amputation through the Metatarsus. — In
consequence of injury or disease it not unfrequently
becomes necessary to remove a part or all of the
metatarsal bones. In amputations through individ-
ual bones of the metatarsus, conservatism must be
particularly insisted upon, since, except in that of the
great toe, the complete removal of a metatarsal
Bone cannot be accomplished without opening the
large synovial sac which separates it from the first
row of the tarsus. For amputations through the
second, third, and fourth metatarsal bones, the
longitudinal incision necessary for disarticulation at
the metatarso-phalangeal joint must be carried
upward for a distance varying according to the
extent of bone to be removed. A short transverse
incision is then made to facilitate the separation of the
soft parts and the use of either chain-saw or bone-
cutting forceps. When the bone has been divided.
its distal end is drawn from the wound with a pair of
stout forceps, and the operation is completed by
severing the soft parts on the plantar surface of the foot
with short strokes of the scalpel. The removal of the
first and fifth metatarsal bones can be accomplished
by the oval method or by internal and external flaps
respectively. The oval method, where it is practi-
cable, is doubtless preferable, since it yields a smaller
wound and a cicatrix protected from pressure. The
incisions for the oval amputations of the great toe
with its metatarsal bone are well shown in Fig. 145.
( in account of the great width of the base of the latter
bone, a short transverse incision facilitates the libera-
tion of the flaps. In disarticulations of the fifth
metatarsal bone the oblique line of its articulation
with the cuboid bone should be borne in mind.
When the first or fifth metatarsal bone is amputated
in its continuity, the section should be made obliquely
to avoid undue prominence of the stump.
Amputation in the continuity of all the metatarsal
bones is not very infrequently called for, in consequence
Of injury or gangrene following frost-bile. \\ hen it can
be resorted to, it is preferable to amputation through
ihe tarsometatarsal articulation. The operation is
commenced with a curved incision carried along the
anterior furrow of the Bole of
the foot , from bonier to border,
and the semilunar flap thus
outlined is reflected to the line
where section of the bones is
to be made. A smaller semi-
lunar flap is then shaped from
the dorsal surface of the foot.
The interosseous soft parts are
then divided transversely with
a narrow knife,
and retracted by
means of narrow
strips of linen, when the bones
are sufficiently exposed for the
application of the saw (Fig.
140). The appearance of the
wound resulting from t his oper-
ation is well shown in Fig. 1 IT.
In this age of conservatism
Fia. 146. in surgery, in which "the least
sacrifice of parts" is the lead-
ing tenet of surgical creed and practice, every half-inch
of the foot that can be saved to the economy is properly
considered of incalculable value. It is for this reason
that, whereas before the times of Hey, Chopart, and
Lisfranc, amputations of the foot above the ankle
were made comparatively often, they have of late
been largely replaced by partial
amputations through the differ-
ent articulations which it con-
tains. The partial amputations
which will be considered are the
tarsometatarsal, the mediotarsal,
the subastragaloid, and their
modifications.
Tarsometatarsal Amputa-
tion. — A glance at Fig. 149
shows the difficulty which the
surgeon must contend with in
this amputation of the foot. It
is the firm impaction of the base
of the second metatarsal bone
between the internal and ex- Fig. 147.
ternal cuneiform bones. In
1797, Mr. Hey, of Leeds, overcame this difficulty by
disarticulating the outer metatarsal bones, and divid-
ing the prominent internal cuneiform with a saw.
.Surgeons after him have generally adopted the plan of
separating the outer three and the internal metatarsal
Fig. 148.
bones at their articulations, and dividing the base of
the second metatarsal below its articulation with the
middle cuneiform. When disarticulation of all the
metatarsal bones is effected the operation is known as
Lisfranc's (1815).
2S7
Amputation
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Lisfranc's amputation of the foot is made as follows:
The joint between the cuboid and prominent base of
the fifth metatarsal bone having been marked on the
outer side of the foot, and that
between the first metatarsal and
internal cuneiform (about one inch
and a half below the tuberosity of
the scaphoid) on the inner side, a
large semilunar incision is made
between them on the sole of the
foot, the convexity of which should
pass over the heads of the metatarsal
bones. The plantar flap thus out-
lined may then be dissected up to
its base. The foot being then for-
cibly extended, a slightly convex
dorsal incision is carried between
the ends of the plantar flap (Fig.
149). The flaps being retracted and
the foot forcibly extended, the
operator opens the joint from the
outer or inner side, according to
whether the right or the left foot
be the seat of the operation (Fig.
150). The articulation of the second metatarsal
bone, which is less than half an inch above the
general level of the joints, must then be opened by a
transverse cut, the lateral attachments of the bone
Fig. 149.
Fig. 150.
to the cuneiform being severed with the point of the
knife by longitudinal incision (Fig. 148). When all
the joints are widely opened by this process, the re-
maining ligaments at the side and sole of the foot, and
the soft parts still undivided, are
severed. As the operation is gen-
erally performed, the plantar flap
is merely outlined by an incision
through the skin in the first step
of the operation, the flap being
cut from within outward after dis-
articulation has been effected.
The vessels usually requiring liga-
tion are the dorsal artery of the
great toe, the metatarsal branches,
and the plantar arteries. When
the parts are brought together
by suture, the stump should be
placed in a posterior splint, to
overcome the contraction of the
powerful muscles of the calf of
the leg. In Hey's amputation,
the external incisions are identical
with those necessary for the Lis-
franc operation. The cicatrix
resulting from either of these procedures is far re-
moved from pressure, and the stump, on account of
it- length, is one admirably fitted for use.
288
Fig. 151.
Mediotausal Amputation. — Although Garengeot
and Heister mentioned the practicability of ampu-
tation between the rows of the tarsal bones, the
operation was first performed by "Du Vivier of
Rochefort in 1781. In 1701 Chopart repeated the
operation a number of times. anc ] published his
Fig. 15U.
Fig. 152.
experience with it. It has since been known as
" Chopart 's amputation," and the joint between the
rows of the tarsus is not infrequently designated by
his name. Although it was opposed by Larrey, who
preferred to amputate in the lower part of the leg,
the operation was popularized by Roux and Walt her
on the Continent, and by Mr.
James of Exeter and by Syme, in
Great Britain.
The articulation between the
scaphoid and the head of the
astragalus, and that between the
cuboid and os calcis are respec-
tively placed one-half inch above
the tuberosity of the scaphoid on
the inner border, and one inch or
more above the prominence of the
fifth metatarsal bone upon the
outer border of the foot. These
two points being fixed, a curved
incision, extending to within an
inch or less of the heads of the
metatarsal bones, is carried across
the sole of the foot, and connects
them. The foot being then forci-
bly extended, a curvilinear inci-
sion, with convexity below, is carried between the
same points across the dorsal surface. The small
dorsal cutaneous flap thus outlined is retracted, and
by one stroke of the knife the tendons are divided
and the joint widely opened. The point of the knife
then divides the la.e.al and plantar ligaments, which
are put on the
si ret eh by forcible
extension until the
articular surfaces
of the scaphoid
and cuboid bones
are completely
liberated. By in-
serting the knife
behind these
bones, the plantar
flap is completed
by cutting from
within outward
(Fig. 152). The vessels requiring ligation are tin-
dorsal and two plantar arteries, and occasionally a
few muscular twigs. The appearance of the stump
after the completion of Chopart 's amputation is well
shown in Fig. 153, from Esmarch.
The only difficulty at times encountered in this
operation is in the opening of the joint in front of
instead of behind tlie scaphoid bone. The error is
readily recognized through the presence of three
Fig. 154.
REFERENCE HANDBOOK <>F Till'. MEDICAL SCIENCES
Amputation
articular facets cm the anterior surface of the scaphoid
DOne> and ran easily be corrected if it be desired, or
:!,, operation may be completed by dividing the
cu boia bone with a saw on a line with the anterior
, ,. of the scaphoid. In this ma unci' the operator
would be practising Forbes' modifi-
cation of the mediotarsal amputa-
t ion, a mm lificai inn also menl ioned
by Mr. Hancock and Professor
Agnew.
After Chopart's amputation, the
gastrocnemius and soleus having
exclusive control of the stump,
there is a marked tendency toward
iis hyperextension. This may as-
sume such a decree (lull I lie cical rix
itself will he pressed upon in loco-
motion. This objection to the
operation is best overcome by
bandaging the leg from above down-
ward, and keeping (he limb flexed.
In extreme cases the difficulty is
easily remedied by division of the
tendo Achillis, and forced flexion
of the stump.
SuBAsruAOAi.oiD Amputation. —
Although, according to Velpeau, this operation was
I by De Lignerolles and by Textor, it was first
given prominence by Malgaigne, in 1846. In this
amputation all the bones of the foot, except the
astragalus, are removed. The operation is com-
menced by an incision, which, beginning behind and
i m me tl iat ely
abov ■ the great
tuberosity of
the os calcis, at
once divides the
tendo Achillis.
The incision is
then carried in
a wide curve on
the outer sur-
of the os
below the
external malle-
olus (Fig. 154,
Malgaigne). Thence it is continued over the middle of
l lie cuboid and anterior margin of the scaphoid, across
the dorsum of the foot (Fig. 155), and over its inter-
nal border to the center of the sole (Figs. 150 and 157).
From this point the incision is turned at a right
angle and continued directly back till it meets the
beginning of the incision at the inner
border of the tendo Achillis (Es-
march). The short internal and long
internoplantar flaps thus formed arc
dissected up until the lateral surfaces
of the os calcis are exposed, when dis-
articulation of the anterior part of
the foot is effected in the mediotarsal
joint. The anterior end of the os
calcis being then seized with a lion-
jawed forceps, and rotated from side
to side, the operation is completed
by dividing the external lateral and
interosseous ligaments. The appear-
ance of the stump after this opera! inn
is shown in Fig. 158 (Esmareh). The
marked irregularities of the inferior
surface of the astragalus do not inter-
fere with its usefulness in locomotion.
In a case of gangrene in a deformed
limb, Linhart performed the sub-
astragaloid amputation, and was enabled two years
later to examine the stump. The astragalus, which had
maintained a perpendicular position before, and even
at the time of amputation, had been forced into its
normal horizontal position by the act of walking.
Vol. I.— 19
Fia. 156.
Fig. 157.
Fig. 158.
A number of modifications of the subastragaloid
amputations, both in the direction of the inci ions
and in the preservation of parts of 'in- c, calcis, have
been devised. In the operation of Mr. Hancock, a.
large plantar flap i.-; reflected a fai back a i he i uber-
osities of the calcaneum, and a short dorsal flap is
formed by a transverse incision across the fool on a
le\ el u ii h i he anterior margin of the
astragalus. By (he use of a saw, the
plantar flap being ret racted, a per-
pendicular section of the os calo is
then made in front of the tuberosities.
Disarticulation of the foot, with the
anterior port ion of tin rj calci .in (lie
mediotarsal joint is next effected, and
the operation completed by making
a transverse section of i he astragalus.
When the flaps are approximated the
divided surfaces of the latter bone
and os calcis are broughl into appo-
sition. The operation of Mr. Han-
cock, although as ingenious as that of
1'irogolf, is much more difficult of ex-
ecution, and lime will probably show
that the results obtained from it are
far less valuable. In Tripier's opera-
tion the incision is made in the form
of an oval, the apex of which is on the outer side of the
foot, just beneath the external malleolus, while the
Miles pass forward and inward over the back and sole
of the foot, and meet at its inner border. After
disarticulation in the mediotarsal joint, a transverse
section of the os calcis completes the operation.
Partial amputations of the foot, at least in civil
practice, are not attended with great mortality. Of
152 cases of Chopart's amputation examined by
Hancock, only eleven terminated fatally, seven per
cent.; the fatality following this operation in France
has been much greater, fourteen out of thirty-eight
cases recorded by Larger (3G.8 per cent.) having died
(Ashhurst). Of twenty-two cases of the subastrag-
aloid amputation, twenty recovered.
Of 123 partial amputations of the foot, made during
the Civil War, in which the result was determined,
eighteen were unsuccessful, the mortality being
fifteen per cent. Of these partial amputations there
were eighty-three of the mediotarsals, with eleven
deaths; twenty-three Lisfranc operations with one
death, and seventeen Hey's amputations with six
deaths. Of sixteen amputations of the foot at the
Cincinnati Hospital, one died. The mortality accor-
ding to Erdmann's tables is 7.8 per cent. According
to Page's tables the mortality is 3.8 per cent, for
traumatic and 1.6 per cent, for pathological cases.
In making a partial amputation, it must be remem-
bered that the
value of the stump
for locomotion is
proportionate to
the length of foot
maintained. Man-
ufacturers of arti-
ficial limbs main-
tain that conserva-
tism is out of place
here, ami that am-
putation several
inches above the Fig. 159.
ankle should be
given preference over partial amputations m front of
or at the ankle.
Amputation at the Ankle. — Historically associ-
ated with this operation is the name of Synie of
Edinburgh who, in 1842, devised and practised a
method by which a shapely and useful stump could
be obtained after removal of the entire foot. Dis-
articulation at the ankle had been performed during
the last and early part of this century. It was pcr-
289
Amputation
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
formed by S6dillier, Rossi, and Baudens, and recom-
mended by Brasdor and Sabaticr. But the circular
ration of the latter and the dorsal flap method of
Baudens yielded alike unsatisfactory results, and the
operation was, therefore, discarded for amputation
in the lower part of the leg. Lateral flaps taken from
below the malleoli, as suggested by Velpeau, also
failed to form a sufficient cushion for the end of the
tibia. This great desideratum in amputation at the
ankle is squarely met by the operation of Syme,
since its principal feature is the retention of the integ-
ument of the heel, which is accustomed to pressure, to
form the end of the stump. The operation is made
in the following manner: The foot being held at a
right angle to the body, the malleoli are fixed by the
thumb and fingers of the left hand, the heel resting
between them. A perpendicular incision touching
the bone is then made across the sole of the foot from
the tip of one malleolus to that of the other, the
incision on the inner side, however, ending at least
one-half inch below the malleolus (Fig. 159). The
posterior lip of the wound is then seized with the left
hand, and the soft parts covering the calcaneum are
separated from it by short strokes of the knife, which
must be kept close against the bone to prevent
perforation of the integument and damage to tin-
plantar vessels. When, by this process of dissection,
the tuberosities of the os calcis nave been fairly ex-
posed, a transverse incision joining the two extrem-
ities of the first is carried across the instep (Fig. 159).
The ankle-joint being thus opened from in front, the
knife is carried down on each side of the astragalus
until the lateral ligaments are divided, when complete
disarticulation is effected. By forcibly depressing
the foot the tendo Achillis should then be divided
from before backward, when by a few strokes of the
knife the foot can be removed (Fig. 160, Esmarch).
Fig. 160.
Lastly, the knife is drawn around the extremities of
the tibia and fibula, so as to expose them sufficiently
for being grasped in the hand and removed by the
saw. "After the vessels have been tied and before
the climes (.1 the wound are stitched together an open-
ing should be made through the posterior part of the
flap where it is thinnest, to afford a dependent drain
for the matter."
The appearance of the wound after Syme's amputa-
tion is well shown in Fig. 161. It will be seen thai
the heel flap presents the form of a cup, which must
be flattened by pressure against the bones of the leg.
While there is danger, therefore, of making the flap
too short, there is likewise a danger in making it too
long, since a pouch would be formed for the retention
of inflammatory products.
Moschcowitz 12 modified the Syme operation by
making osteoplastic flaps, whereby no exposed bone
is left in the wound. From the external malleolus
he chisels a triangular wedge and from the internal
malleolus a rectangular wedge. When the exposed
bone surfaces are brought in contact only bone
covered by periosteum and the cartilaginous lower
end of the tibia come in contact with the wound.
The favorable results which follow Syme's amputa-
tion in civil practice are shown by the statistics of
Hancock and Spence, who, among 316 operations,
found only 25 deaths (7 per
cent.). In military practice
the results are far less favor-
able. Of 159 amputations
made at the ankle during the
Civil War, and in which the
result was determined, 40
terminated fatally (25.1 per
cent.).
Pirogoff's Amputation. —
On the principle that by
preserving the posterior por-
tion of the calcaneum the
natural length of the limb
could almost be preserved,
Pirogoff, during the Crimean
war, devised the osteoplastic
operation that bears his name.
It differs from the operation
of Syme in preserving a por-
tion of the os calcis, in the
expectation that it will unite
firmly to the divided end of
the tibia. The incisions for
this amputation are identical with those made in
Syme's operation. After opening the joint from in
front, the foot is depressed until the posterior ex-
tremity of the astragalus is exposed, when a saw is
introduced behind this, and the os calcis divided ex-
actly on a level with the incision in the sole of the
foot (Figs. 162 and 163, Esmarch). Both malleoli
and a thin section of the tibia are removed, as i,i
Syme's operation. It is generally advisable to divide
the tendo Achillis and at the same time to perforate
the skin for the passage of a drainage tube. The
Fig. 161.
appearance of the stump after a successful Pirogoff
amputation is well shown in Fig. 164, taken from a
man who died three years after the operation was
made by Linhart.
A number of modifications of Pirogoff's amputa-
tion have been devised. Ferguson and Agnew have
wedged the end of the os calcis into the interval
between the malleoli, and have obtained good re-
sults. Different methods of dividing the bone have
been devised by Sedillot, Gunther, Le Fort, and
Bruns, to remove the pressure from the thin part of
290
REFERENCE HANDBOOK OF TIIK MKDH'AI. SCll'.xri'.S
Amputation
ili,' integument on the back of the heel, which mil I
bear it after the Pirogoff amputation, and to keep the
retained part of the os calcis in its natural position.
Sgdillot and i Silnthei . therefore, ad-
vised t liat an oblique sect en 1 1
abi i\ e dowm* ard and forw ard I oi
the calcaneum, tii>ia. and fibula be
made. Le Fort ( Fig. 163 i advised
a Iran- verse ection of t he bone, by
imp obtains a very
broad base.
Bruns has
modified t he
operation of
Le Fort by
sawing the
os calcis in
such a man-
ner as to
make the
upper sur-
face of the retained part concave, the concavity thus
formed receiving the convex section of the tibia and
fibula.
A further modification of Syme's amputation is
that of Guyon. It is an amputation above the mal-
leoli. The operation is begun with an elliptical in-
Fig. 163.
Fig. 164.
cision beginning one inch above the lower edge of the
tibia in front, which, passing obliquely in front of the
ankle, crosses the heel below the attachment of the
tendo Achillis. The posterior portion of the flap is
dissected from the heel and the tendon divided close
to its insertion. The anterior extensor tendons are
divided transversely
as high as possible.
After the malleoli are
exposed the fibula
and the tibia are
divided just above
them. The heel end
of the flap is then
brought forward to
cover them. The
suture line is safe
from pressure.
A comparison of
the merits of Syme's
amputation and its
osteoplastic modification shows that a cure follows
more rapidly after the latter than after the former,
although the mortality of Pirogoff's amputation
against 21.4
147 cases of
in military practice is
Fig. 165.
per cent.
per cent, following that of Syme. Of
Pirogoff's amputation collected bj li
"hl\ foui ' ' ived fatal, and Volk-
mann has performed the operation thirty-fo
without a death. Considering the number of reampu
tations after S\ me' and Pirogofi operation l
ter would seem to 1 ii ul. < >f eighty-
t In- -i-es cif Syme's amputation, i v enty, or twenty-
four per cent., submit ted to reamputation ; ol fo
nine Pirogoff's operation . eight, or L6.3 per rent.,
were subjected to reamputat ion.
In cases of caries involving all the bone- of the tar-
sus, preference should be given to the Syme opera-
tion, since disease is not unlikely to develop in the
retained segment of the calcaneum. In traumatic
the greater ease with which it is made and the
length of limb which follows it should incline the
operator to choose the operation of Pirogoff. That
necrosis often follows the latter operation is emphatic-
ally denied by its originator, who had never witne ''I
it in over sixty cases in which he had performed it.
Amputation op the Leg. — An amputation may
be performed in any part of the leg. according to the
nature and seat of disease or injury. When the sur-
geon can select the seat of operation, the amputation
should be made two or three inches above the mal-
leoli, on account of the greater safety of the opera-
tion in this locality and the greater power to be
exerted over an artificial limb. In all amputations
of the leg, the fibula should be divided from half an
inch to an inch above the saw line of the tibia, to
prevent pressure against the outer wound margin.
The operations which have hitherto been most fre-
quently performed in amputations above the malleoli
are the circular and that by lateral flaps. Unhappily,
the anatomical construction of the part is such that
after these operations the cicatrices are central and
not infrequently adherent, and therefore unable to
bear pressure. In this situation M. Guyon practises
the elliptical method. According to Stimson, this
operation promises well. " The incision is made in
the form of an ellipse, whose lower end crosses the
heel below the insertion of the tendo Achillis, and
whose upper end is about an inch above the anterior
articular edge of the tibia. Beginning at the lower
end and dividing the tendo Achillis at its insertion,
and hugging the bone all the way, the operator dis-
sects up the flap posteriorly as high as the upper end
of the ellipse. The anterior muscles are then divided
by transfixion, the bones sawn through, and the pos-
terior tibial nerve resected. In this operation the
sheath of the tendo Achillis is not opened, and the
tendon itself serves afterward as a covering for the
ends of the bones."
Fig. 166.
In amputations in the lower third of the leg in
fleshy subjects, a long anterior flap containing the
interosseous muscles may sometimes be used with
advantage (Bell).
The rectangular operation of Teale may likewise be
practised in this region, the long anterior flap being
made from the soft part of its anterior aspect (Fig.
134 see above, Methods of Amputation). By this
method the cicatrix, being placed posteriorly, is out
of the way of pressure.
291
Amputation
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
In the middle and upper thirds of the leg very
many operators amputate by means of anteropus-
terior flaps, after the following manner (for the left
limb): The point of the knife being entered at the
posterior edge of the tibia, an incision is carried down-
ward along this for a distance of an inch and a half
or two inches; then by a wide curve across the ante-
rior surface of the leg it is continued to the posterior
border of the fibula, up which it is carried until
the level of its commencement on the opposite side
is reached. The broad flap thus outlined is rapidly
operation the knife is entered a little external to
the crest of the tibia, and while the soft parts are
drawn to the outer side with the left hand, it is made
to graze the surface of the fibula and to perforate the
posterior surface of the limb as far to the inner side
of the fibula as possible. By cutting downward
close to the bones a broad rounded flap three to
four inches long is formed. The extremities of this
flap are then united by a slightly convex incision
across the anterointernal aspect of the limb. '[ he
remaining soft parts being
then divided by circular in-
cision, the operation is com-
pleted in the ordinary way.
In Langenbeck's operation,
the internal incision is semi-
circular, and the external flap
being cut from without pre-
Fio. 167. Fig. 16S. Fig. 169. Fig. 170.
Figs. 167 to 170. — Osteoplastic Amputation, after the -Method of Bier. (Langenbeck's Arch. f. Chir., vol. xlvi.)
dissected up, the interosseous muscles being care-
fully severed from the underlying membrane. The
posterior flap is then made by transfixion and cutting
from within outward, and should be about three
inches long (Fig. 166, Erichsen). The flaps being
held out of the way, the catlin is to be used for com-
pleting the division of the interosseous soft parts,
care being taken that the arteries be divided trans-
versely and only once. After division of the bones
with a saw, the sharp anterior edge of the tibia should
be removed with the saw or bone-cutting forceps.
For the upper portions of the leg the long poste-
rior rectangular flap amputation advised b3 r Henry
Lee gives an excellent result. Tin' incisions, similar
to those of the Teale operation, involve only the skin,
the long flap being made from the posterior, the short
one from the anterior surface of the limb. With
the long posterior flap only the superficial muscles
of the calf are reflected, the remaining soft parts
being divided by a circular incision. A good covering
is likewise obtained in this region by an external flap,
made either by transfixion (Sedillot), or by cutting
from without inward (Langenbeek). In the former
292
sents a smoother surface and a more perfect outline.
The arteries requiring ligation after amputation of the
leg are the tibials, peroneal, and a varying number of
muscular-branches.
,S iili/n rinst, nl Amputation. — When amputations of
the leg are unsatisfactory, it is chiefly because of two
things, namely, gangrene of the flaps, and the ten-
dency of the stump to become conical, or. at any rate,
to be unable to bear pressure. It is for this reason
that Bruns devised his subperiosteal amputation, of
which he reported seventeen cases in 1S93. Accord-
ing to a report by Hahn 13 this operation was per-
formed in eighty-four cases without a death. In only
three cases was there gangrene of the flaps and in only
two cases was a second amputation necessary. The
operation is performed as follows: The skin being
well retracted by an assistant, a circular incision
involving all the soft parts is carried down to the
bone. The two perpendicular incisions, from two to
three inches in length, are then made, one along the
inner border of the tibia, the other between the mus-
cles over the fibula. Both incisions are carried to the
bone through the periosteum. Through these inci-
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Amputation
aiona all the sofl parts, including the periosteum,
are raised from the bone. After the soft pari- are
well retracted the bones arc divided in the usual way.
\i ;i . r the amputation has been completed, there
remain an anterior and a posterior Hap of periosteum,
muscles, and skin. The mu cles are united sepa-
rated by buried suture. When the amputation is
in the upper portion of the leg, tne circular
incision through the skin is made as a higher level
than thai through the muscles.
Osteoplastic AmptUations of the Leg.— la 1892,
Bier' firs! described a method of securing a weight-
bearing stump, which, in patients who are unable to
purchase an artificial limb, secures for them a stump
which will bear the body weight. The operation con-
sists of the usual circular amputation. Thereupon
follows, through an oval window cut into the sofl
parts, a cuneiform excision of part of the Sbula.
a the resection surfaces of the tibia are brought
apposition a kind of artificial foot project - ante-
riorly. The posterior surface of the tibia covered
by the -oft parts of the calf bear pressure. Bier has
ned iii many cases with uniformly good results.
Some German surgeons think that this should l>e
the normal procedure. A number of minor modifi-
cations of the original method have been made.
When there is any possibility that the patient can
scrim- an artificial limb, the operation has nothing
to commend it. Figures 167 to 170 will illustrate
the method of amputation and the result.
Since good results follow all the different methods
of operation in the middle and upper portions of the
leg, the surgeon should be guided in his choice solely
by the desire to sacrifice as little of the limb as pos-
sible. An exception should probably be made in the
upper portion of the upper third, where it is better
to amputate at the knee than to save only the por-
tion of the tibia above its tubercle.
The mortality following amputation of the leg, as
ha- already been seen, is largely determined by the
conditions necessitating it. According to Chadwick,
the mortality- of pathological amputations is sixteen
per cent.; that of amputations for trauma nearly
thirty-seven per cent. The general mortality of the
operation at Guy's Hospital for a period of thirty
years was thirty-five per cent.; that for traumatic
amputations being fifty-five per cent., against fifteen
per cent, following those for disease. Volkmann who
employs a long anterior and short posterior flap per-
formed the operation in fifty-four cases with only
four deaths (seven per cent.), of which there were
fourteen traumatic cases with only two deaths
(fourteen per cent.). Of forty-six amputations in the
lei; made by Brums, seven succumbed (sixteen per
lent.). The fatality following amputations of the
leg in military' practice is well shown by the stat is-
le- of Otis. Of 5,314 amputations in which the
result was determined, 1,753 terminated fatally, the
mortality being 32.9 per cent. From statistics ob-
tained during the late War of the Rebellion, it appears
that amputation of the leg is attended with least
danger when performed in the middle third". The
fatality of operations in the upper third was twenty-
en per cent., in the middle third, 20.6 per cent..
and in the lower third, 27.6 per cent. The mortality
of amputations of the leg has been greatly reduced.
Of eighty-one amputation- of the leg five, or 6.2 per
cent., died. In the New York hospitals the mor-
tality is twelve per cent. In the Newcastle-on-Tyne
Infirmary it is nearly seven per cent.
Amputation at the Knee. — According to Sab-
atier, this operation was first performed by Fabricius
Hildanus in 1581, in a case of gunshot injury. Al-
though advocated by Guillemeau (1612) in prefer-
ence to higher amputation, there is no record of a
repetition of the operation until 1764. when it was
successfully performed by Hoin of Dijon for trau-
matic gangrene. Brasdo'r and J. L. Petit advised
the operation, the latter having twice witnessed it.
In L830, Velpeau attempted with success firmi- to
establish the operation by citing a number of sua
iHi cases. The operation was first performed in thi
country by Nathan Smith, of New Haven, in 1824,
since which time it has gradually grown in popularity.
Fergusson and Legouesl for a long ii [uestioned
the advisability of the operation, preferring amputa-
tion in the lower portion of ilc thigh. Tne rea o
which prevailed to give this operation recognition
are the greater length of the slump and it>. ability
to bear pressure, tin- smaller probability of pyemia,
lie- medullary canal remaining unopened, ami,
most important of all, the smaller mortality which
follows thi- operation, at least in civil practice, as
compared with amputations of the thigh.
Fig. 171.
Amputation at the knee may be practised by either
the circular, the flap, or the oval method. In all
methods of amputation it is best, if possible, to pre-
serve the semilunar cartilages. Thereby the fascial
attachments are maintained intact and the tendency
to retraction of the flaps is greatly reduced. The
circular operation recommended by Velpeau, San-
son, and Malgaigne, made by an incision two or three
inches below the patella and the reflection of a cuff,
is difficult of execution, and should be resorted to
only when an insufficiency of tissue prevents the adop-
tion of one of the other methods. The oval method
has been practised by Baudens and Sedillot, the for-
mer preferring the integument from the anterior
portion of the leg, the latter that from the posterior
portion, as a covering for the end of the femur. The
operation of Baudens is performed as follows: An
oval incision is carried around the leg, crossing its
anterior surface five finger-breadths below the end
Fig. 172.
of the patella, and its posterior surface three finger-
breadths higher than in front. The anterior and
lateral portions of the oval are then reflected until
the ligamentum patellae is fairly exposed. This is then
divided transversely, the capsule is fairly opened, and
the lateral and crucial ligaments are divided. In this
as in all amputations of the knee, the latter structures
should be divided with the point of the knife, and
293
Amputation
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
$m^'m
Fig. 173.
from behind forward, to prevent injury of the pop-
liteal vessels. When disarticulation has been effected,
the soft parts on the posterior aspect of the limb
are divided with one sweep of the knife. This opera-
tion is, doubtless, preferable to Sedillot's method,
according to which the
lower part of the oval is
placed behind.
In amputating at the
knee, a long flap may be
taken from the anterior or
posterior surface of the
leg. The latter method,
that of Hoin (Fig. 171),
can be most readily exe-
cuted, but is objectionable
on account of the excess
of muscular tissue in the
flap, and the difficulty of
establishing thorough
drainage. Lateral flaps
have been advised by
Rossi and Stephen Smith.
The operation which is
generally performed, how-
ever, is that by one long
anterior and one short
posterior flap. It is
readily performed, and
leaves a wound that is
easily drained, and a
stump in which the cica-
trix is protected from
pressure.
Operation. — The leg being raised, a semilunar flap,
three to four inches long, is outlined from the calf, the
incision beginning a little below the middle of the
lateral border of the condyles. This flap is dissected
up as far as its base. The leg being then flexed an
anterior flap four to five inches long is outlined on
the anterior surface of the leg from the ends of the
posterior incision (Fig. 172,
Esmarch). The anterior
flap is then raised from its
attachments until the liga-
mentum patellae is en-
countered and trans-
versely divided. The cap-
sule is then extensively
incised laterally and the
anterior flap including the
patella, reflected (Fig.
173). Disarticulation and
division of the soft parts
on the posterior aspect of
the limb are then effected
in the manner already de-
scribed. This operation is
preferable to forming the
posterior flap without the
guidance of a cutaneous
incision. The vessels re-
quiring ligation are the
popliteal artery and vein,
which should be carefully
separated and tied indi-
vidually. A number of
smaller arteries, sural and
muscular, will also require
ligation in the posterior
portion of the wound.
A number of operators
f Billroth among them) ad-
vise the removal of the patella, lest inflammatory
products accumulate in the pouch above it. This
prpcedgire is generally held to be superfluous, since
tin' upper part of the wound can readily be drained
without it, and the removal of the patella endangers
294
the vitality of the long flap. It is always advisable,
to insure drainage, to divide the lateral attachments
of the synovial membrane to the femoral condyles,
by which means the retention of inflammatory prod-
ucts in the pouch alluded to can be avoided.
In 1870 Stephen Smith 15 described an amputation
by "lateral hooded flap." It leaves an admirable
stump, the cicatrix being placed behind and between
the condyles. The writer gives it the preference over
other amputations through or immediately above
the knee.
Fig. 174 illustrates the incisions of this amputa-
tion and the method of forming the flaps. The inci-
sion begins an inch below the tuberosity of the tibia
and passes over the outer side of the leg and is carried
in a gentle curve to the middle of the posterior sur-
face. Here it ends opposite to tin' interarticular line.
A similar but longer flap is outlined on the inner
side. The flaps are then dissected up and are made to
include everything down to the bone. While the
flaps are being formed the limb must be maintained
in extension. The disarticulation completes the oper-
ation, the semilunar cartilages being retained in the
stump.
In the last forty years a number of modifications of
the operations just described have been introduce, 1.
They all have the feature in common that a portion
of, or the entire condyles of the femur are to be re-
moved. In 1845 Syme advised amputation through
the condjdes, making a large posterior musculo-
tegumentary flap. In 1S46 Mr. Carden first per-
formed the operation which has since borne his name,
and has become deservedly popular. The operation
consists in the formation of a long anterior flap,
which, like a hood, falls easily over the divided end
of the bone. The incision, similar to that made for
amputation at the knee, extends no farther down than
the tubercle of the tibia. The anterior flap being re-
flected, the joint is opened aboi'c the patella, which
is not included in the flap. After disarticulation has
been effected, the soft parts of the posterior aspect
of the limb are severed by a single stroke of the knife,
and the saw is applied through the bases of the con-
dyles. For the better coaptation of the cutaneous
margins of the wound Lister has advised the forma-
tion of a short posterior tegumentary flap. Mr.
Carden has recorded thirty operations, with only
five deaths from this method. Of twent3'-six Car-
den amputations made by Volkmann, three termi-
nated fatally.
In 1857 Gritti of Milan devised an osteoplastic
operation by which the articular surface of the pa-
tella is removed and placed in apposition with the
divided ends of the femoral condyles. The opera-
tion was first practised by Sawostytzki in 1862. In
this operation long anterior and short posterior
rectangular flaps are formed. Paikrt and Linhart
after raising the anterior flap amputate without
first disarticulating. In 1870 Dr. William Stokes
still further modified Gritti's operation by making
an oval flap and dividing the femur at least half an
inch 'above the anterosuperior margin of the con-
dyloid cartilage. Hence this amputation is gener-
ally known as the supracondyloid amputation, that
of Carden being known as the transcondyloid operation.
A further modification of the Gritti osteoplastic am-
putation is that of Ssabanajeff. An anterior and a
posterior flap are fashioned in the usual manner bul
the knee is opened from behind. After this has been
done the leg is hyperextended so that the anterior sur-
face of the leg and thigh are in contact. The lower
end of the femur is then divided transversely through
the thickness of the condyles. Finally a bone flap
is made over the upper and anterior part of the
tibia to which the attachment of the fibular ligament:
is left undistrubed. The sawed surfaces of the tibial
bone flap and of the femur an' then brought in con-
tact and retained by a suture. The attachmenf of
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Amputation
the patella is ool disturbed. The relative merits o)
these various methods of amputation at the knee have
extensively investigated by American, English,
.,,„! German writers. Edmund Andrews oi Chicago
j thai disarticulation al the knee and transcondy-
loid amputation present alike mortality (twentj eight
uejcent). Of < rritti's operation and Stokes' modifica-
tion Dr. R. F. Weir has collected seventy-six cases
with twenty-two deaths. In the reports of the
Munich Surgical Clinic, 1895-1907, Paul Weiden-
uesch" found there were twenty-three Gritti opera-
tions without any deaths, although primary union
Ited in only fourteen of the cases. While time
may show that the last-mentioned procedures maj
,i service in amputations for disease, sufficient
lence has been adduced by Zeiss, Beck, and
man, that, so far as military practice is con-
cerned, the operation ought to be abandoned. From
the mure recent statistics ([noted above for other am-
putations, the mortality of amputations at the knee
h il practice is 11 per cent., there being seven
deaths for sixty-two operations.
The mortality of amputations at the knee in civil
tice appears from an examination of Table III.
above). Of 1S7 amputations made for gunshot
injury, in which the result was determined, 10(3 suc-
cumbed, the mortality being 56.6 per cent., and ex-
ling by 2.8 per cent, the fatality of amputations
in the lower part of the femur.
Amputation of the Thigh. — This operation may
died for in any part of the thigh. The central
position of the femur and its extensive muscular
ring -auction the application of any of the va-
rious methods of amputation in this part. The
choice from among the different operations permits
um i at all times to save as much of the femur
as possible. Until twenty years ago amputation
of the thigh was generally performed by the trans-
fixion method, by which an anterior and a posterior
flap were formed. The rapidity and ease with which
it could be performed were its chief commendation-.
The manner in which it is generally performed i- the
following: Grasping and raising the soft parts on
the anterior aspect of the limb with his left hand,
the operator introduces the knife at the side of the
limb, at a point an inch or more below the level of the
Fig. 175.
proposed section of the femur, and, carrying it across
the anterior surface of the femur, transfixes and cuts
out a broad flap equal in length to half the diameter
of the limb (Fig. 175, Fergusson). The flap thus
formed being retracted, the knife is again introduced
into the wound behind the femur, and a posterior
:lap formed by cutting from within outward and
downward through the soft parts. The flap thus
made should be quite as long as the anterior, since
the greater retraction of the posterior muscles would
otherwise reduce it to a size that would prevent the
accurate coaptation of the cutaneous margins of the
wound. In very fleshy subjects, all of the muscular
Fig. 176.
1 1 ue hould "< i 1 1 1 , and on the left to the trochanter. The sup-
puration which was established almost separated the
right thigh, the round ligament and great sciatic nerve
alone holding it to the trunk. Lacroix, surgeon to the
hospital, completed the separation of the member.
This operation succeeded so well that four days later
he also amputated the left thigh. There was "neither
hemorrhage nor pain, and the patient progressed well
till the tenth day, when fever supervened, and death
followed fifteen days after the first operation." In
1773 Perault removed the entire thigh in a case of
traumatic gangrene "of several months' duration,"
in which a complete recovery ensued in eighteen
months.
Although in 1774 and 1778 Kerr and Thomson
made the first amputations at the hip through living
tissues in cases of coxalgia, both operations termi-
nated fatally, and the procedure was not again resort-
ed to till the last decade of the past century. Ampu-
tation at thr hip in reality owes its existence to the
wars of the French Revolution. In 1794 the elder
Blandin performed it thrice, with one recovery. Dur-
ing his different campaigns, Larrey repeated the
operation seven times and gave it a standing among
surgical procedures, although it is doubtful whether
any of his cases recovered. In 1812 and 1815,
Brownrigg and Guthrie, after repeated failures, were
enabled to report successful amputations at the hip
for gunshot injury. The first operation in this coun-
try was made in Kentucky in 1S06, by Brashear, for
compound fracture, and ended in recovery.
296
The most comprehensive statistics of the operation
in question have been collected by Otis, Liming, and
Ashhurst. Over three-fourths of all the operations
have been made since the introduction of anesthe-
sia, and fully two-thirds of the entire number were
performed later than 1860. Up to 1875 Liining was
enabled to collect but 497 well-authenticated cases
while in 1881 Ashhurst tabulated 633 operations'
since which time over 100 cases have been added to
the list.
The question of supreme moment in amputation
at the hip joint is that which pertains to a complete
anil yet safe method of controlling the circulation
during the operation. Its importance becomes mani-
fest from the fact that five per cent, of the patients
operated on do not survive the operation, and that
seventy per cent, of the deaths occur during the fir-t
five days (Liining). To overcome this great and im-
mediate danger of amputation at the hip, progress
has been made in the direction of preserving the blood
contained in the condemned part and by temporarily
or permanently occluding the sources of its blood
supply. By the use of the elastic bandage from the
toes to the groin, and by keeping it in place during
the operation (Erskine Mason), or, in cases of exten-
sive suppuration of the extremity, by maintaining the
lat ter in a vertical position for some minutes before the
operation, a not inconsiderable amount of blood can
be saved to the economy.
In I860 Pancoast first called attention to the
practicability of compressing the aorta against the
vertebral column by means of an abdominal tourni-
quet. A number of instruments have since been
devised similar to that of Pancoast, by Lister, Skey,
and Esmarch, and it is to one of these contrivances
that most surgeons have recourse before proceeding
to the operation proper. In the tourniquet of Es-
march, the aortic pad exerts its compression by mi
of an elastic band which is passed through its handle.
In the absence of a tourniquet, a pad can be impro-
vised by firmly winding a long roller bandage around
the middle of a stick, which should be about a foot
long and of the thickness of the thumb. The pad
thus formed being placed in position, is retained by
five or six turns of an elastic bandage around the ab-
domen (Esmarch). Spence resorts to a similar pro-
cedure. Whatever tourniquet be used, it should be
applied while the patient is lying on the right side, the
pad being placed a little to the left of the umbilicus
(Fig. 178, Esmarch). The operation should not be
commenced until
the operator has
satisfied himself
that the circula-
tion in the lower
extremities is com-
pletely controlled.
It having been
held, but without
sufficient clinical
evidence, that pro-
longed compres-
sion of the abdom-
inal aorta is injuri-
ous from damage
to the branches of
the solar plexus,
and by interfering
with respiration,
compression of the common iliac artery through the
rectum has been advised and practised. A\ -
bury of Philadelphia and Van Buren of New-
York proposed that this be accomplished by the hand
of an assistant, while R. Davy of London devised for
the same purpose a polished rod twenty inches long,
and from one-half to three-fourths of an inch thick,
surmounted at its extremity by an ivory enlargement,
with which the artery is to be compressed against the
Fig. 178.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Amputation
brim of tin' pelvis. 1" one case in which Davy used
the lever on the right iliac artery, deal h followed from
B rent in the rectum. In seventeen other cases in which
ho had resorted to its use an accident resulted.
\, cording to the originator of the "lever," this instru-
ment has been used in forty cases, in an ulnu >-t equal
proportion of amputations of the right and left side,
and sixty-five per cent, of the
,..(.,.< recovered. Davy 11 has re-
ported ten cases with right re-
coveries.
[ n thin or emaciated
Bubjects, the circular
(ion can be controlli
Fig. 179.
by digital compression of the aorta or external iliac
artery, or both may be employed (Gross). It may
likewise be effected by the use of a wide roller
bandage placed over the external iliac and held in
position by an elastic bandage. The latter should be
about two yards in length, its center being placed
between the anus and tuberosity of the ischium; the
anterior part of the bandage is brought above the
crest of the ilium, the posterior portion crossing the
sacrosciatic notch and meeting the anterior above
the iliac crest; both are firmly held in position by an
assistant. This method of preventing hemorrhage
from both anterior and posterior flaps has been
resorted to in four cases by Jordan Lloyd of
Birmingham; three of the patients recovered.
With the introduction of better methods
against hemorrhage, the use of the abdominal
tourniquet, of Davy's lever, and of digital
compression can no longer be advised.
In- 1S76 Trendelenburg of Rostock devised
a steel rod fifteen inches long, one-fourth of an
inch wide, and one-eighth of an inch thick,
with a movable point attachment which is to
be pushed through the soft parts in front of
the joint, an inch above the level where trans-
fixion is to be made with the knife. "The
rod having been pushed through the soft parts,
the point is removed and a rubber tube wound
around the protruding ends of the rod in
figure-of-S turns. In this manner compression
of all the soft parts in front of the joint is effected,
and the flap can be made without loss of blood. After
the vessels divided in the anterior flap have been
ligated, the rod is introduced through the soft parts
behind the joint in a similar manner before the
posterior flap is made." Although tedious in its
performance, this method of controlling hemorrhage
is thoroughly practicable and promises good results.
It has been successfully resorted to by Varrick in
a case of traumatic amputation in a subject very
anemic from hemorrhage.
In 1890, Wyeth" described a bl Hess amputa-
tion at the hip, which, while it appears to be an
amplification ot Trendelenburg's method, is exceed-
ingly simple, and can be highly recommended for
all amputations at the nip, save those rare ca
which the di ea e involves the trochanter. In these
cases the transperitoneal ligation of the external, or,
better still, of the i mon, iliac is to be pre-
ferred to the pins and constriction used by
Trendelenburg and Wyeth. The accompanying
diagrams (Figs. 17U and 180), inserted with Dr.
Wyeth's permission, illu trate the method of
the introduction of the pins.
The patient is placed with the hip well over
the end of the table, and an Esmarch bandai
is applied. With the bandage still in position,
Wyeth's needles are inserted as follows: "Two
steel mattress n lie-, t h i eo-sixteenths of an
inch iii diameter and a foot long, are used.
The point of one is inserted an inch and a half
below the anterior superior .-pine of the ilium
^ and slightly to the inner side of this prominence,
and is made to traverse the muscles and deep
fascia, passing about half way between tic great
trochanter and the iliac spine, external to the
neck of the femur and through the substance
of the tensor vagina' femoris, coining out just
back of the trochanter. About four inches "f
the needle should be concealed by the tissues.
The point of the second needle is entered an
inch below the level of the crotch, internally to
the saphenous opening, and, passing through
the adductors, comes out about an inch and a
half in front of the tuber ischii. No vessels are
endangered by these needles. The points are
protected by corks to prevent injuries to the
operator's hands. A piece of strong white rub-
ber tube, half an inch in diameter, and long enough
when tightened in position to go five or six times
around the thigh, is now wound very tightly around
and above the fixation needles and tied." The
Esmarch bandage is then removed, and if the oper-
ation is to be completed according to Wyeth's plan,
a circular incision is made, the skin flap is turned up,
the muscles are divided at the lesser trochanter, and
the bone is sawed
through. All vessels
are then tied. The
remaining portion of
Fig. ISO.
the femur is then removed by division of the attach-
ments of the muscles.
The methods of hemostasis above described will
probably be supplanted by the constriction of the
abdominal aorta by an ordinary rubber tourniquet
as devised by Momberg in 190S. It is a method
applicable to amputations of the thigh, of the hip, and
of the os innominatum. I have used it in high am-
putations of the thigh and in controlling the bleed-
ing during an aneurysmorrhaphy. It is applied as
follows:
297
Amputation
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
The patient is placed in the Trendelenburg position.
The end of a piece of soft rubber tubing, having the
thickness of the index finger and the length of about
four feet, is passed through under the back of the
patient to be grasped by the hand of an assistant who
stand-; at the opposite side of the operating table.
This tube is then stretched to the utmost, and thus
stretched, is passed by the surgeon midway between
the border of the ribs and the "iliac crests across the
abdomen to the other hand of the assistant, whose
duty it is to maintain tension. The free end of the
tube is now led back under the patient by the sur-
geon and is again put on the stretch, the assistant
in the meanwhile gradually releasing the bite of the
stretched tubing which now firmly encircles the waist.
\\ liile this is being done another assistant places a
finger on the femoral artery to ascertain the moment
of the cessation of the pulse. Observing the same
steps,_two, three, or more turns of tubing are exactly
superimposed until the femoral pulse disappear-.
In slim individuals two turns will suffice; in fat or
muscular ones, as many as six may be necessary.
As soon as the femoral pulse is suppressed the ends
of the tube are crossed and secured by forceps or
ligature. After this is done constrictors are applied
to the thighs below Poupart's ligaments, and to the legs
below the popliteal spaces. As soon as the operation
is finished and all the vessels have been secured by
ligatures, the rubber band encircling the waist is re-
moved. Directly after this the other rubber liga-
tures embracing the thighs and legs are untied one by
one. The object of this is the gradual extension of
the scope of the circulation and the avoidance of a
too sudden demand upon the efficienc}- of the heart
muscle. By this switching on of one segment of the
circulatory system after another, the readaptation of
the heart to the changed conditions is gradually
effected.
Two dangers would seem to attend the tubular con-
striction of the aorta; namely, the sudden lowering
of blood pressure on removal of the tourniquet and
injury to the intestines. How to avoid the former
has already been shown. The second is averted by
having the bowels thoroughly emptied and by placing
them out of reach of the tourniquet, by using the
Trendelenburg position. Mayer 18 has recorded nearly
200 cases in which it was used, and in only two was
there damage to the intestines. Matas* 20 experi-
mented on eight healthy students without any ill
effects.
Fig. 181.
Methods. — Although a large number of methods of
amputation at the hip have been devised (according
to Ashhurst there are forty-five), only a few of them
are of practical value, and are, therefore, commonly
employed. The methods which will be considered
are, that by musculotegumentary flaps, that by
cutaneous flaps and circular division of the remaining
soft parts, and that by a high circular amputation
with subsequent excision.
298
Musculotegumentary Flaps. — Amputation at the
hip can be most quickly accomplished by means of
anteroposterior muscular flaps, of which the anterior
is made by transfixion, and the posterior by cutting
from within outward. With able assistance the
operation can easily be performed in less than twenty
seconds. At least three assistants are required in
this, as in all amputations of the hip. One of these is
entrusted with the control of the circulation in the
limb, the second follows the knife to grasp the flap
before the artery is divided (Fig. 181, Hueter) and
then to retract it, and the third takes charge of the
condemned limb.
Fig. 182.
The patient's body having been brought to the foot
of the table, the nates are made to project over its
edge, and the scrotum and sound thigh are held out
of the way. While the condemned limb is slightly
flexed, the operator, standing on the left side, enters
the point of an amputating knife, the blade of which
is at least a foot long, midway between the anterior
superior spinous process of the ilium and the trochan-
ter major. It is carried deeply into the limb in a
direction parallel to Poupart's ligament, across the
anterior surface of the joint, which is thus opened,
and made to issue on the inner surface of the thigh
close to the perineum and just in front of the tuberos-
ity of the ischium. Transfixion accomplished, a
broad rounded flap, five to seven inches in length,
is made by carrying the knife downward in front of the
bone and cutting outward. This flap is at once
reflected and held out of the way. By a transverse
incision on the head of the bone the capsule is then
widely opened, while the limb is forcibly abducted
and everted. Hyperextension then causes the head
of the bone to start from its socket with a " popping''
noise when the ligamentum teres is cut. The knife
being then introduced behind the head of the femur,
the posterior portion of the capsule is divided and a
posterior flap four inches in length is cut from within
outward (Piston). When the operation is made on
the right side, the knife is entered from the inner side
just above the ischial tuberosity. When the poster-
ior flap is cut from within outward the cutaneous
margin of the wound is generally irregular and not
well_ suited for close coaptation with the anterior flap.
It is advisable, therefore, particularly in robust
limbs, .either to outline this flap by an incision through
the skin, or to cut it altogether from without inward
(Fig. 182, F.smarch) (Manec). Indeed, both flaps
may advantageously be cut in this manner (Guthrie).
The great advantage of the operation just described
is in the rapidity with which it can be executed. Its
disadvantages are in the excessively large wound
which it leaves, the tendency to the retention of pus
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
A mputatlon
in the intermuscular spaces, and the great probability
3 ive hemorrhage from the posterior flap.
\ W ound better suited for drainage is thai made by
lateral flaps In this form of operation a semicircular
incision is made, beginning at the tuberosity ofthe
: chium and terminating on the outer side oi the
femoral vessels in the center of the groin. The
incision crosses the outer surface oi the thigh four or
five inches below the trochanter. The flap thus
outlined is then reflected over the latter and the joint
tied. The inner flap is then made by cutting
from within outward. , . , ,
gumentary Flap Method. — Tins is an admirable
method to overcome the superfluity of muscular
tissue in the wound and the consequent tendencj to
purulent infection, and it is therefore preferred by a
number of operators, among whom are Agnew and
Volkmann. The operation is described by Agnew
Hows: "The surgeon makes a semilunar incision
in front of the limb with its convexity downward
commencing midway between the anterior sup-
erior spinous process and the trochanter on the
outside, descending the thigh in a longitudinal
urn for five inches, then passing across the
front of the limb in an oval course, adding thereby
an inch to the length of the flap, and, lastly, ascending
the inner border of the thigh, and terminating one
inch below the ramus of the pubes. The integument
,v rapidly dissected up from the deep fascia and
isted to the lingers of an assistant."
The next step is to isolate the femoral vessels above
th, origin of the profunda and to apply separately to
the artery and vein a strong ligature. Volkmann
divides the vessels between two ligatures. By dis-
placing the pectineus muscle the obturator artery can
be readily found and ligated below the obturator
membrane.
The limb being now raised, the surgeon proceeds
to cut a semilunar tegumentary flap from the back of
the thigh, one inch shorter than the anterior. With
amputating knife the muscles are then severed
circularly in front of the joint, "when after liberation
of the head of the bone, as in other methods, the
operation is completed by dividing through the soft
parts posteriorly. According to Agnew, this opera-
tion can be completed in forty seconds.
Circular Amputation. — In order to make a smaller
wound, and to divide the vessels where they are
.smaller, a circular amputation of the thigh at the
lower part of the upper third is made. This may be
accomplished by a single incision in thin subjects,
while in robust extremities it is preferable to resort
to a double incision. When the amputation in this
part is effected, all the blood-vessels that can be
recognized must be ligated. An incision is then
made along the outer side of the stump from a point
two inches above the trochanter to the circular
wound, and dividing everything down to the bone
(Dieffenbach). The operator then seizes the stump
of the femur with a lion-jawed forceps, and while the
edges of the vertical incision are separated by an
assistant, the soft parts, including the periosteum,
are stripped from the bone, and the capsule is opened
and disarticulation effected as in other procedures.
Fig. 179 from Wyeth shows the circular amputation
Wound with pins in situ and before the head of the
bone has been removed. In 1S80 Mr. Furneaux
Jordan of Birmingham published a method of
amputating at the hip which docs not differ essentially
from the method just described. In his operation
the outer incision is first made, disarticulation is
effected, and the circular incision forms the last step
of the operation.
finally, mention must be made of the methods of
Verneuil and Ed. Rose, and of Senn, 21 who in ampu-
tating at the hip treat the lower extremity as they
Would a neoplasm that is to be removed, cutting from
Wi! hout inward and tying each vessel as it is encoun-
tered. A shorter internal and longer external inci-
sion is made through the skin wnen the femoral
artery and vein are to lie divided between two
ligatures. The incisions are then gradually carried
through the muscles in front and on the outer side
until the articulation is reached, when, after dis-
articulation has been effected, the addueted muscles
are divided last of all.
Amputations at I he hip of nece it y pre ent a
deplorable mortality. Of 633 ca e tabulated by
Dr. 1'. C. Sheppard for Ashhurst, 393 terminated
fatally, and in twenty the result was undetermined.
The general mortality of the operation is, therefore,
sixty-four per cent. The most unfavorable results
obtained are those from military practice. Of 249
cases of this character in which the result was ascer-
tained, including sixty-six operations performed
during the War of the Rebellion, only twenty-seven
patients recovered, the mortality being 89.1 per cent.;
twenty-five of the sixty-six cases referred to were
primary amputations, of which three recovered;
twenty-three of the operations were secondary, and
all terminated fatally. Of nine secondary operations,
two survived, and of nine reamputations, six recov-
ered. Of seventy-one cases of hip-joint amputation
for injury in civil practice, forty-seven died, the
mortality being 60.1 per cent. Of 270 cases of hip-
joint amputation for disease, of which fifteen were
undetermined, 105 terminated fatally, the mortality
being 40.2 per cent.
Owing to the improved methods of preventing
hemorrhage, and particularly through the use of
Wyeth 's method, the mortality of amputations at
the hip has been very greatly reduced. Wyeth- 2
collected sixty-nine cases with only eleven deaths.
Of the fatal cases, five had severe injuries. I have
collected 138 cases of amputations at the hip, pub-
lished between 1889 and 1900, including the sixty-
nine cases collected by Wyeth. The total mortality
of the 139 cases was twenty-seven, giving a mor-
tality of a little over nineteen per cent. Of the
amputations there were 121 for disease with twenty-
one deaths — in this estimate I include three cases of
my own, one of which was fatal — or a mortality of
seventeen per cent. I find that six amputations
were done for injury, with only one recovery — the
cases reported by McBurney. In fifteen cases the
cause for the amputations was not stated; of these
one died.
Interilio-abdominal Amputations. — The indi-
cations for interilio-abdominal amputations have
thus far been neoplasms of the upper end of the
femur and of the pelvis and intractable tuberculous
coxitis involving the acetabulum and the iliac pan.
The first operation was performed in 1891 by Billroth
and ended fatally in a few hours. Extensive con-
sideration of the operation was given after the report
of three operations by Jaboulay. The original
operation of Jaboulay consisted of making one large
posterior flap. The first incision was made from
the symphysis parallel to and over Poupart's ligament
and the entire length of the iliac crest. By retracting
the upper wound margins the soft parts are lifted
from the iliac fossa, and the vessels easily reached
for tying. A circular incision is next made at the
upper third of the thigh, through the center of which,
on the anterior surface, the two incisions diverge
toward the pubes and the iliac crest. Thus a very
large posterior flap is left which completely and
easily covers the wound.
Girard operated in three cases by making internal
and posterior flaps, Bardenhauer formed external
and internal flaps, and Salistcheff in his successful
case operated by the racquet method. His incision
begins below the twelfth rib and passes over the
anterior superior spine of the ilium to Poupart's
ligament, which it follows to the pubes. Through
this incision the vessels are secured. The wide end
299
Amputation
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
of the racquet incision sweeps over the buttock to the
point of starting. The simplest method, from an
operative standpoint, is that of the long internal flap
the method of Savariaud slightly modified by Keen
and adopted by me. It has the signal disadvantage
Of having to be exceedingly long to cover the wound,
ihe risks of gangrene I believe to be larger after this
operation than after any other. Where it is feasible
it appears to me that the incision of Salistcheff has
superior advantages.
Interilio-abdominal amputation must always re-
main a desperate operation. It should not be re-
sorted to where a less mutilating procedure is possible
artial resection of the os innominatum for tumors of
the iliac pan ought to be performed in preference to
the mterilio-abdominal amputation. Strange as it
may seem the three complete hemipelvic resections
performed by Kocher (2) and Roux (1) all recovered.
Whereas according to Croisier, of the partial resection
there were eight deaths and seven operative recoveries.
It is need ess to add that these conservative operations
have a place only for limited neoplasms. So far as
the usefulness of the ilium is concerned in hemiresec-
tion of the pelvis, there has been less impairment of
stability and usefulness than one might imagine
in the cases of interiliac amputation that have sur-
vived, there has been no tendency toward eventra-
tion, a condition which one would judge to be a cer-
tainty after removing so much of the bony support of
the abdominal viscera.
Table I.— Operations in One Stage for Sarcoma.
'. Bi "roth (1891). Death in a few hours. Verbal communi-
call.Mi. .-.nvari.-iud. It, -v. dc Chir., vul xxvi p ,T,0
i»oi Jab ^ ay (1S94) - Deathin thirty-six hours! Lyon Med
ioLr-i, p. o07.
,, ; , J ;'':,' ull ,y (1 , S ? 5) - Death in twenty-four hours. Province
4. Jaboulay (1895). Death in five days. Girard, verbal com-
munication (Pnrigle).
5. Cacciopoli (1894). Death in three hours. Centralbl f
Chir. (quoted), 1S94, p. 988.
6. Gayet (1S95). Death in one hour. Province Me, 1 1894
J\o. XXXV. '
7. Girard (1895). Recovery. Congres Chirurg., 1898
8. *aure (1S99). Operation abandoned. Savariaud, Rev do
Chir., vol. xxvi., p. 365.
9 Freeman (1S99). Recovery. Annals of Surg., vol. xxxiii.,
10 Nann (1900). Recovered from operation. Gangrene of
other leg. Congres. Intermit. Paris, 1900
_ 11. SaUstcheff (1900). Recovery. Arohiv. f. klin Chir vol
ix., p. 57. ' '
12. Savariaud (1901). Death in two hours. Rev de Chir
vol. xxvi., p. 360.
13. Gallat (1901). Death in one hour. Annal.de Chir .Beige)
vol. ix., p. 569. "
nJ*' Jir"", (19 ° 2) - Dea,h in nine h " ur «- A »*- Gen. de
Chir., 1903, vol. cxii . p. 1665
15. DeRuyter (1902). Death in an hour. Henri Myer, Inang
Thesis., Leipzig, 1902.
, J 6 ' ^ e ™,. and DaC °Sta (1903). Death in thirty-three hours
internal. Clinics, vol. lv., Series 13.
Chir" no''' 1 ''' I™'' Death ° nBeCOnd day " Jahresbericht f.
Chir' 190°' ler 003° 3> ' De '' lth °" SeC ° nd day - Jahresberi <*t f-
19. Lastaria (1907). Died „,, table. Reiforma Med Nanoli
vol. v., p. 457.
Chir' ?902 W IK)!'' I '' VOd thir ' y " five days - Jahresbericht f.
, n ™ Bi tC (190S) - R «=overy. Momburg., Centblt. f. Chir
22. Ransohoff (1909) Recovery. Lived thirty-eight days.
Anuals of Surg., Nov., 1909
It will be seen from Table No. 1 that the post-
operative mortality of this amputation "the mosl
extensivfe operation in all the realm of surgery " is
sixty-eight per cent., counting the cases of death' after
* In a personal communication Prof. Bier informs me thai his
patient died two months after operation, of recurrence in the
abdominal wall.
twenty days with the operative recoveries
I have followed the lead of Keen. In 'the ca,^
where the resection of the pelvis was preceded bv
amputation at the hip, no deaths followed the tlnd
operation. From this it might be inferred iu
tins course is preferable as a routine procedure r„
fortunately in tumors of the pelvis the two-staaa
operation is not feasible and in those for tuberculosis
none other is ordinarily applicable. In the c!
corded by Freeman, the amputation at 1 . | •'
^mediately followed by resection of the pelvb
Ihe ex en of the disease was evidently not apparent'
until the hip-ioint amputation had been done In
the cases of Girard and Pringle the second operations
at'tlu n hi p recurrent di * ase ^ter disarticulat^
Doleful as are the immediate results of interilio-
abdominal amputation, the end results have been
even more unpromising The cases of Girard classed
with recoveries, died within six months of recurrent
Pringle s case died in five months with metastases!
Salistcheff's case was reported well within four
months of the operation. The end result I do not
know. I he record case is probably I hat of Freeman
Although he left the anterior third of the acetabulum
and of the ilium, the case belongs in the category o
intenho-abdominal amputations. Freeman's patient
was well at the end of sixteen months, when reported
but died twenty months after operation from recur-
rence in the abdominal wall (personal communica-
tion). Of the end results of the operation for tuber-
culosis, the data are extremely meager. The case
of Bardenheuer gained in health and strength four
months after the operation, and it is presumed was a
permanent recovery. The case of Pringle was with-
out recurrence seven years after the operation.
Table II.— Operation in two Stages for Sarcoma.
1. Girard (1S95). Amputation at hip. Some months later
resection of pelvis. Recovery. Rev. de Chir., vol. xxvi ,, : 6 S
.f^"™; 1 ll f S) : Amputation at hip. Death six months
alter reaecUon of os innominatum. Lancet, Feb. 20, 1909.
In the face of these unpromising results, it may be
questioned whether the operation is justified 'Tic
same question has been put for every major operation
in surgery, and has in the course of time with un-
varying uniformity been answered affirmatively
By limiting the operation to suitable cases and per-
orming it at a time when there is at least a probability
that the patient can bear the shock connected there-
with, it is almost certain that the prognosis will
improve as it has so markedly for amputation at the
up. _ Disseminating the knowledge that the opera-
tion is feasible will, by bringing the eases earlier to the
surgeon, contribute much toward this desirable end
\\ ith two exceptions, I know of no text-book in which
the operation is even mentioned.
Table III. — Amputations for Tuberculosis.*
1. Girard (1S95). I lied in fifty minutes. Rev. de Chir 1S98
p. 1111.
2. Bardenheuer (1897). Recovery. Gesellsch. d. Chir., xxvi
I, p. 130.
3. Gallet (1900). Died in six hours. Gesellsch. d. Chir xxvi
I, p. 130.
4 Ribera (Madrid) (1902). Died, collapse. Luis y Simon
Siglo Med., 1903, vol. v,
5. Ribera (1902). Died eighth day. Luis y Simon, Siglo Med.,
1903, vol. v.
6. Ribera (1902). Died, collapse. Luis y Simon, Siglo Med
1903, vol. v.
7. H. Vermeuil (1905). Died in two hours. Jour de Chir
(Beige)., vol. v., p. 406.
The operations for tuberculosis were practically all done in
two stages, the first being either a hip resection or amputa
I he extent ol the resection of the pelvic bone varies much. I have,
however, excluded all cases in which the resection did not involve
the major part of the ilium.
300
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Amygdala
8 Morestin (1908). Recovery. Bull. Soe. de Chir., Paris,
vol n\i v i P ""'"
., pringlo 1908) R very. Lancet, Feb. 20, 1909.
1908). I >< iii' on in i day, Lanoet, Feb. 20,
M r. Fiaschi. Recovery. Australian Med. .lour., Deo. 23,
1911.
In an operation of such magnitude, the initial
mortality is largely due to hemorrhage and to shock.
i if all the cases thai arc not included under postopera-
tive recoveries, only two survived the fourth day.
The prevention of hemorrhage has in mosl rases been
;.i ii\ preliminary tying of the common iliac,
internal iliac, or the external iliac. Many believe
the tying of the corresponding veins ought
always to be practised. Kocher and Kadjan encoun-
i severe venous bleeding. Tying of the thin-
walled large veins doubtless would increase the diffi-
culties of the operation. Fame, after a, median
my, applied a temporary ligature to tin- aorta
below the common iliac. Nevertheless, a severe
venous hemorrhage from subcutaneous and subperi-
toneal veins necessitated abandonment of the opera-
tion. Xanu, Jaboulay, Cacciopoli, and Salistcheff
also ligated the common iliac. Bardenheuer tied
h i he external and the internal iliac vessels. Free-
man lied the external iliac and, later in the operation,
common iliac. Keen tied the internal iliac artery.
by the tying of the common iliac artery pre-
ventive' hemostasis can be accomplished, has been
amply demonstrated in the case reported, and it was
satisfactory. Unfortunately where a long
nal Hap is, as in our case, a matter of necessity,
there is great danger of gangrene. This had already
commenced in Keen's case, although the patient
lived only thirty-three hours. The gangrene strangely
loped in the superior flap and not in the margin
ot the long internal. In my ease the gangrene in-
volved the long flap only. Were a similar case to
e under my observation, I would tie the external
iliac and the posterior trunk of the internal. In that
manner the obturator artery would be left intact for
tin- nutrition of the long internal flap.
Joseph Ransohoff.
Bibliography.
1. Hippocrates: Sydenham Society edition, vol. ii., p. 639.
2. Paulus Aeginetus: Sydenham Society edition, vol. ii., p.
110.
3. Billroth nnd Pitha: Handbuch der Chirurgie, vol. ii.,
!, Abth. 2, p. 19.
1 Agnew: System of Surgery, vol. ii., p. 305.
.".. Burow: Deutsche Klinik, 18.36.
6. Gueterbock, P.: Archiv fur klinische Chirurgie, Bd. x\\, and
stvii.
7 Gross: System of Surgery, voL i., p. 530.
3 I rdmann, .1. F.: Annals of Surgery, vol. xxii., p. 358.
0. Paget: Lancet, 1S95, i., p. 023.
10. Bruns: Beitrage z. klin. Chirurgie, vol. xxii., p. 2.
11. Barling: Clinical Society Transactions, xxxi., p. 1S2.
12. Moschcowitz: Annals of Surgery, vol. xxxix, p. 794.
13. Ilalm: Beitrage zur klinischen Chirurgie, vol. xxii., part 2.
I I. Bier: Deutsche Zeitschrift fur Chirurgie, vol. xxxiv., p. 436.
15. Smith, Stephen: Am. Journal of the Med. Sciences, vol.
Kix, ii :;;, 1S70.
III. Weidenpesch, Paul: Dissertation, Munich, 190S.
17. Davy: Lancet, 1892, ii., p. 570.
is. Wyeth: New York MedicalJournal, 1890, ii., p. 528.
19. Mayer: Journal de Chirurgie, 1910, p. 121.
20, Matas: Transactions of the Am. Surgical Association, vol.
xxviii., 1910, p. 622.
-'1 Senn: Chicago Clinical Review, 1S92, p. 343.
22. Wyeth: Annals of Surgery, vol. xxv., p. 129.
Amussat, Jean Zulema. — Born at St. Maixent,
France, November 21, 1706. He studied the rudi-
ments of medicine under his father, a physician, com-
pleting his education at Paris. His earlier medical
life was devoted chiefly to anatomy which he taught
to artists as well as to medical students. While
FIG.1S3. — Jean Zulema Amussat.
preparing for a concours in competition for appoint-
ment to a professorship he acquired an infection
which nearly ended his life and left him invalided for
so long thai he was forced lo give up the public
teaching of anal y. On recovering his health hi?
turned his attention lo surgery in which he -nun
acquired fame, lie was an indefatigable worker, a
skilful Operator, an orig-
inal thinker, and in-
genious in devising new
operations and in the
i n ve n t io n of instru-
ments. While an in-
terne at the Salpetriere
he invented a rachitome
for exposing the spinal
cord. He developed tin;
operation of lithotrity,
.Ii > ising a probe, which
st ill bears his name, for
i e in locating and
steadying the stone in
thai procedure. He ga\ e
his name also to theoper-
aiion for lumbar colos-
tomy in the ascending
colon. He was the recip-
ient of several grants, aggregating 1,500 francs, from
medical and scientific bodies in recognition of his
labors in advancing the science and art of surgery.
He died .May 13, 1856.
Amussat was a most prolific writer of monographs
and journal articles on a great variety of gynecological
and surgical subjects, his most extensive work being a
treatise on "Torsion des Arteres," published in 1829.
Other minor works were on the Entrance of Air into
the Veins, and on his special operations of Lithotrity
and Lumbar Colostomy. T. L. S.
Amygdala. — Almond. A. dtjlcis. Street almond.
The ripe seed of Prunus amygdalus dulcis D. C.
(Fam. Rosacea:). (U. S. P.). A. aiiaha. Bitter
almond. The ripe seed of Prunus amygdalus
arnara D. C. (Fam. Rosacea).
The almond tree is a native of the east Mediterra-
nean region and is now cultivated in all warm-
temperate regions, especially in California. The tree,
with its leaves and flowers closely resembles the
peach. The fruit differs in being dry instead of
fleshy, and in splitting to discharge the stone, which,
with its contained seed, is the unshelled almond of
commerce. The shelled almond is the article here
considered. The bitter almond is probably the
original wild form, from which -the sweet has been
derived by selection, breeding, and cultivation. There
are so many forms of both the sweet and bitter varieties
that it is useless to attempt any differential description
of the two, except as to order, tests, and constituents.
Those used as drugs are about an inch in length, ovoid,
with strongly rounded base and obtusely pointed
apex, flattened so as to be three times as broad as
thick, and about one-half longer than broad. The
surface is of some shade of brown, more or less
wrinkled, scurfy, with a dense covering of short,
thick, microscopical hairs, and with numerous lines
radiating from the base. The kernel consists entirely
of two oily cotyledons of the same form as the seed, in
contact by their flat faces, and of a nearly white color.
The bitter almond has a characteristically bitter
taste, the sweet ones being entirely bland, sweet, oily,
and nutty.
Of sweet almonds, the important constituent is
fifty per cent, or more of a fixed oil (see Oleum
Amygdala- Expressum), which occurs with about three
per cent, of gum and six per cent, of sugar, and a
large amount of albuminoid matter. There is a very
small amount of tannin in the seed coat. Their
301
Amygdala
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Eroperties are purely demulcent and nutritive. We
ave an official emulsion and a syrup, which are used
as vehicles.
In composition, bitter almonds have about one-
sixth less of the same fixed oil, and contain from
one to three per cent, of a peculiar glucoside (see
Amygdalin and Emulsln) which yields hydrocyanic
acid and benzaldehyde, as described under Hydrocy-
1. ■id. The yield of oil of bitter almond is about
one per cent., that of prussic acid about .00 to .18
of one per cent., of the weight of the seeds.
It is evident that the bitter almond combines the
properties of sweet almonds and prussic acid, and
that an ounce of the drug is equivalent to almost one
grain of the latter. It does not follow that the effect
would be the same as that dose, inasmuch as the
development of the acid would be neither so sudden
nor so complete. Nevertheless, bitter almonds must
be regarded as poisonous. Even a small number of
them, if eaten, are apt to produce a slight gastric
irritation as an after effect. Their chief use is a
flavoring agent, though small doses are used for their
sedative effect.
Peach seeds are often used to adulterate bitter
almond, and their composition is very similar. Sweet
almonds are also used as an adulterant.
H. H. Rusby.
Amygdalin. — The source, occurrence, and general
nature of amygdalin will be been stated in discussing
hydrocyanic acid. It is not official and is scarcely
used in its own form, although occurring in com-
merce. Boiling alcohol is used to extract it from
almond oil cake, after which it is precipitated by ether.
It occurs in crystals or scales which are soluble in
twelve parts of water. It is odorless, but very bitter.
If entirely free from emulsin, it does not yield prussic
acid and is not poisonous.
H. H. Rusby.
Amvlene Chloral. — Dormiol, chloral-dimethvl-
ethyl-carbinol, C(CH,) 2 C s H 5 OH.CCLCOH, is a coin-
pound of one molecule of amvlene hydrate and one
molecule of chloral. It is a colorless, oily-looking liquid,
with an aromatic odor and a pungent, followed 1>\
cooling, taste. It is practically insoluble in water,
and is freely miscible with alcohol, ether, acetone,
and volatile and fixed oils. It goes under the trade
name of dormiol, and is claimed to be a certain
hypnotic without depressing effect on the heart or
respiration. Its dose is njf. viii.-xxx. (0.5-2.0), given
in syrup, or in emulsion with a small amount of olive
or almond oil, and flavored with lemon or cinnamon.
R. J. E. Scott.
Amvlene Hvdrate. — Tertiary amyl alcohol, di-
methyl-ethyl-carbinol, (CH 3 ) 2 C,H-.COH. This is a
clear, colorless, thin, neutral liquid, with a burning
taste and an aromatic odor somewhat resembling
camphor. It is soluble in eight parts of water and
in alcohol, ether, glycerin, and oils; specific gravity.
0.812 at 53.6° F. It has been recommended for its
soporific properties. Its advantage over chloral is,
that it has no depressing effect on the heart. Its
smaller dose and less disagreeable odor make it
preferable to paraldehyde in many cases. It is a
rather mild hypnotic, producing a calm, refreshing
sleep, which lasts for six or eight hours, from which
the patient awakens without any bad symptoms.
It has not proved of use when the sleeplessness is due
to pain. In very large doses it produces coma, a
lowered temperature, shallow 7 respiration, feeble and
iregular pulse, loss of reflexes, and paralysis of the
extremities, its poisonous symptoms resembling
those of alcohol and ether. Its taste and odor often
prove objectionable, but may be disguised by extract
of licorice, syrup of lemon, lemonade, or some aro-
matic. Occasionally it is administered by rectum in
solution in water. Its dose is tin xxx.-xlv. (2.0-3.0)
but administered in capsules.
A case of poisoning has been reported. The patient
who had taken 27 grams (about 4oo grains), « L ,<
stimulated with mustard plasters and inject inns ,,f
ether, and recovered. R. J. E. Scoi i.
Amylene. — Valerine, C 5 H l0 . Amylene is a volatile
and inflammable ethereal fluid of an unpleasant odor
resembling that of cabbage. It was experimented
with by Snow in 1856, as an anesthetic, and prove I
itself powerful, after the manner of chloroform; but
proving itself also capable of killing, it never came into
accepted service. R. J. E. Scott.
Amyl Iodide. — Iodamyl. C\,H„I, is an oily liquid
obtained by distilling together iodine, isoamyl alcohol,
and red phosphorus. It is purified by washing with
water and redistilling. This liquid is about as heavy
as chloroform, boils at 148° C, is freely soluble in
alcohol, and insoluble in water. It is used for the
same purpose as amyl nitrite in asthma and angina
pectoris, but has distinctly less effect in relaxing
the arterial muscle. Dose, r^ ii.-v. (0.13-0.3) by
inhalation. W. A. Bastedo.
Amyl Nitrite. — Amylis nitris, a liquid containing
about eighty per cent, of amyl (chiefly isoamyl)
nitrite (U. S. P.). It is a yellowish, ethereal, very
volatile liquid, of a not disagreeable fruit-like odor
and pungent taste, insoluble in water but soluble in
alcohol and ether; it is neutral in reaction, but becomes
acid on exposure to air, and should be kept in well-
stoppered containers away from the light. When
inhaled or administered by the mouth or hypoder-
mically, it causes rapid heart action and flushing
of the surface, dilating the vessels and reducing blood-
pressure, and induces general muscular relaxation.
1 1 is employed by inhalation in asthma, dysmenorrhea,
muscular spasm, and especially in angina pectoris.
For the latter purpose pearls of very thin glass, con-
taining three minims (0.2), are prepared; thesi
be crushed in the handkerchief and the fumes inhaled
to cut short an attack. The dose for inhalation is
usually from two to five minims (0.13-0.3). Fi
fuller discussion of the physiological action and
therapeutic uses, see Nitrites.
Amyl Valerate. — Amyl valerianate, apple oil, apple
essence, C 5 H 11 C 5 H 9 2 , is obtained by the action of
valeric acid on isoamyl alcohol, in the presence of
sulphuric acid. It is a clear, colorless liquid, lighter
than water, having an odor like that of apples and a
sharp ethereal taste. It is insoluble in water, soluble
in alcohol and ether, and it boils at 18S°-190° C.
Amyl valerate is used in place of valerian in func-
tional nervous disorders, especially hysteria. As il
is a solvent for cholesterin, it was thought to have
the power to diminish the size of gallstones, but il ia
hardly probable that this solvent action could take
place in the system. In fact, alcohol and other
cholesterin solvents taken in large quantities ha\
effect whatever on the size of the stone. Amyl
valerate is administered in dose of n\ ii.-v. (0.13 I
in capsules, or in five-per-cent. alcoholic solution
with an equivalent quantity of amyl acetate.
W. A. Bastedo.
Amyloid. — From i/ivKov, starch, and efSos, resem-
blance, so called from the fact that the amyloid sub-
stance gives with iodine and sulphuric acid a reaction
302
REFERENC] EANDBOOK OP THE MEDICAL SCIENCES
i 1. .1.1
similar to that of starch. Uso called chondroid, ■
lardaceou or albuminous degeneration. French,
p iloide; German, Amyloidentartung,
ii. mg.
lii,- term amyloid degeneration is applied to the
appearance, in the body, of a clear, colorless, shining,
homogeneous, highly refractive, and translucent
body, greatly resembling wax, firm in consistency,
and possessing but little elasticity. Winn treated
with iodine solution, it takes on a mahogany color,
which in marked cases may become bluish or green
Plate VII.). If the specimen thus treated is
further subjected to the action of dilute sulphuric acid,
zinc or calcium chloride, the mahogany color may be
ed, or a play of colors — red, violet, blue, or
i may be produced. This reaction, however,
docs not always occur.
iuse of this characteristic reaction with iodine,
nalogous to that of starch, Virchow was led to
believe that the newly discovered substance was
oid of nitrogen and closely allied to cellulose or
starch, and for this reason gave it the name amyloid.
It was further designated as "animal cellulose."
On the other hand, Meckel believed it to be closely
related to cholesterin. Several years after, the chem-
ical investigations of Friedrich, Kekule, Schmidt,
.-new, and Kuhne proved conclusively that the
so-called amyloid was in reality a nitrogenous body
u albuminous nature. According to Tscher-
niak, it is a coagulated, albuminous substance, and
i- possibly an intermediate product between the pro-
tein- on one side and fat and cholesterin on the other.
The exact chemical nature of amyloid is not yet
known. It is very probable that its chemical con-
stitution is not the same in all organs, and that it
represents different phases of a progressive metamor-
is of albumin. The great variation shown in
the different staining reactions of amyloid speaks is
favor of such a view. In the amyloid isolated by
means of digestion of amyloid organs, there is
always found a certain amount of ehondroitin-sul-
phuric acid, and recent writers have, therefore, re-
garded amy I. .id as a compound of a basic albuminous
body and this acid. The latest researches by Haus-
1908) do not favor this view; according to his in-
vestigations the amyloid isolated mechanically from
sago-spleens contains no chondroitin-sulphuric acid.
Bo that this substance cannot be regarded as an
essential component of amyloid. Nevertheless the
in ijority of amyloid tissues show an increased con-
tent of chondroitin-sulphuric acid. Lipoids soluble
in alcohol are also usually obtainable from amyloid.
A irding to Krakow there occur normally in the wall
of the aorta of the horse, in the ligamentum nuchas of
cattle, and in the spleen and stomach-wall of calves,
combinations of chrondroitin-sulphuric acid closely
related to amyloid. The writers who accept Krakow's
view that amyloid is a combination of a protein and
chondroitin-sulphuric acid would, therefore, class amy-
loid as a glycoprotein allied to cartilage and yellow
elastic tissue. Experimental feeding of chondroitin-
sulphuric acid salts does not give rise to the formation
of amyloid.
Amyloid bears also a very close chemical relation to
the hyaline deposits found in blood-vessels and eon-
nective tissue, as is shown by the fact that amyloid
organs sometimes contain hyaline masses in no way
distinguishable from the neighboring amyloid ex-
cept by the application of specific staining methods.
In some cases the periphery of large masses of
amyloid gives the reactions for hyalin and not for
amyloid. Litten found that pieces of amyloid tissue
lost their characteristic reactions and became changed
to hyalin when introduced into the abdominal cavity
of animals. The strong general resemblances be-
i ween the two bodies, their similarity of location, and
the frequent coincidence of occurrence make it very
probable that the two substances are so very closely
ed thai they 1 1 1 : i \ cha uge from Oni it her.
ie writers regard the coincidence of hyalin and
amyloid as accidental and reject the view thai the
formation of hyalin may be a preliminary step to the
de\ elopment of amyloid.
Amyloid differs from other albuminous bodies in its
characteristic .staining reactions, in its resistance to
tin- action of pepsin, and in its very slight tendency to
putrefaction. When exposed for a long time t,i the
action of gastric juice ii slowly dissolves, so that it is
po ible that its resistance to pepsin and agents of
putrefaction is due to its great den ity, which hinders
the penetration of fluids. It is likewise resistant to
acids and alkalies, and is not altered by alcohol and
chromic acid. Through the prolonged action of di-
lute sulphuric acid tyrosin and leucin may be obtained
from amyloid, its end products thus harmonizing with
its albuminous nature.
Hut little is known with certainty regarding the
causes and nature of amyloid formation. It is one of
I lie most common pal holoL'i eal conditions of the body,
and may exist as a local change, or be widely distri-
buted through many organs and tissues. It usually
occurs as a slowly progressive disease in association
with various cachectic conditions. In these eases of
widespread formation it must be the result of some
general disturbance of metabolism. The amyloid
substance does not exist in the blood as such, but the
material from which it is formed may be derived from
the blood, or some ferment circulating in the blood
may cause a fermentative coagulation of albuminous
substances outside of the vessels. Though called
amyloid degeneration, the process is not to be classed
with the true degenerations of cell protoplasm, but is
rather to be regarded as a pathological deposit, in the
tissues, of a substance derived from the circulation.
It has been conclusively shown that the cells of the
affected tissue take no active part in the formation of
amyloid. The location of the deposit is practically
always in the walls of the blood-vessels or in the inter-
stices of the tissues immediately around the vessel-,
and the organs which show the greatest degree of the
change are those abundantly supplied with blood, as
the liver, spleen, and kidneys. It is possible that the
amyloid substance is the result of the union of some
albuminous material derived from the blood with
some constituent of the tissues, and that the lowered
vitality of the tissues resulting from general or local
disturbances of nutrition favors its formation; or, as
the result of impaired nutrition, a peculiarly modified
albuminous body may be separated from the blood
through the activity of the secretory cells of the blood-
vessel walls. As the chief seat of the amyloid deposit
is always just outside the endothelium of the blood-
vessels, it becomes highly probable that it is a product
of endothelial cell activity, and is deposited in the
tissues outside the endothelium in a manner analogous
to the deposit of hyalin, lime salts, or silver pigment.
This pathological secretion may be the result of
general changes in the circulation whereby the secre-
tory function of the cells of the vessels is changed, or
the changes may be primary in the cells themselves.
The fact that local deposits of amyloid occur without
apparent general changes of nutrition favors this view.
Another probability is that the formation of amydoid
outside of the blood-vessels depends upon the action
of a ferment derived from the blood, this ferment
causing a coagulation and precipitation in the damaged
tissues of some decomposition product of albumin.
Of the origin of this ferment nothing is known.
According to Davidsohn it is probably formed in the
spleen, since experimental amyloidosis cannot be
produced in splenectomized white mice. In the
widespread deposit of amyloid in cachectic conditions
the pathological condition of the cells may be pro-
duced by the altered state of the blood or by toxins;
in the local deposits it may be due to local changes in
the vessels, caused by local inflammatory processes.
303
Amyloid
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
In the majority of cases the deposit of amyloid
appears as a secondary phenomenon in various
cachectic states, being most commonly associated with
chronic tuberculosis of the lungs and bones, chronic
staphylococcus osteomyelitis, chronic suppurative
processes, syphilis both congenital and acquired,
chronic dysentery, and leucemia. In these diseases
the most extensive deposits may be found. It rarely
occurs in the cachexia of carcinoma, and usually only
when there is ulceration of the growth. Amyloidosis
has also been observed in cases of hypernephroma.
1 1 is also found, though less frequently, in association
with pseudoleucemia, chronic arthritis, nephritis,
chronic diarrhea, typhoid fever, prolonged malaria,
chronic gonorrhea, chronic empyema, chronic bron-
chitis, bronchiectasis, pyelitis, gout, lead poisoning,
beriberi, actinomycosis, hypertrophic cirrhosis, and
after severe forms of rachitis. Occasionally there may
occur in children a widespread deposit of amyloid
without any discoverable cause.
According to Cohnheim, amyloid deposits may
become well developed in from two to three months.
Czerny and Krawkow claim to have produced it in
animals in from three to sixty days through the estab-
lishment of suppurative processes, caused by inject-
ions of turpentine and of staphylococci. Experi-
ments made in Ziegler's laboratory throw doubt upon
these investigations although they are generally
accepted. The administration of the sodium salt of
chondroitin-sulphuric acid to animals does not pro-
duce amyloid change (Oddi, Kettner, Wells). There
is also no evidence that amyloid is formed from dis-
integrating red blood-cells. Experimental amyloidi isis
has also been produced by injections of gonococci and
other bacteria, various bacterial products and many
chemical substances. Amyloidosis is not-uncommon
in white mice affected with carcinoma or sarcoma, but
will not develop in such mice after extirpation of the
spleen. Amyloidosis is also said to occur in horses
used for the production of antidiphthcritic serum
(Pearce and Pease). As a rule, the formation of
amyloid takes place very slowly. It occurs most
frequently between the tenth and thirtieth years, but
may be found in new-born infants (congenital syphilis) ,
and also in extreme old age.
Occurrence. — Amyloid occurs most frequently as
a widespread deposit in one or several organs, especi-
ally affecting the spleen, liver, kidneys, and lymph
glands. Next to these the mucosa of the endocar-
dium, stomach and intestine, the adrenals, and the
omentum may show a marked degree of the change.
In all of the organs it may occur to such an extent
that it affects greatly the gross appearance. It is
less frequently found in the intima of the great vessels,
mucosa of the respiratory and urinary passages, thy-
roid, lungs, ovaries, testicles, prostate, bone marrow,
salivary glands, and muscle. In these its occurrence
is usually so limited that its presence can be made out
only by means of the microscope.
The degree of the change varies very much in
different cases. The kidneys may show a marked
deposit while the other organs may contain but little
amyloid; in other cases the liver or spleen may be the
chief seat of the change. The primary seat of the
deposit and the order in which the different organs a re
affected vary with the individual case, and bear no
definite relation to the associated pathological
condition.
Local deposits of amyloid occur rarely in single lymph
glands following inflammatory processes (mesenteric
glands after typhoid), in scars, local inflammations,
hyperplastic growths, tumors (osteofibroma of tongue,
chondroma of lung), in the tongue, tonsils, larynx,
trachea, and bronchi, following syphilitic processes
in the wall of the urinary bladder, and in the scars of
liver gum ma ta. Klebs obtained the amyloid reactions
in a hard chancre. Numerous authors have found
amyloid in pathological conditions of the cornea and
conjunctiva (trachoma, staphyloma, etc.). It has
also been found in old blood clots and thrombi, and
frequently in the cartilages of old individuals who
have presented none of the pathological conditions
with which amyloid is usually associated. Localized
amyloid is sometimes found in tumors, usually in
endotheliomata. These local deposits of amyloid
sometimes form tumor-like masses under conditions
in which it is impossible to establish any relationship
between them and any other pathological process.
The causes and manner of formation of localized
amyloid are unknown. There appears to be some
relationship between cartilage and elastic tissue and
these localized amyloid masses. In the local forma-
tions the amyloid is found chiefly around the lymph-
vessels, but also in the vessel-walls and tissue-spaces.
On the whole these local amyloid deposits must be
very rare; and it is probable that hyaline formations
have sometimes been mistaken for amyloid. In a
wide and varied pathological experience I have never
seen any localized deposits of true amyloid. The
corpora amylacea found in the prostate, nervous
-\ stem, lung, etc., sometimes give a reaction resembl-
ing that of amyloid (see Corpora Amylacea).
Macroscopical Appearances. — When the de-
posit of amyloid is at all extensive, it is readily rec-
ognizable by the naked eye; but the degree and
nature of the deposit and of the associated degenera-
tive conditions vary so much that no general descrip-
tion can be given which will apply to all cases. The
organ is usually swollen and plumper that normal, its
edges are more rounded and its fissures deepened.
Its volume and weight are increased, the latter
sometimes four- to fivefold. The consistency is
greatly increased; in severe cases the organ may
have a wooden hardness. There is also a great loss
of elasticity, so that pressure indentations made upon
the surface of the organ remain for a long time. The
blood-content of the" affected organ is usually greatly
diminished, so that its color becomes grayish or yellow
if much fatty change is present. Very characteristic is
the shining, translucent, waxy appearance of the cut
surface, resembling that of bacon (lardaceous). The
differences in histological structure of the various
organs lead to individual appearances when amyloid
is present, and these will be described separately.
The iodine test is best applied to fresh tissue. A
moderately strong LugoPs solution should be used
after washing out the blood with dilute acetic acid,
as the color resulting from the combination of the
red hemoglobin and yellowish-brown iodine very
closely resembles the mahogany red of the amyloid.
The iodine solution is poured over the freshly cut
surface, allowed to stand for a minute or so, and then
washed off. The amyloid areas are reddish-brown,
the non-amyloid ones yellow. If dilute sulphuric
acid is now applied, the amyloid portion may become
dark green to black, or dark violet, while the unaffected
tissue is of a clear gray color. This gross reaction
is plainly seen, as a rule, only when the amyloid
deposit is marked; but sometimes, as in the intima
of the large arteries, it may be brought out very
distinctly when no other appearances point to the pres-
ence of amyloid (see Plate VII.).
Microscopical Appearances. — Microscopically,
amyloid appears as a homogeneous, hyaline substance,
of "rather high refraction, which is deposited al-
most exclusively in the walls of the capillaries and
smaller arterioles and veins. In its earliest stages it
appears as a homogeneous layer outside the endothel-
ium, but in more advanced cases, owing to the
atrophv of the intervening tissue, the masses of amy-
loid increase greatly in size and may finally become con-
fluent, so that the entire tissue, or a large part of it,
may be replaced by amyloid. The amyloid in the
tissue-spaces probably lies around the small lym-
304
REFERENCE HANDBOOK
OF THE
MEDICAL SCIENCES
PLATE VI
~»*.
^
Fig. 3.
Fig. 1.
H
Fig. 2.
AMYLOID DEGENERATION IN DIFFERENT ORGANS
FIG. 1. Section i if an Amyloid Liver, Showing the Effects of stain-
ing it Willi aSolutionof Iodine, re. Normal liver tissue; '>. tissue tliat
has undergone amyloid degeneration; c, Glisson's capsule magnified
35 diameters. (Ziegler.)
Fig. 2.— Amyloid Kidney, stained with Aniline Violet. The amy-
loid is stained red. The deposit is most marked in the capillaries of
the glomeruli and in the small arteries, and is seen also as a tine
hyaline ring surrounding the membrana propria of the tubules. Mag-
nified 400 diameters, i Ribbert.)
Fig. 3.— Section of an Amyloid Liver After being Treated with
Methyl violet and Acetic Acid, a. Elongated masses of liver cells ; 6,
amyloid substance: i\ endothelium of the capillaries; e, colorless
blood corpuscles. Magnified 150 diameters. (Ziegler.)
Fig. 4. — Amyloid Degeneration of the Follicles and Pulp of the
Spleen. (Alcohol; methyl violet; hydrochloric acid.) «. Follicular
tissue in a marked state of amyloid degeneration; o. pulp tissue in
which the degeneration has begun. Magnified 300 diameters.
(Ziegler.)
i: i ; i 1 : i : 1 x < i : handbook ok tiii: medical SCIENCES
Amyloid
phatics. In severe grades of amyloid formation the
fibers of the connective-tissue reticulum and the base-
menl membranes of the glands may give an amyloid
reaction so that the entire organ or tissue may appear
tn have undergone an amyloid transformation.
In this way large nodules or tumor-like masses are
formed. I' must be emphasized, however, that inits
earliest stages the first appearance of amyloid is
rys next to endothelium.
[t is never deposited in living cells. The tissue
Cells proper take no active put in the process, and
the cnanges found in these cells are to be regarded as
secondary. The lumen of the affected vessel is
,,.„ narrowed by the increasing deposit, and the
ilting disturbance of blood supply leads to degen-
ve changes (atrophy and fatty degeneration)
of the cells of the affected region. Pressure-atrophy
is commonly found in the amyloid liver, while el lv
swelling anil fatty degeneration arc more common in
unyloid kidney. The deposit of amyloid between
ami around the cells near the blood-vessels leads to
similar changes. The individual vessels are not.
illy affected throughout, and different vessels
of the same organ may show the change in very
different degrees.
The microscopical appearance of amyloid in sec-
tions stained with hematoxylin and eosin is so similar
to that of hyalin that a differential diagnosis be-
tween the two deposits can be made only by means of
e specific staining reaction. Of these the be I
and most practical is the Van Gieson method. The
sections are overstained in hematoxylin and then
stained for one-half to one minute in a concentrated
water solution of picric acid to which enough of a
concentrated water solution of acid fuchsin has
been added to give it a distinctly red color. By this
met hod amyloid is stained a pinkish-brown or yellow,
while hyalin takes a deep red color.
The iodine reaction does not show so well in hard-
ened material, so is best applied to fresh tissue. The
specific reactions of amyloid with various aniline
dyes are classic in the history of microchemistry, and
it is largely to the wonderful amount of interest be-
stowed upon these that this branch of pathological
technique owes a very great part of its development.
The aniline stains most commonly used are methyl and
gentian violet, methyl green, thionin, toluidin-blue,
kresyl-echt-violett, and iodine green. The amyloid
tissue is best hardened in alcohol or formol and cut
without embedding or upon the freezing microtome
after washing out the alcohol. The sections are
then stained for five to ten minutes in a two to five
per cent, solution of the stain, differentiated with
dilute acetic acid, and mounted in glycerin or syrup.
With all of these stains amyloid exhibits a metachro-
masia. Methyl and gentian violet, kresyl-echt-violett,
ami iodine green stain the amyloid portion ruby red,
while the non-amyloid is stained blue. Methyl green
stains the amyloid a sky-blue, the non-amyloid tissue
a bright green. Thionin, toluidin-blue, polychrome-
methylene blue and other metachromatic dyes are
used to give similar reactions with amyloid, but are
not as satisfactory, as kresyl-echt-violett which is
best used in a five per cent, carbolic acid solution.
The best metachromatic stains are secured by fixing
in formol for twenty-four hours, sectioning on a
ing microtome, staining, and examining in water.
The metachromatic reactions are not satisfactory
with celloidin sections but good results can be ob-
tained, with paraffin sections. Amyloid may also be
stained with scharlach R and Sudan III, but the
Its are not satisfactory. The reactions with
the fat-dyes are due to the presence of lipoids in the
amyloid tissue. None of the metachromatic reac-
tions is permanent; the sections so treated gradually
fade. On the whole, the Van Gieson method,
which can be applied to either paraffin or celloidin
sections, is the most convenient and practical stain for
Vol. I.— 20
the differentiation of amyloid, since it differentiates
connective-tissue hyalin by staining it deep red;
and epithelial hyalin which stains like amyloid
with this stain is differentiated by its different tissue-
relations. The variability in staining of amyloid
may be dependent upon differences of composition as
well as of density. The met hyl-violet reaction
appears to depend upon the albuminous constituents,
while the iodine reaction depends upon unknown
substances that can in various ways be removed from
the amyloid.
Liecr. — This organ is very frequently I he seat of
amyloid deposit. Outside the endothelium oi the
liver capillaries, between it and the liver cells, t here is
deposited a layer of amyloid, which, as it increases in
thickness, presses upon the liver cells and separates
them from their normal relations with the blood, SO
that (hey undergo atrophy and degeneration, and
finally may entirely disappear. The amyloid masses
thus become confluent, the capillary walls are pressed
together, and the only cells left in the area are the
endothelial cells, which may persist for a long time.
The intermediate zone of the lobule is almost always
affected to a greater extent than either the central
or the peripheral one. The walls of the larger blood-
vessels may also show the deposit. In more advanced
cases the entire lobule may be replaced by amyloid.
This marked change is usually confined to single
scattered lobules, so that these appear to the naked
eye as grains of boiled sago (sago-liver). More rarely
the greater part of the liver may be replaced by con-
fluent masses of amyloid, whereby the organ acquires
a wooden hardness and on section resembles the
translucent portions of bacon (S peck-leber) .
Spleen. — In the spleen the amyloid deposit takes
place in the fine reticulum of the pulp beneath the
endothelium of the blood spaces. The follicles may
alone be affected, appearing enlarged and translucent
like boiled sago (sago spleen); or the chief deposit
may be throughout the pulp, or may involve both
pulp and follicles (Speckmilz, Schinkenmilz, lardace-
ous spleen). The arterioles of the follicles are often
the only portions of the organ which show the deposit,
and it is in these that the earliest appearance of
amyloid in the body as a rule occurs. The lymphoid
cells disappear, and the spleen may ultimately con-
sist only of an amyloid network between and around
the blood spaces, the endothelium of which may be
preserved.
Kidney. — The afferent arterioles of the glomeruli
are usually first affected, then the glomerular capil-
laries and efferent vessels, and finally the smaller
vessels throughout the entire organ. The change is
never so marked in the medullary pyramids as in the
cortex, but it may appear early in the straight vessels
of the former. As the disease advances the deposit
extends from the intertubular capillaries to the
basement membrane of the tubules, which may ap-
pear as if surrounded by a hyaline ring. The intinia
of the larger branches of the renal artery may show
small and irregularly scattered deposits. Since the
glomeruli are the chief seat of the deposit, they
appear on the freshly cut surface of the organ as small,
firm, translucent dots usually about the size of pin-
heads. Marked fatty degeneration and cloudy
swelling of the renal epithelium are always present,
and the kidney presents the microscopic picture of a
chronic parenchymatous nephritis, more rarely that
of a chronic interstitial process.
Lymph Glands. — Extensive amyloid deposit is not
common in the lymph glands, but scattered masses
are very frequently found in them; and the walls of
their small arterioles usually show a. moderate degree
of change in all cases in which the liver, spleen, and
kidneys are extensively affected. Local inflamma-
tory changes, both of the lymph glands and the tonsils,
are frequently accompanied by the formation of
small masses of amyloid in connection with hyaline
305
Amyloid
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
deposit, and the close relation of these substances is
nowhere else so well shown as in these organs. In
advanced cases the deposit may extend from the
neighborhood of the capillaries into the reticulum,
causing atrophy of the lymphadenoid cells.
Muscle, Fat Tissue, etc. — In striated muscle amy-
loid deposit is rarely found. It has been found in the
tongue and in the muscles of the larynx in the shape
of nodular masses. The deposit takes place first in
the walls of the capillaries of the endomysium, and as
it increases in size the sarcolemma comes to be sur-
rounded by a clear, hyaline mass. As the muscle
fiber is thus separated from its blood-supply it under-
goes atrophy and degeneration, finally disappearing, so
that the deposits of amyloid become confluent into
nodular masses. A similar process may take place
in heart muscle and in unstriped muscle, but
is of rare occurrence. The amyloid deposits in striped
muscle occur very frequently in the scars of gum-
mata, but occasionally no evidences of preceding
pathological changes can be made out. Adipose tissue
is often extensively affected by amyloid disease,
the deposit taking place in the walls of the larger
blood-vessels and of the intercellular capillaries, so
that the fat cells come to be surrounded by a thin
hyaline layer.
Heart. — Amyloid degeneration of the endocardium,
particularly in the right auricle, is not rare. I If
rarer occurrence is the formation of amyloid in the
myocardium.
Adrenals. — In this organ the cortex is usually the
seat of amyloid change. As the amyloid is formed
between the capillary wall and the epithelial cords
the latter undergo atrophy and may in part
disappear.
Mucous Membranes. — The mucous membranes of
the respiratory tract are very rarely affected. Scat-
tered deposits may occur in the mucosa of the
stomach and intestine, producing more or less ex-
tensive thickenings of the mucosa, which show the
characteristic homogeneous, glassy appearance of
amyloid. Large elevations may undergo ulceration,
and at the bottom of the ulcer remains of the amyloid
may be preserved. The large intestine is more
frequently affected than the small. The deposit is in
the walls of the capillaries of the mucosa and sub-
mucosa, particularly in those of the villi; amyloid
deposits also occur in the intestinal muscularis.
Only in very rare cases is amyloid found in the mucosa
of the genito-urinary tract.
General Nature op Amyloid Disease. — As
stated above, the formation of amyloid is almost
always secondary to other processes which are
ulcerative or inflammatory in character, and of in-
fective nature. While not in itself a true degenera-
tion of ceil protoplasm, the process is essentially
degenerative in character, in that it leads to marked
disturbances of nutrition. The deposit in the walls
of the blood-vessels leads to partial or complete ob-
literation of their lumina, thus producing permanent
interference with the circulation. As a result of this
disturbance of nutrition, atrophy, fatty degeneration,
or necrosis of the tissue cells takes place. The pres-
sure of the amyloid deposits between the cells leads to
similar results. Fatty degeneration and infiltration
are almost always present to a greater or less degree
in amyloid disease, and to a certain extent must be
regarded as coincident processes produced, perhaps, by
the same general disturbances of metabolism which
give rise to amyloid. Severe anaemia is usually
associated with the condition, and death takes place as
a rule from a gradually increasing marasmus. The
presence of the amyloid in the tissues does not
usually set up any local reactive process. Only
rarely (usually in local amyloid formations) does
the amyloid act as a foreign body and give rise to the
formation of foreign-body giant cells that may exert
a phagocytic action upon fragments of amyloid.
The formation of such phagocytic foreign-body
giant cells has been observed in the experimental
amyloidosis of rabbits.
Symptoms. — The marked alterations in the struc-
ture of the affected organs and tissues lead to func-
tional disturbances, which, however, may be very
slight when compared to the extent of the deposit.
The general clinical picture of the condition will vary,
of course, with the organ affected and with the extent
of the disease, so that a comprehensive description
is not possible. Moreover, from the nature of the case,
it is manifestly difficult or impossible to separate the
symptoms of amyloid deposit from those of the dis-
ease leading to or associated with it. The nature
of the primary process will modify very much the
clinical appearances dependent upon the amyloid
change. Frequently the beginning of the condition is
shown by a rapid increase in the marasmus already exis-
ting, and by the enlargement of liver and spleen. These
phenomena are always more marked in syphilis and
in chronic ulcerative processes than in pulmonary
tuberculosis. In such conditions as chronic varicose
ulcers of several years' standing a rapid increase of the
cachexia is usually pathognomonic of amyloid disea
Associated with enlargement of the liver certain
disturbances of digestion go hand-in-hand: absence
of bile-pigment in the feces, fecal decomposition,
meteorism, etc. Icterus is rarely present, and ascites
only as associated with a general hydremic or cachectic-
anemia. Marked amyloid deposit in the kidneys is
not always known by disturbances of its function.
The urine may show no changes; but as a rule al-
bumin is present, the amount is increased, and the
sediment contains hyaline casts, though usually not
in great numbers. The latter never give the amyloid
reaction, in spite of the repeated statements that
they do. As amyloid deposit in the kidneys is, in the
majority of cases, associated with chronic inflamma-
tory changes, the character of the urine may vary
greatly. Usually the picture is that of a chronic
parenchymatous nephritis. Marked amyloid dis-
ease of the intestine is usually accompanied by foul
diarrhea.
Diagnosis. — The nature of the primary affection
must first be considered. If in patients affected
with any one of the chronic diseases known to be
associated with amyloid (chronic tuberculosis, syphi-
lis, chronic suppurative processes), painless swellings
of the liver and spleen arise, in association with albu-
minuria and extreme paleness of the skin and mucous
membranes, the diagnosis of amyloid is made very
probable, but in early stages of the disease the
diagnosis is difficult.
Duration. — The earliest stages of amyloid change
cannot be ascertained clinically. It is probable that
in many cases the process develops through several, or
even many years, with alternate periods of improve-
ment and exacerbation. It may, however, develop
within shorter periods, as in a case observed by
Cohnheim, in which suppuration of bone after a frac-
ture led to well-developed amyloid disease within a
few months. The duration of well-marked cases de-
pends upon the organ chiefly affected. Extensive
changes in the kidney are much more serious than
those of the liver or spleen, as they may lead to
.death within a few weeks or months.
Prognosis. — This is in general unfavorable. It is
probable that amyloid, when once formed, is not
removed from the site of deposit. In all cases in
which the condition is so marked that the diagnosis is
certain, death usually occurs within short periods.
Temporary improvement may take place; and in some
cases, especially after operation for chronic purulent
conditions of bone, the disease apparently comes to a
standstill, marked general improvement takes place,
306
REFERENCE EANDBOOK OF THE MEDICAL SCIENCES
Amylum
the liver swelling decreases, and the albuminuria dis-
appears It is, of course, impossible to say to what
extent these symptoms were due to the amyloid
A similar improvement has been - the
jl ,,,' a prolonged inunction cure in a case of amy-
loid associated with syphilis so that the | is in
syphilitic amyloid is usually regarded as more favor-
able. Corneal tumors may slowly disappear under
the influence of local irritation and inflammation.
Treatment. — For the well-established condition
it is hardly probable that treatment will avail, though
iodine, ammonium chloride, potassium iodide, dilute
nitric acid, etc., have been recommended. When
syphilis is present tin- treatment should be anti-
syphilitic. The improvement of the local or general
primary condition is, of course, the most important
therapeutic line to be followed: and in connection with
this the general improvement of nutrition. Of far
, r importance are prophylactic measures, even
to the extent of such radical procedures as amputation
in cases of chronic varicose ulcerations, chronic
suppuration of bone-, etc., in which persistent opera-
tive and therapeutic measures have been without
result. General amyloid disease is much less common
than it was fifteen years ago, and this change is to be
ascribed to the greater tendency to surgical operations,
and the greater success attending the preventive treat-
ment of suppurative processes. Even in the case of
inic pulmonary tuberculosis modern methods of
treatment seem to have lessened the occurrence of
amyloid. Aldeed Scott \Yarthin-.
Amvlopsin. — See Pancreas. Anatomy and Physiology
of the.'
Amylum. — Starch. Corn starch. The starch
grains* separated from the fruit of Zea mays Linn£
u. Graminea), i V . S. P.). There appears to be no
ial reason why the Pharmacopoeia should thus
restrict its requirements to corn-starch, except that
this variety is cheap and abundant and readil3 r defined
Fig. 1S4. — Section of Seed of Vetch. Vicia salira Linn, showing
rounded granules of starch in ceils otherwise filled with granular
nitrogenous substance. X 190.
and described. Our account of starch, therefore,
will apply to the entire class, and will be followed by
the differential characters of the more important
varieties.
Starch is the ordinary form of reserve carbohydrate
nutriment in plants, at least in most of those of the
higher classes, and in many of those of the lower
classes. It may be reserved for but a brief period, at
the point where it is produced, or it may, after pro-
duction, be changed into diffusible forms and trans-
ported to special storage reservoirs, where it is again
transformed into starch, and may remain for months
or even for years. For example, being produced only
under the influence of light, it may be consumed dur-
ing the succeeding hours of darkness, or, upon the
; hand, it may l>e transported to the bulb or tuber
of a desert plant, which may exist dormant ii
sand for several years, consuming this starch supply
upon the recurrence of a period of activity. In the
most highly developed and largest family of plants,
. and in some others, inulin, a rel ' I
compound, altogether replaces starch as a reserve
food. Th of starch present in vegetable
tissues is often very great, being about seventy per
J Si
Fig. 185. — Wheal Starch.
Fie. 1S6. — Maize Starch.
cent, in dried potato, and about the same in corn meal
and wheat flour. With the exception of some rare
cases in which special forms are found, starch occurs
in peculiar grains, which are free in the cell cavity.
It originates in a small colorless body known as the
amylogenic body, upon which the starch gathers
in layers, the central body becoming the nucleus, and
being located in the grain at the hilum. The numer-
ous layers of the grain are discernible under the micro-
scope by their different degrees of refraction, due
apparently to different amounts of water, as they
disappear under the effect of drying heat. The grains
may exist singly, or coherent in masses containing a
variable number. The limits of this numerical varia-
tion are often fairly constant in a given plant, and
Fig. 1S7. — Potato Starch.
may thus be utilized as a characteristic. This cohe-
sion often produces peculiar forms of the grains,
which forms also become characteristic. Even if
this is not the case, the form of the grains in a given
plant is usually characteristic, as is the position of the
hilum. The larger grains usually become ruptured
or fissured at the hilum. This fissure may be simple
or in various ways compound, and the forms so result-
ing are also characteristic. In all starches in the
living plant there must be small grains of various
sizes in process of formation, but the largest of them
usually fall fairly well within certain limits, so that
the extreme limits of a given variety are of diagnostic
value. Although single starch grains are colorless
and semitransparent. masses of them are pure white.
Starch powder is very fine and smooth, but the ulti-
mate grains are hard and gritty. They are very
hygroscopic.
307
Am.\ linn
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Fig. 188.— A Granule
of Potato Starch Swollen
by Boiling.
Starch has no odor, but a peculiar, though slight,
farinaceous taste. The grain consists of two sub-
stances, granulose, which is colored blue by iodine,
and another substance very similar to cellulose,
colored pale yellow by iodine. Starch is insoluble in
water and alcohol. Several substances are often
spoken of as solvents of starch, but they all apparently
change it into some other com-
pound before the solution takes
place. Water, under the influ-
ence of heat, converts it into
hydrated starch, a transparent,
jelly-like mass, which is then
soluble in water. Alkali hy-
drates of a strength of more
than five per cent, similarly
dissolve it. Both these solu-
tions are then precipitated by
lime water, lead acetate, tan-
nin, and some other reagents.
Diastase, the principal enzyme
which naturally exists with
starch, is the agent which in
the plant converts it into sugar, suitable for imme-
diate use as food. The same agent can be made to
perform this office artificially, as can dilute acids under
the influence of heat, and as is done by the natural
processes of digestion within the animal body. From
the above-mentioned characters of starch, it is seen
that it can readily be obtained by grinding finely any
cellular structure
which contains it,
washing out with cold
water and filtering or
allowing to settle. It
is also seen that, be-
sides the interest
which centers in
starch for its own
value, the character-
istics of the starches
contained in different
plants, and more
especially in drugs,
may be utilized in the
identification of the
latter, in powdered form, as well as in the detection
of adulterations.
Fig. 189. — Arrowroot Starch.
Varieties. — The only certain means of determining
from what source a given specimen of starch has been
derived is to examine it microscopically, when the size,
shape, markings, and other visible peculiarities of the
granules will generally
suffice to make it cer-
tain. The accompany-
ing illustrations of the
commoner kinds are
magnified uniformly
350 diameters.
1. Wheat Starch, from
various species and
varieties of Triticum
L. (fam. Graminea )
(Fig. 185). In irreg-
ular, angular masses,
which are easily re-
duced to powder; under
the microscope appear-
ing as granules, mostly very minute, more or less
lenticular in form, and indistinctly concentrically
striated. The granules average about 0.050 milli-
meter in diameter.
2. Maize, or Corn Starch (defined above, Fig.
186), i- smaller than the preceding, about 0.030
millimeter in diameter, of polyhedral form, with
central hilum.
3. Rice Starch, from Oryza saliva L. (fam. Gram-
308
Fig. 190. -Sa K o.
ineee) resembles maize starch, but is very much
smaller.
4. Potato Starch, from Solanum tuberosum L.
(fam. Solanacecr), (Fig. 1S7) consists of two classes
of granules mingled together — fine spherical ours,
from 0.01 to 0.03 millimeter in diameter, and large
ovoid ones with very eccentric hilums and very
distinct ruga-, recalling oyster or clam shells, from
0.14 to 0.18 millimeter long.
5. Arrow-root, from Maranta arundinacea L. (fam.
Marautacew) (Fig. 1S9) is finer than potato starch,
which it somewhat resembles; the granules are more
spherical, with blunter, thicker ends, very distinct
eccentric fissures, and less distinct ruga. Canna
Fig. 192.— Oat Starch.
starchy a variety of arrow-root, has enormous granules,
nearly twice as large as those of potato. Neither of
these varieties has the small forms of that from
potato.
6. Sago, chiefly from several species of Metroxylon
Rottb. (fam. Sabalacea?) (Fig. 190) has medium-sized
(0.04-0.07 mm.), oblong, rather irregular, often
faceted, sometimes shoe-shaped granules, with eccen-
tric hilum and fairly distinct ruga. The sago of com-
merce is often half-cooked, with many of the granules
destroyed, and is still more often merely tapioca.
7. Tapioca (Fig. 191) has spherical, medium-sized
granules, with large facets; commercial tapioca is also
partly cooked. (See also separate article on Tapioca).
Besides the above are the starches of numerous
familiar grains and roots, which are not separated for
sale or use, but which are of interest in detecting
adulterations, mixtures, etc., or in identifying the
powders of drugs. The accompanying cuts of oat
and turmeric starches will serve as illustrations of
this large class.
Fig. 193.— Turmeric Starch.
Medical and Surgical, Uses of Starch. — This sub-
stance can in no sense be called a medicine, :i - it is abso-
lutely without physiological action. It is the type of
crude carbonaceous or non-nitrogenous food, and its
conversion into sugar in the mouth, stomach, and intes-
tine is one of the elementary facts of digestive physi-
ology. Asa toilet powder the finer varieties — rice and
corn starches — are in universal use, and one or other
of these is the foundation of most of the proprietary
powders.
Boiled starch, and especially the flours of starchy
substances, are frequently used as poultices, but they
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Anuphrurilslacs
arc mil so convenient and suitable as the mucilaginous
of linseed and slippery elm.
Starch mucilage is occasionally used for immovable
bandages, but it is less adhesive and less suitable for
ibis purpose than flour paste, glue, dextrin, silicate of
potash, or plaster of Paris. One part dissolved glue,
as prepared for cabinet-makers' use, and two or three
parts starch mucilage, a little thinner than the laun-
dress uses it, mixed and applied hot, make a most
, Unit ( ibination for such bandages — light, very
and agreeable in color.
The only official preparation of starch is the Glycer-
Glyceritum Amyli, ten parts of starch dissolved in
■i v of hoi glycerin). This is a permanent trans-
lucent jelly, useful in moistening pill masses, for
emulsions and similar purposes. Iodized Starch
i/kiii I odd I ii in), formerly official, is rather a prepa-
ration of iodine. It is made by triturating five parts
of iodine with ninety-five of starch, with the aid of a lit-
tle water. It is a blue-black powder, and a suitable
preparation to administer for free iodine if it is desired
to give that drug internally.
Henry II. Rusby.
Amyotonia Congenita. — This disorder was first
described by Oppenheim in 1900, under the term
\1\ iinnia Congenita. It was later called Amyotonia
i ongenita by Collier and Wilson, since the name
myotonia congenita, or Thompson's disease could
so readily be confused with myatonia congenita or
i tppenheim's disease. It has been termed congenital
muscular atony by French writers. It is a condition
illy found in children, in which there is extreme
flaccidity of the muscles associated with the entire
loss of the deep reflexes, most marked as a rule at
birth, and tending to slow but gradual amelioration.
The muscles are weak, but are apparently not para-
lyzed. In a paper which appeared in 1904, Oppenheim
published more in detail concerning the condition,
lie says that he had observed for some years children
of from several months to two years whose muscles,
chiefly those of the lower extremities are immobile
and flaccid. Objectively there is marked hypotonus,
almost atony, with loss of the reflexes. The flaccidity
is so marked at times that the limbs can be placed
in almost any position. The motility is always
diminished, varying considerably according to the
patient. In severe grades the motility is almost nil.
In the milder cases certain groups of muscles may
ontracted, but feebly. In very light involvement
the hypotonus is marked, and the patients lack
force in their muscular movements. In the majority
of instances the lower extremities are involved, but in
a few, other muscles are involved. Thus far, the
eyes, tongue, pharynx, and diaphragm seem to be
spared. The intercostals have been known to be
affected. On palpation, the muscles are soft and
flabby, are thin, but not apparently atrophied.
Electrical excitability is usually markedly diminished,
at times lost, again only slightly involved. The
intelligence is apparently uninvolved, as is also the
sensibility. It is apparently a congenital affair.
There is a tendency to progressive amelioration. The
disorder simulates infantile poliomyelitis, but has
nothing in common with it. It is a disease of the
muscles.
This was Oppenheim's disease as he left it in 190-1.
Batten, Collier and Wilson, Spiller, Orbison, Skoog,
Comby, Haberman, and Maserey have written upon
it, and Chene published a small thesis upon the
disease in 1910, reporting forty-three cases. Marburg
gave a small study in 1911. Spiller was the first to
report upon the pathology in 1905.
The general tendency has been to regard the dis-
order in the light of a dystrophy; most of the authors
have said that poliomyelitis could be excluded.
Marburg, on the other hand, claims, and with con-
siderable evidence, that amyotonia congenita of
Oppenheim is a fetal poliomyelitis.
Smith Eli Jelliffe.
Anabolism.— See V, tula lism.
Anacarcliacea.\ — Terebinthinaeea . (The< 'ashew fam-
ily.) A remarkable and important family of some
fifty-nine genera, chiefly tropical or subtropical, ex-
ceedingly vaired in the nature of its products. The
mango, the cashew, and the spondias or hog-plum,
are important fruits; those of Pistacia furnish a well-
known flavoring agent, while the bark of another
species yields the commercial resin mastic; the milk
juice of several Japanese species of Rhus furnishes
Japanese lacquer, and the leaves and fruits of other
species Of this genus yield tanning agents. The oil
which abounds in several species Of Rhus I more prop-
erly called Toxicodendron), and in some other genera,
acts as a powerful cutaneous poison. (See Poisonous
PI, nils.) II. II. RtJSBY.
Anaemia. — See Anemia.
Anaesthesia. — See Anesthesia.
Anaesthol. — This is an anesthetic introduced by
Willy Meyer of New York to replace the A.C.E.
mixture. He mixes chloroform and ether in molecu-
lar proportions, i.e. 43.25 per cent, of chloroform and
56.75 per cent, of ether by volume, and calls the
mixture "M. S." Of this he takes eighty-three
volumes, and adds seventeen volumes of ethyl
chloride. The mixture has a boiling point of 40° C.
{ 104° F.), and would seem to be open to the objection
urged against the A.C.E. mixture, that constituents
of different volatilities do not volatilize equally.
We might expect the ethyl chloride to vaporize
more rapidly than the ether, and this more rapidly
than the chloroform. The experience of anesthetists
is that the action of the mixture is little if any differ-
ent from that of pure chloroform, and that the
amount required is about twice that of chloroform.
In other words, the quantities of ether and ethyl
chloride are too small to have much effect. The
dangers are those of chloroform.
W. A. Bastedo.
Analeptics. — This term was formerly used to include
several classes of agents which were employed to re-
store the body to health, after a period of sickness.
They were also called restoratives, and included hy-
giene, rest, food, warmth, stimulants, and tonics.
R. J. E. S.
Analgesics. — See Anodynes.
Anaphrodisiacs. — These are agents which are used
to lessen an immoderate or morbid sexual desire.
In the usual and narrow acceptation of the term it
includes only the medicinal and physical remedies,
but "in a wider sense it embraces as well all the
moral, dietetic, hygienic, and surgical measures hav-
ing this end in view. The causes of aphrodisia are
many, and not the least important is reflex irritation
of the genitalia, resulting from physical peculiarities or
deformities, phimosis, stricture of the urethra, dis-
ease of the prostate, chronic constipation, hemor-
rhoids, eczema or fissures of the anus, highly concen-
trated urine, etc. In other cases the reflex irritation
may be caused by the presence of worms in the rectum,
or in the vagina in the case of female children, and by
friction of the thighs produced by horseback riding,
bicycling, running the sewing-machine, etc. These
conditions will each call for its own special treatment
in addition to the general measures which should be
309
Anaphrodisiacs
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
adopted; for the detection and relief of the exciting
cause are difficult problems and far more important
than the exhibition of drugs. For another class of
patients, those suffering from diseases of the nervous
system or those with psychical perversion, psycho-
therapeutic measures are of special value.
The principal anaphrodisiac drugs are the bromides,
camphor, hops, salicin, potassium iodide, coniuni.
and chloral and other hypnotics. When there is
excessive acidity of the urine, potassium acetate may
be of service indirectly in removing this source of
irritation.
In general, for the treatment of habitual sexual
erethism nothing will be found better than physical
and particularly mental work to the point of fatigue.
The latter accomplishes its results in two ways: first,
by exhausting the brain where the sexual impulse
(if not reflex) has its origin; and secondly, by so
absorbing the patient's interest as to preclude the
occupation of his mind by lascivious thoughts.
In the general management of a case the physician
should advise a non-sedentary life, as much as possible
in the open air, light diet, with an absence of meats,
coffee, highly seasoned foods, and alcoholic stimulants;
the kidneys should be kept well flushed, the bowels
well open, and the patient should sleep on a hair
mattress, with light covering, in a cool, well-ventilated
room. As a full bladder is frequently a cause of
irritation, U should be emptied upon going to bed and
the first thing in the morning. The patient should
arise early and take a cold douche or sponge bath.
Charles Adams Holder.
Anaphylaxis. — The term anaphylaxis (from &m.
up, away, and v\ai, guard, or 0i/Xa|«, protection!
also called hypersusceptibility, supersensitiveness,
allergy, is a condition of unusual or exaggerated sen-
sitiveness of an organism to foreign proteins; in other
words, an altered power of reaction toward such pro-
teins. Anaphylaxis may be congenital or acquired,
local or general; it is specific in nature. Hypersus-
ceptibility to any strange protein in itself quite non-
poisonous may be readily induced in certain animals
by the introduction of a minute quantity of that par-
ticular protein into the body.
The word anaphylaxis was coined by Richet in
1902 to suggest the opposite condition to prophylaxis,
or protection, since it appeared that in certain cases
the second injection of a poisonous substance instead
of reinforcing the immunity induced by the first,
iter susceptibility, so that less than a
minimal lethal dose of it caused death. But more
recent investigations have shown that the contradic-
tion between immunity and anaphylaxis is only
apparent, that they have to do with the same general
mechanism of the animal body and that in fact the
former may be dependent on the latter. For this
reason von Pirquet has suggested the word '"allergy
(fi/./os, different, and ep)-sta, reactivity) to indicate
an altered power of reaction of the body toward a
foreign substance, thus combining in the same term a
conception of acquired immunity and the related
state of acquired hypersusceptibility.
Historical. — The first to note and record accurately
his observation on this altered power of reaction of
the human body was probably Jenner, who at the
end of the eighteenth century in England began to
study the modification of the form of smallpox by
previous vaccination, and noted particularly the
immediate reaction to variolous matter by the skin
of persons who had had either smallpox or cowpox.
This we now recognize as an anaphylactic phenome-
non of great importance, as we shall show later.
Early in the last century (1839) Magendie found
that rabbits which had tolerated two intravenous
injections of egg albumin without any ill effects
immediately succumbed to a further injection made
after a number of days. Later, workers attempting
to obtain precipitins frequently found that some of
their animals died suddenly during the course of treat-
ment from no apparent cause, though we now know
they were in a state of anaphylaxis to the foreign
protein. Other analogous instances may be found
scattered throughout the literature, the true import
of which was not realized until 1905.
Von Behring and Kitashima (1901) reported an
increasing sensitiveness on the part of guinea-pigs
to successive small doses of diphtheria and tetanus
toxins. This they called the paradoxical phenomenon
or "hypersusceptibility'' (the first use of this term in
a specific sense). This hypersensitiveness to toxil -
is not true anaphylaxis, which is produced by prot
which are non-poisonous in themselves and, as
Hektoen has recently pointed out, the animal dies
with the symptoms of the disease in question and nut
those of anaphylaxis, which are constant for the same
species of animal. Furthermore, the "hypersuscepti-
bility" described by von Behring seems incapable of
passive transmission to normal animals, though
anaphylactic hypersensitiveness is thus transferable.
Portier and Richet (1902) found that if dogs were
given a small dose of a glycerin extract from the
tentacles of actinia, and then in fifteen or twenty days
given a second small dose, the animals quickly
succumbed. The dose given was so small as to cause
no symptoms in a normal animal. They were the
first to use the word "anaphylaxis" to indi
hypersensitiveness to a poison, which they interpreted
as the opposite of prophylaxis.
Arthus (1903) was the first to experiment with a
non-poisonous substance, and at the instigation of
Richet, studied the effect of repeated subcutaneous
injections of sterile normal horse serum in rabbits.
These caused a local reaction, even a necrosis, about
the site of injection which is called the "Arthua
phenomenon," and is now interpreted as a local
anaphylaxis.
At about this time Theobald Smith began to be
puzzled at the sudden and unexplained death of
guinea-pigs used in the standardizing and subsequent
testing of diphtheria antitoxin, while von Pirquet,
approaching the same subject from an entirely
different angle, was noting clinically the peculiar
reactions of the human bod}- to serum therapy in
diphtheria. The fact that guinea-pigs which had
been used for the testing of diphtheria antitoxin
frequently died when later given an injection of
serum had been noticed in several laboratories soon
after the discovery of diphtheria antitoxin, but no
one seems to have perceived any connection between
the two injections until this time. Most of the
workers with serum regarded it as an accident pure
and simple or that the animal's vital resistance had
been lowered by the first treatment; some even
thought that it was the effect of cold, as the serums
were usually kept in the ice chest and were injected
at once after removal from the ice box. During
Ehrlich's visit to America, however, in 1904, 1
bald Smith told him the fact that guinea-pigs often
died suddenly when used a second time as described
above, and upon Ehrlich's return he gave the problem
to Otto, at that time his assistant. Otto began to
publish the results of his work the next year, describ-
ing acute anaphylactic shock under the name of
"Theobald Smith's phenomenon."
Meanwhile, the clinical studies of von Pirquet and
Schick bore fruit in their classic monograph on " the
serum disease" (1905). which described in detail the
syndrome that often follows injections of horse serum
in man. They noted an "altered reaction" of the
human body to repeated injections of serum, pointing
out its profound bearing on the meaning of the in-
cubation period of disease; they drew original and
far-reaching conclusions concerning the relation of
these clinical observations to hypersusceptibility,
310 •
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Anaphylaxis
and they called al tention to the tuberculin rea<
an analogous instance <>f anaphylactic sensitivi
In moo and liiini. ll.i-i-nau and Anderson simul-
eously with Otto took up a systematic study of
anaphylaxis. They bad also encountered the phe-
nomenon described by Theobald Smith to Ehrlich, and
it occurred to them thai there might be some relation
between it and certain exceptional instances of
; iath following the injection of horse serum in
man. Otto, whose "paper appeared first (1905
described the typical anaphylactic reaction of the
. ig to a second injection of horse serum; be
onstrated that the diphtheria poisons play no
part in the reaction, and later worked out many of the
ntial features of the phenomenon, notably the
"refractory" period and the passive transference of
the anaphylactic state to normal animals by means of
the serum of sensitized animals (19i)7). Kosenau and
lerson, working also mainly with horse serum and
ea-pigs, established in a series of researches ex-
ling over several years (1905—1909) many of the
facts of experimental anaphylaxis, notably the
itieity of the reaction and the nature of anaphylac-
tic substances, the maternal transmission, the relation
to endotoxins, and immunity, etc.
Noteworthy contributions to the study of this
interesting subject have been made in ever increasing
volume in recent years. The chemistry of the
itizing substances has been investigated by
Vaughan and Wheeler, and Wells; the physiology
and pathology of the anaphylactic state by 7 Gay,
Southard, Besredka, Auer and Lewis, and Schultz
and Jordan. The important subject of anaphylaxis
in relation to bacterial proteins is still in the con-
troversial stage, and active researches have been
carried out by Friedberger and his assistants, Doerr,
lemann, Rosenow, Cole, and others, and finally
the important bearing of anaphylaxis upon clinical
and forensic medicine has been demonstrated by von
Pirquet, Uhlenhuth, Thomsen, Pfeiffer, and others.
Serum Anaphylaxis. — Horse serum, either normal
or antitoxic, when injected into normal guinea-pigs,
causes no symptoms. By "normal" guinea-pigs is
meant animals that have not previously received
treatment of any kind and were born of untreated
mothers. As much as 20 c.c. may be injected into
the peritoneal cavity of a guinea-pig without causing
any apparent inconvenience to the animal. When
injected subcutaneously there may be a slight
traumatic local reaction, which disappears in a few
hours. Small amounts of horse serum, such as 0.25
c.c. may be injected directly into the brain without
causing any untoward symptoms.
Very characteristic symptoms, however, are pro-
duced by horse serum when injected into a susceptible
guinea-pig, i.e. one that has received a prior injection
of horse serum. The symptoms are apparently 7 the
" whether the injection is made subcutaneously
or into the peritoneal cavity, or whether normal or
antitoxic horse serum is used. In five or ten minutes
after injection the pig manifests indications of respi-
ratory embarrassment by scratching at the mouth,
coughing, and sometimes by spasmodic, rapid, or
irregular breathing; the pig becomes restless and
agitated; there is a discharge of urine and feces.
This stage of exhilaration is soon followed by one of
paresis or complete paralysis with arrest of breathing.
The pig is unable to stand or, if it attempts to move,
falls upon its side; when taken up it is limp. Spas-
modic, jerky 7 , and convulsive movements now super-
vene. This chain of sy 7 mptoms is very character-
istic, although not always following in the order
given. Pigs in the stage of complete paralysis may
fully recover, but usually convulsions appear, and
are almost invariably a forerunner of death. Symp-
toms appear about ten minutes after the injection
has been given; occasionally in pigs not very sus-
ceptible they are delayed thirty to forty-five minutes.
Only in one or two instances of tic- many bund
observed by Rosenau and Anderson bave the
symptoms developed after on.- hour. Piga developing
symptoms as late as this are not very susceptible
ami do not die. Death usually occurs within an hour
and frequently in less than thirty minutes. If the
second injection be made directly into the brain or
circulation, the symptoms are manifested with explo-
the animal frequently dying within
two or three minute .
A tall in temperature occurs which in fatal cases
may be as great as 13° C. (Pfeiffer). Owing to
apparent relation betv a the depression in ten
ature ami the severity of the symptoms, the extent
duration of the fall have beet
degree of anaphylaxis. Very minute reinjeetions
of antigen, however, have 1 n known to raise the
temperature. The blood during anaphylactic shock
shows a leucopenia, and a diminution in complement.
Immediate autopsy shows a striking condition of the
lungs described by Gay and Southard, also by Auer
and Lewis. When the chest is opened the lungs do
not collapse but remain fully and permanently dis-
tended, forming a cast of the pleural cavities. The
heart continues to beat strongly for some time.
Asphyxia, due to inspiratory immobilization of tic-
lungs, is therefore probably the immediate cause of
death.
The essential features, then, of experimental
anaphydaxis are: (1) the first injection, consisting of a
bland alien protein, non-poisonous in itself, which
sensitizes the animal; (2) an interval of about eight
to fourteen days; (3) the second injection of the same
protein which produces a reaction known as acute
anaphylactic shock.
Judged by the severity of the symptoms of the
acute anaphylactic reaction the guinea-pig is appa-
rently the most susceptible of animals (being 400
times more sensitive than the rabbit, according to
Doerr), but probably all animals may be sensitized
to a greater or lesser degree, although our methods of
observation are still too crude to admit of any accu-
rately graded comparison. White mice were long
thought to be incapable of anaphylaxis, probably
because of the absence of sudden death from as-
phyxia, so constant and striking in the guinea-pig; but
Schultz and Jordan have shown that white mice do
react toward horse serum with restlessness, marked
irritability 7 of the skin, passage of urine and feces, and
temperature and blood-pressure changes.
In dogs (according to Richet, who worked with
them almost exclusively 7 ) the principal symptoms
are gastrointestinal. Tiiere is immediate vomiting,
followed by tenesmus and bloody discharges from
the intestines. Death is infrequent, but there may
develop a condition of hemorrhagic inflammation
in both the large and the small intestine which is
called by Richet "chronic anaphylaxis.'' and by
Schittenhelm and Weichardt, enteritis anaphy-
lactic*. " Another important sign is the rapid fall
in blood pressure, sometimes 80 to 100 millimeters;
coagulation of the blood is delayed. Dyspnea is not
marked, but as in other animals, there are initial rest-
lessness and skin irritability 7 ; there may be paralysis
and death.
Rabbits are apt to react to a reinjection of horse
serum by edema and even necrosis at the site of
injection — the "Arthus phenomenon" or local
anaphydaxis. Arthus also described, in non-fatal
cases in rabbits, respiratory 7 disturbance, general
prostration, fall in blood pressure, and increased
peristalsis. In cases of acute lethal anaphylaxis
produced in rabbits highly 7 sensitized by repeated
minute injections, Auer describes the slow 7 respiration,
the sudden falling of the animal on its side witli a
short clonic convulsion, stoppage of the respiration,
weak heart beat, and death within a few minutes.
Auer believes, from observations made at immediate
311
Anaphylaxis
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
autopsy and by actual inspection of the chest contents
during shock, that acute anaphylactic death in rab-
bits is due primarily to a failure of the heart muscle to
perform its work, and not to a condition in the lungs
causing asphyxia, as in guinea-pigs. The lungs
collapse well, "though not fully; but the right heart
remains dilated, and its muscle is seen to be changed
anatomically and functionally, as though in chemical
rigor.
Altered reaction to a second injection of serum has
been observed, though not studied so carefully, in
numerous other animals, e.g. in cows, horses, goats,
sheep, and cats, in hens and pigeons, and in certain
cold-blooded animals, with symptoms varying accord-
ing to the species.
It is evident that no one symptom, or group of
symptoms can be taken as an adequate criterion of
anaphylaxis in all cases. For while the symptoms
of anaphylactic shock are characteristic and practi-
cally constant in the same species of animal, a differ-
ent species will give a widely differing picture with
the same protein agent, because the same organs are
not involved to the same degree. An explanation of
these differences from the physiological point of view
has been given by Schultz. He has shown that
serum anaphylaxis is essentially a matter of hypersen-
sitization of smooth muscle in general. He concludes,
as a result of his experiments that during anaphy-
lactic shock, all smooth muscle contracts. This is
fatal to the guinea-pig owing to the peculiar though
normal anatomical condition of its bronchial tree;
the mucosal layer of the secondary bronchi is relatively
thick in comparison with the lumen, and the contrac-
tion of the smooth muscle throws it into folds which
completely occlude the bronchi (Schultz and Jordan).
The guinea-pig dies of asphyxia the cause of which is
purely local and not in the central nervous system, as
the first investigators believed. Auer and Lewis had
previously shown the same thing by producing
immobilization of the lungs with a toxic dose of pro-
tein in sensitized animals whose cord and medulla
were destroyed. The bronchi of mice, dogs, and
rabbits, however, are relatively poor in mucous
membrane, which accounts for the almost complete
absence of death from asphyxia in the animals during
anaphylaxic shock. In the dog the contraction of
smooth muscle sets up a vigorous intestinal peristalsis
and a forced emptying of the urinary bladder; the
characteristic initial rise in blood pressure may be due
to constriction of the pulmonary, coronary, and
systemic arteries, and according to Auer the sub-
sequent marked fall to direct action on the heart
muscle itself, particularly of the right side, causing a
venous accumulation of blood, an effect typified most
strikingly in the rabbit. This provides also an ade-
quate pharmacological explanation of the action of
atropine and the anesthetics in alleviating the symp-
toms of acute anaphylaxis.
Serum anaphylaxis in man is met with most fre-
quently following the use of antitoxic sera and has
been carefully described by von Pirquet and Schick
(1005). After an injection of scrum (usually in from
eight to twelve days) there is apt to be a febrile
reaction, now generally known as "serum-sickness."
The common symptoms are local redness, itching, and
pain at the point of injection, swelling of the lymph
nodes, fever, and a general urticaria lasting from two
to six days. In more severe cases there are general
malaise, albuminuria, pronounced joint pains and
even effusions, swelling of the mucous membranes,
hoarseness and cough, nausea and vomiting, vertigo,
and remarkable skin manifestations varying from
hyperemias and erythemas to efflorescences resem-
bling measles or scarlatina.
Rarely there may be subnormal temperature, a
weak and rapid pulse, a catarrhal or hemorrhagic
enteritis and extreme weakness approaching collapse.
These results are independent of the antitoxic quali-
ties of the serum, for Johannessen obtained the same
symptoms by introducing normal horse serum into
the bodies of perfectly healthy human beings. Indeed
the very earliest animal experiments were particu-
larly concerned in determining whether the antitoxin
played any part in the phenomenon and it was soon
conclusively eliminated as a factor.
Both the incidence and the severity of serum
sickness are proportional to the amount injected up
to. a certain point, but the acute (sometimes fatal)
reaction in man is more dependent upon the hyper-
susceptibility of the individual than upon the amount
of serum injected. If the serum is "concentrated"
(i.e. serum-globulin) the reactions are correspondingly
lessened because smaller quantities of the foreign
protein are injected, and the albumins and certain
other proteins have been eliminated. If the serum
be properly aged (a year or two old) the incidence of
serum-sickness is believed to be decreased. The
peculiarity of serum sickness in man is that it may
follow the first injection of a foreign serum, though
only after a definite incubation period corresponding
to the time required to sensitize an experimental
animal. It has been suggested that enough serum
remains unchanged or incompletely changed near the
point of injection to cause a sharp reaction when the
body becomes sensitized. There is no proof more-
over that other animals do not develop a reaction to
the first dose which never rises to the threshold of
clinical observation. In fact Ehrlich, Francione, and
others have observed a temporary diminution of
complement in the blood of guinea-pigs ten to twelve
days after the first injection.
A second injection of serum after some days finds
the human organism in a sensitive condition and if a
clinical reaction is produced, it is, as we might expect,
immediate and often severe, but of shorter duration
than the first. Von Pirquet noticed that if many
months or years elapsed between the two injections,
the reaction was no longer "immediate" but only
"accelerated," coming between the sixth and eighth
days instead of between the eighth and twelfth days
which is the normal incubation period for serum sick-
ness. He concluded that sensitiveness may disap-
pear in course of time, but is more quickly regenerated
on a second occasion.
Besides the typical serum sickness, there have been
reported since the introduction of serum therapy a
certain small number of unforeseen and fatal catas-
trophes attending the injection of serum into human
beings. The following case published by H. F.
Gillette will serve to illustrate them all:
" The patient was a man of fifty-two, a subject of
asthma. He asked me to administer diphtheria
antitoxin to him hoping it might cure his asthma.
I administered 2,00(3 units under the left scapula
with the usual precautions. He had about com-
pleted dressing when he said he had a pricking
sensation in the neck and chest; soon he sat down and
said he could not breathe, nor did he breathe again.
His pulse at the wrist remained regular
and full for some time after respiration ceased. He
had a mild degree of cyanosis and edema of the face.
He died in tonic spasm ten minutes after injection.
Autopsy revealed no palpable cause of death."
The same author collected twenty-eight cases of
collapse or death after serum injection, of which fifteen
ended fatally. There was a common history of previous
asthmatic trouble in all but five of the twenty-eight,
and all, after injection, showed common symptoms of
sudden intense dyspnea, a sense of overwhelming
anxiety, edema and cyanosis of the face, a sudden
massive urticaria, tonic muscular spasms, and con-
tinued beating of the heart long after the ceasing of
respiration. Rosenau and Anderson collected nine-
teen cases and were able to examine the serum used
in two of them. It was found to be no more toxic to
sensitized guinea-pigs than other horse serum. These
312
REFERENCE HANDBOOK OF THE MEDICAL SCIEM T,S
Anaphylaxis
rases of severe systemic shock seem susceptible of no
other explanation than that the unfortunate individ-
uals had been in some manner at a previous time
sensitized to horse protein. They present a picture
which is almost the counterpart of typical anaphylactic
shock in guinea-pigs, and the most striking thing
n them is that practically all give a history of
piratory trouble in the past, especially horse-
,1,1a. Schultz and .Ionian suggest that these
occasional cases of sudden death in man may perhaps
be due to an abnormal development or condition of
mucous membrane and smooth muscle of the
bronchi (as in asthmatics), and that the smooth
muscle, being hypersensitive, produces asphyxia
by sudden contraction. One thing is clear, that
(hese immediate and sometimes fatal reactions are
not dependent upon any peculiar property in the
in. bul to an altered powered of reaction of the
individual to the foreign protein injected.* The
anaphylactic reactions following the injection of
serum in man may l>e summed up briefly as follows:
Reactions following first injection:
'Serum sickness," incubation eight to twelve
days.
Vcute anaphylactic shock, with collapse or
death i rarely).
Reactions following second injection:
interval between injections less than eight days,
iction.
b | interval twelve to forty days, immediate reaction.
c) interval fifteen days to six months, either
immediate or accelerated reaction, or both.
,/ interval over six months, accelerated reaction.
The above table represents the usual course of events,
but exceptions may occur, and the time intervals are
only approximate. Sometimes the reactions in man
do not appear until the third, fourth, or some subse-
quent injection.
Two precautions are suggested in serum therapy:
1. Except in urgent cases, avoid injecting horse
serum into individuals known to be asthmatic, or to
have symptoms when around horses.
2, If hypersensitiveness is suspected, give at first
a very small portion of the dose, following it in an
hour or so with the rest, injecting it exceedingly
slowly and avoiding a direct injection into the
circulation.
Experimental Anaphylaxis. — 1. The Anaphy-
lactic Agents, or Allergens. — A great variety of pro-
teins, animal, vegetable, and bacterial, can induce
hypersensitiveness. Such substances also give
rise to antibodies, and are therefore true antigens;
toxins which are also antigens are not able to produce
a -late of true anaphylaxis. Gelatin, a protein of a
Eeculiar sort, is not an allergenic substance. This
as led to the supposition that sensitizing power has
some connection with the aromatic radicle of the pro-
tein molecule, which is not found in gelatin.
The stability of anaphylactic antigens is remarkable.
Chemicals can destroy the sensitizing power only by
breaking down the protein molecule into cleavage
products as low as peptones. The antigens are ther-
mostable to a high degree. Eel serum, naturally a very
toxic substance, is rendered quite non-toxic at 60°,
but its sensitizing power is unaffected. When ths
physical state of a substance is altered by heat, as in
coagulation, its allergenic properties disappear, but
if coagulable substances such as egg-white, horse
serum and milk are first carefully dried, thev may then
be heated to 130° C. for two hours, or to 170° C. for
ten minutes without appreciably affecting their
♦Rosenau and Amoss have recently indicated a possible
explanation of the way in which such persons may become sensi-
tized. They have proved that a protein material is given off in
the expired breath of human beings. There is thus some reason
to suppose that an interchange of protein may take place between
two individuals of different species by way of the lungs.
anaphylactic powers i Rosenau and Anderson).
\:e also is proved to have no appreciable effect, Bince
I'lilenhuth has sensitized animals with the flesh of
mummies.
An incredibly small amount of ant igen is sufficient
to induce hypersuseept ibilii v. Uoseiiau and Ander-
son used on an average 0.004 CC. of serum in their
experi ntS, and once sensitized a guinea-pig with
one one-millionth of a cubic, centimeter. Well;
sensitized a guinea-pig with such a minute amount as
one twenty-millionth of a gram of purified egg-albu-
min.
The first injection or sensitizing dose may be given
subcutaneously, intraperitoneally or directly into the
circulation. In fact, susceptible animals may be
sensitized by intrpducing the alien protein into the
body by any route through which it may be absorbed.
For example, guinea-pigs have been sensitized by the
inhalation of a fine spray of serum, and even by tier
ingestion of horse serum or horse meat over a period
of two or three weeks (Rosenau ami Anderson). As
an interesting parallel to the latter fact Uhlenhuth
has shown that precipitins are formed in the blood
after the prolonged ingestion of meat and Carrol has
induced the production of specific agglutinins by the
ingestion of dead typhoid bacilli. The second injec-
tion or reacting dose must be relatively larger than
the sensitizing dose, but the actual quantity required
to produce poisonous symptoms is nevertheless very
small. One-tenth of a cubic centimeter of horse
serum injected into the peritoneal cavity is sometimes
sufficient to cause death in a sensitized guinea-pig;
0.1 c.e. subcutaneously may cause symptoms, while
much smaller amounts given into the brain or directly
into the circulation may be fatal. Proteins vary in
this respect; for example, egg-white is effective in
even smaller quantities than horse serum at the second
injection, whereas a larger amount of milk is necessary
to produce an equivalent reaction.
The anaphylactic reaction is specific. Thus a
guinea-pig sensitized with horse serum does not
react to a subsequent injection of egg-white, vege-
table protein or milk. The specificity extends even
further than this: in order to give rise to anaphylactic
symptoms, the protein material given at the first and
second injections must be from the same species or
from some closely related species. Thus a guinea-pig
sensitized with cow's milk will not react to a subse-
quent injection of woman's milk. Guinea-pigs
sensitized with the albumin of hen's eggs will not
react to a subsequent injection of the albumin of the
eggs of pigeons, but do react mildly to duck egg-white
(Rosenau and Anderson). This specificity according
to species is therefore of the same degree as that of
certain immune reactions, notably the precipitins.
That is, there is a group reaction in the proteins of
allied species, but no reaction between the proteins of
widely different species or between proteins of
widely different origin. The maximum effect at
second injection is obtained by the use of the identical
protein used for sensitization. Certain sera which
react interchangeably to precipitins, as, for example,
human and ape, horse and ass, sheep and goat, rat
and mouse, remain indistinguishable also by the
anaphylactic reaction. The same specificity holds
with respect to bacterial proteins: an animal sensitized
with typhoid bacilli will react strongly toward paraty-
phoid, and somewhat toward colon bacilli, but not at
all to unrelated species.
One of the remarkable facts in relation to the
specificity of anaphylaxis is that guinea-pigs may be
in a condition of anaphylaxis to three protein sub-
stances at the same time. For instance, a guinea-
pig may be sensitized with egg-white, milk and horse
serum, and subsequently react separately to a
second injection of each one of these substances. The
guinea-pig may be sensitized by giving these strange
proteins either at the same time or at different times,
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Anaphylaxis
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
in the same place or in different places, or by in-
jecting them separately or mixed. The guinea-pig
differentiates each anaphylactogenic protein in a
perfectly distinct and separate manner. The animal
is susceptible to the second injection of each one of
the three substances in the same sense that it is
susceptible to three separate infectious diseases
(Rosenau and Anderson).
That there may be exceptions to the rule of species-
specificity is shown in the case of the crystalline lens.
A guinea-pig sensitized to the lens-extract of one
species of animal will react to the lens-extracts of
widely different species, or even of its own species but
not to other tissues (Andrejew). Here too there is an
exact parallel in the precipitin reaction which fails to
distinguish the lens of one species from that of
another (Uhlenhuth). This is an example of organ-
specificity. It is said, but without definite confirma-
tion, that the tissue of the uveal tract, and of neo-
plasms also contain organ-specific proteins. In the
vegetable world, Osborne has shown that whereas
preparations of globulins from hemp, flax, and
squash do not react with each other, gliadin from
rye reacts strongly with gliadin from wheat, a result
in accord with the fact that by chemical and physical
means, no differences have been detected which were
sufficient to indicate that these gliadins were different
substances.
It is probable that only proteins which have a
complete or partial chemical identity of structure will
react with each other. Differences too small to be
detected by analytic means at our disposal, may yet
prevent any tendency toward interaction, and the
anaphylactic phenomenon may thus be used to deter-
mine the finer relationships of proteins. It is evident
from these facts, as Osborne concludes, that struc-
tural differences exist between very similar proteins
of different origin, and that chemically identical
proteins apparently do not occur in animals and plants
of different species unless they are biologically very
closely related.
The identity of the sensitizing with the intoxicating
substance has been frequently brought into question
in the past. Besredka, Vaughan, and others report
results which led them to the conclusion that anaphy-
lactic antigens contain two separable substances, one
of which acts as sensitizer, the other as the reacting
agent. The impossibility of obtaining, at present, a
chemically pure protein to work with, renders it
difficult to establish this point. Wells, however, has
shown that the purer the protein, the smaller is the
amount necessary both to sensitize and to intoxicate,
a fact pointing to the identity of the two substances.
Rosenau and Anderson as well as Doerr and Russ
have shown that both qualities of a foreign serum
are affected equally by age, heat, and other modifying
influences, indicating that both phases of the anaphy-
lactic phenomenon have to do with one and the same
sul i-tance.
2. Incubation Period. — Sensitization in an animal
appears only after a period of from eight to twelve
days after the first injection. This corresponds to
the incubation period of a large group of the infectious
diseases, and to that of serum-sickness in man.
That infection and sensitization are in some way
correlated phenomena has long been believed. Von
Pirquet's explanation of the incubation period of
both in common terms of "allergy" with be discussed
later. A second injection, given within the incuba-
tion period, produces no symptoms of reaction, and
indeed postpones or prevents the appearance of
sensitization. Similarly it has been said that a
large initial dose prolongs the incubation period.
However, once the condition of hypersensitiveness is
established, it lasts (with perhaps a slight but gradual
waning of intensity) for an indefinite period. The
exact limit is not known, but Rosenau and Anderson
have found a guinea-pig highly sensitive 1,096 days
after the first injection, and they believe that the
condition is persistent throughout life.
3. The Refractory Slate (antianaphylaxis, anergy
immunity). — If a sensitized animal recovers from
acute anaphylactic shock, or is given a second
comparatively large dose of protein within the
incubation period, it immediately enters a so-called
refractory state or antianaphylaxis (Nicolle), in which
it is "immune" to further injections of that particular
protein and acts like an animal that has never been
sensitized.
The state of antianaphylaxis is not believed to be
a true "immunity" in a serological sense, becau.-e it
appears at once, without any incubation period;
it disappears in the course of a few weeks leaving the
animal again sensitive; and the serum of refractory
animals is not protective against anaphylaxis when
introduced into other animals, but on the contrary
actually confers a condition of hypersensitiveness.
No adequate explanation of this state has been
advanced; it is commonly attributed either to dis-
appearance of complement, which is apparently a
necessary factor in anaphylactic shock, or to neutral-
ization (saturation) of the antibodies upon which
the state of hypersensitiveness seems to depend
(Friedberger). A pseudo-refractory ' state may be
induced by certain drugs, notably the anesthetics
which merely mask the symptoms of shock by
paralyzing the central nervous system; or by large
intravenous injections of physiological salt solution,
which seem to prevent shock by temporary deviation
of complement. A correct conception of this interest-
ing phenomenon of antianaphylaxis is not possible
until we have mastered the fundamental principles
underlying anaphylaxis.
4. Passive Hypersusceptibility (passive anaphy-
laxis). — Otto was the first to describe the passive
sensitization of guinea-pigs. He noted that if serum
from a sensitized animal be transferred directly to a
normal animal, the recipient becomes hypersuscep-
tible without the intervention of the usual incubation
period and remains hypersusceptible for one or two
weeks. Otto, Gay, and Southard, and others found
that a latent period of about twenty-four hours must
elapse after the transference of serum before a reaction
could be elicited. It has recenth' been stated (Doerr
and Russ) that under proper conditions, an immediate
passive hypersusceptibility can be obtained. This
would make the condition analogous to passive
immunity and it is generally known therefore as
"passive anaphylaxis." At the same time, as
Hektoen points out, the period of latency observed
in so many of the experiments in passive anaphylaxis
has not been explained altogether satisfactorily.
Furthermore, it has not been conclusively proved
that sensitiveness is capable of heterogenous trans-
mission, i.e. from one species to another, as in the
case of passive antitoxic immunity. Hypersuscepti-
bility is transmitted by the mother guinea-pig
to her young, which may remain sensitive for as much
as a year after birth. This fact (as first pointed out
by Rosenau and Anderson) may throw some light on
the transmission of a tendency to a disease from
generation to generation.
5. Local Anaphylaxis. — The fact that a second
subcutaneous injection of alien protein in a rabbit
may cause local edema and necrosis instead of acute
systemic shock has been referred to as an example
of local anaphylaxis. The ocular instillation of
tuberculin may lead to a sensitization which is local
to a certain extent, and w-hieh renders a subsequent
application liable to misinterpretation. In experi-
ments by Rosenau and Anderson, out of twelve men
who gave an absolutely negative test to the first
conjunctival application of tuberculin, ten reacted
typically to a second application of the same material
after an interval of fifty-one days. Bloch infected
himself with a new species of ringworm which he
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Anaphylaxis
,■ ., Isolating, and two years later found thai he still
gave a vigorous cutaneous reaction to an extract of
the fungus, prepared like tuberculin. He now skin-
grafted a patient from himself, and discovered thai
these graft 3 continued to give a cuti-reaction toward
the same extract, although the patient's own skin
failed to react. This bespeaks a local effecl upon the
in addition to changes in the blood during
certain forms of sensitization— in other word-; ana-
phylaxis is probably a cellular as well as a humoral
omenon.
Practical Relation of Anaphylaxis to Medi-
, im . -One effecf of serum therapy (viz. serum-sick-
i:i- been noted above, but ol her forms of treat-
ment in which protein matter is injected are liable to
be followed by anaphylactic manifestations. In the
Pasteur prophylactic treatment for rallies for example,
there is apl to be a sudden and simultaneous Baring
up of previous points of inoculation sometime during
the second week. Vaughan reports a case receiving
the Pasteur treatment for the bite of a rabid dog in
January, 1906. In March, 19U7, the patient was
bitten by a rabid cat and received a second course of
treatment. Each injection produced almost at once
a local area of aseptic inflammation three inches in
diameter which disappeared in forty-eight hours.
The patient 's sister who received the same emulsion
I no reaction.
Hay fever and asthma form a group of diseases
which are undoubtedly anaphylactic in origin. The
different types of hay fever are characterized by
uniform symptoms at definite seasons, namely, redden-
ing and swelling of mucous membranes and watering
of the eves, sneezing, asthma, and a soreness in the
throat and larynx. Elliotson in 1831 showed the
cause to be pollen. The disease can be produced at
will, even in winter, by exposing sensitive individuals
to pollen; normal persons do not react. Appreci-
ation of this reaction as a phenomenon of hyper-
sensitiveness is due to Wolff-Eisner from whose
monograph the following data are taken. The
pollen test consists in suspending one centigram of
pollen in 5 c.c. of salt solution, and instilling two drops
into the eye. Normal persons feel a slight itching,
but sensitive individuals react with typical symptoms:
the conjunctivae become injected and rapidly che-
motic; the nasal mucous membrane swells and there are
sneezing and asthma. The analogy to serum disease
and to hypersensitiveness to tuberculin is strength-
ened by the fact that the same symptom-complex
may be obtained by subcutaneous injection of the
pollen suspension, in which case an urticaria develops
about the point of inoculation as well. Asthmatics
of the various types presumably are sensitized to
different protein substances found in their environ-
ment. Tims certain individuals may have symp-
toms of hay fever (including asthma) in the presence
of horses, rabbits, guinea-pigs and other animals.
Many substances, which as far as can be discovered,
possess no inherent toxic properties of their own,
and to which the vast majority of human beings are
utterly insensible, cause in certain people intense
inflammatory reactions when they are brought into
contact with their bodies, either directly upon the
skin or in the alimentary tract. Of the external
irritants cases have been reported of severe general
urticaria following contact with satinwood, prim-
roses, and many other substances. Idiosyncrasies
with regard to articles of diet belong to the same
■ gory. Apparently almost every variety of
protein food has at some time or other been reported
as intolerable to certain individuals. Buck had a
patient who was sensitized to pork and suffered
urticaria whenever he ingested it in any form or any
quantity. Ten cubic centimeters of the patient's
serum were put into a guinea-pig, which twenty-four
hours later reacted with acute fatal anaphylactic
shock to 5 c.c. of pig serum, evidently an example of
passive anaphylaxis. Egg-albumin not infrequently
produces the most severe gastrointestinal disturb-
ances, with vomiting ami watery diarrhea, as well as
a generalized urticaria ami asthmatic crises even
when disguised in minute quantities in other funds.
Egg-white as well a-, any other protein substance to
which the individual has bet le sensitized, may
produce; a local reaction when rubbed into the skin.
This is analogous to the von Pirquet reaction with
tuberculin, which will be discussed later. All forms
of sea-f 1 (oysters, lobsters, fish, etc.) an' notorious
intoxicating agents in some people, and among the
vegetables, buckwheat, tomatoes, and strawberries
may cause the same unpleasant effects. In such
cases, it is unknown how the sensitization is originally
'Heeled, but both the alimentary and respiratory
t ract s have been suspected.
Besides serum-sickness, hay-fever, as well as most
of t he asthmas and urticarias, w hich are now generally
accepted as anaphylacl ic in nature, there are a number
of other phenomena which are now being explained in
terms of anaphylaxis. Light is thrown on puerperal
t clampsia by the fact that a pregnant guinea-pig can
be sensitized to her own placental extracts (Rosenau
and Anderson) and probably to her own amniotic
fluid and the serum of her young. This sensitive-
ness has also been passively transferred (Gozony and
Wiesinger). Hektoen points out the fact that
sympathetic ophthalmia may be an allergic phenome-
non, since it has been shown that the lens protein and
possibly also uveal tract protein may cause antibodies
in the same animal from which they are obtained.
The tuberculous diathesis (as well as other diatheses)
is explained in part as an hereditary transmission of
hypersusceptibility. And anaphylaxis has been sug-
gested now and again as a factor in the onset of labor,
the crisis in pneumonia, the spasmophilic diathesis,
the symptoms attendant on the rupture of the cysts
in echinococcus disease, and the effect of quinine in
suddenly liberating hemoglobin in black-water fever.
Anaphylaxis in Diagnosis. — The most important of
the special anaphylactic phenomena are the tuberculin
and mallein reactions.
The hypodermic injection of tuberculin was intro-
duced by Koch in 1S90, but its diagnostic as well as
its therapeutic use was abandoned for a long while,
when its dangers were discovered. The reaction was
determined by the rise in temperature. In a tubercu-
lous individual, the temperature rises in six to twelve
hours, is at its height from twelve to twenty-four
hours, and declines to normal in twenty-four to thirty-
six hours. The patients compare their symptoms to
those of grippe; headache, prostration, pains in the
joints and limbs. In 1907 von Pirquet introduced
the cutaneous tuberculin test, in which a drop of
"old" tuberculin is placed upon a scarified point
on the skin. The specific reaction appears within
twenty-four hours as a red papule at least five milli-
meters in diameter. The reaction reaches its maxi-
mum in forty-eight hours and fades out slowly, ulti-
mately leaving no trace. Simple contact of the outer
skin with "old" tuberculin is sufficient for the specific
reaction where there is a high degree of sensitiveness
of the skin (Lautier). Upon intense rubbing with a
fifty per cent, tuberculin ointment (Moro's percu-
taneous test) the reaction is nearly as delicate as the
cutaneous. The mucous membranes are even more
sensitive than the skin, e.g. the conjunctiva, nose,
urethra, rectum, and vagina. In all tests a non-sen-
sitized person will give no reaction. The explanation
of this advanced by Koch was that the small
addition of the injected tuberculin to the antigen
already in the body is sufficient to cause general symp-
toms. Marmorek thought the dose stimulated old
foci to renewed activity. It is now generally accepted
as an anaphylactic reaction. Indeed it is analogous
to the "accelerated reaction" in serum disease.
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Anaphylaxis
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Tuberculin is believed to be a suspension of ultra-
microscopic particles of the protein material contained
in the bodies of tubercle bacilli. The old tuberculous
focus plays no part except as the sensitizing agent;
the tuberculin injection or cutaneous application acts
as the reacting dose. It is the rapid destruction of
the protein material by the prepared organism which
liberates poisonous products and gives rise to symp-
toms of local inflammation, or of systemic reaction.
Both the prevention and cure of tuberculosis may
be explained on the basis of anaphylaxis. The power
of defense against the tubercle bacillus is directly pro-
portional to the power of the body to react and thus
prevent the invasion, growth, and multiplication of
the parasites. If a tubercle bacillus lodges in a sen-
sitized organ or tissue, a vigorous reaction takes place
at once. The bacillus is attacked by the cells and
fluids which are concentrated upon the point where
they are most needed. If the organ or tissue is not
sensitized, no reaction occurs and the natural defences
of the body are not brought into operation; little or
no obstacle is presented to the development of a
tuberculous focus.
The cure of tuberculosis also depends upon the
power of the tissues to react in the anaphylactic
sense. Thus, the tissues immediately surrounding a
tuberculous focus become sensitized by the autolytic
products of the tubercle bacillus. The power of such
tissues to react may be seen with the naked eye as a
red zone of congestion when tuberculin is injected into
such an animal. The cure of tuberculosis depends
upon the ability of the surrounding tissues to react
promptly and vigorously enough to wall off and thus
neutralize or destroy the tuberculous focus. In case
the power of reaction fails, the primary focus spreads
and the disease advances to a fatal termination.
If instead of the minute quantity of tuberculous
material which gains entrance into the animal body
by natural or artificial inoculation, we inject large
amounts of tubercle bacilli into infected animals,
we get very intense and usually fatal anaphylactic
symptoms, which are elicited equally by living or
dead bacteria, or by bacterial extracts.
Von Pirquet points out that the tuberculin test
fails under the following conditions:
1. Very early in life, i.e. in nurslings. Schlossman
and Moll found that serum disease also is very rare in
nurslings. This led them to experiment on rabbits,
and they showed that no demonstrable antibodies
(such as precipitins and agglutinins) are formed before
the eighth week, and that injections of albumin pro-
duce no anaphylaxis during this period.
2. In advanced stages, in chronic or cachectic forms,
in miliary tuberculosis, and in tuberculous meningitis,
tuberculin tests fail. This is probably due (according
to von Pirquet) to saturation of the antibodies owing
to preponderance of antigen (antianaphylaxis?).
3. Continued treatment with tuberculin will destroy
the reaction for the same reason.
4. A long interval following a healed infection will
allow the antibodies to disappear.
The mallein and leprolin tests in the diagnosis of
glanders and leprosy are precisely similar in theory
and practice to that of tuberculin. A similar test
has been put to use in actinomycosis. The recent
preparation of syphilitic virus in the form of " luet in"
by Xoguchi, may perhaps offer a similar opportunity
to diagnose syphilis by a cutaneous test. Individuals
with many other bacterial infections will respond to
the cutaneous or conjunctival application of the
corresponding bacterial extract, and the test has been
proposed in typhoid fever, gonorrhea, pneumonia, and
other diseases.
Passive anaphylaxis has been tried, but rather un-
successfully as an aid to diagnosis of tuberculosis and
cancer. Yamanouchi (1908) claimed to have sensi-
tized rabbits passively with serum from tuberculous pa-
tients or cadavers, and Capelle has recently (1911)
transferred sensitiveness to tuberculin from one
animal to another. These results have not been
rigidly confirmed, nor applied in any practical manner
toward the diagnosis of the disease. According to
Pfeiffer the serum of cancer patients renders guinea-
pigs passively sensitive to cancer proteins. The
assumption is that the cancer protein is specifically
different from that of the host. This, if confirmed,
would aid not only in the diagnosis of malignant dis-
ease, but in its treatment.
The anaphylactic reaction has forensic value in the
identification of blood stains. Thomsen at the State
Serum Institution in Copenhagen easily rendered
guinea-pigs anaphylactic to homologous serum by
means of an aqueous extract of the blood spot in
question. The specificity of the reaction has made it
valuable in the detection of protein adulterants in
food, such as horse meat in sausages, etc.
Anaphylaxis as a Scientific Instrument. — In
the detection of minute quantities of protein, and in the
study of the relationships of different proteins, the
anaphylactic reaction is invaluable. Rosenau and
Amoss have determined that the expired breath of
human beings contains protein material enough to
sensitize guinea-pigs, a fact which may have a bearing
on the cause of symptoms in crowded, ill-ventilated
places, and also offers an explanation of the way in
which individuals may become sensitive to horse
serum and some other foreign proteins. In cases of
alimentary albuminuria, "Wells has found by this
reaction that the albumin excreted is not chemically
identical with that ingested. Doerr has suggested
using anaphylaxis in the differentiation and grouping
of bacteria. The potentialities of the anaphylactic
reaction are therefore rather broad in the domain of
scientific research. A limitation in the practical
application of anaphylaxis is that the only method of
observing the reaction is in the production of acute
symptoms in experimental animals, a test at present
less capable of accurate, quantitative determination
than hemolysis or precipitatii in in a test-tube, and of no
greater specificity. On the other hand, the minute
quantity required for sensitization gives anaphylaxis
a certain advantage over other specific tests.
Theory of Anaphylaxis. — The literature on this
subject is already immense; the basic facts upon which
it is founded are few and somewhat contradictory.
In general, the theories may be divided into those
which assume the formation of specific antibodies as
necessary to the anaphylactic state, and those which
dispense with antibodies altogether as a factor in the
phenomenon. Examples of the latter group are Gay
and Southard's " anaphylactin " theory and Vaughan's
"proteolytic enzyme" theory, neither of which can be
discussed here for want of space.
The prevailing view is that sensitization depends
in some way upon antibody formation, and that the
anaphylactic reaction is essentially an antibody
reaction. This theory finds support in the facts
already noted above, namely, (1) all anaphylactic
agents are true antigens; (2) the incubation period
agrees precisely with that necessary to the production
of antibodies; (3) complement is a necessary factor
in the anaphylactic reaction; (4) hypersusceptibility
is capable of passive transference in serum; (5) in
point of specificity it bears the closest relation to the
immune reactions of the second order (Ehrlich),
particularly the precipitin reaction. In its simplest
terms, the present conception is that the sensitizing
dose of anaphylactic antigen gives rise after the
usual period, to substances of the general nature of
amboceptors. These combine with the reacting dose
of antigen and form with the aid of complement,
poisonous products which cause the anaphylactic
symptoms and lesions. These toxic substances
according to Vaughan are protein cleavage products
formed during the sudden destruction of the antigen
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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Anaphylaxis
in the body of the sensitized animal. He has pro-
duced from ege-albumin, by chemical means, cleavage
products which are exceedingly poisonous and cause
death in guinea-pigs resembling that of acute lethal
anaphylaxis. Friedberger has mixed together an-
tigen, complement, and serum containing the supposed
antibodies in a test-tube and has obtained a poisonous
product (anaphylatoxin) of which a single injection
in a guinea-pig causes symptoms like those of acute
anaphylactic shock. This is the so-called "ana-
phylaxis in vitro." He concludes that the antigen
is first precipitated and then destroyed by specific
antibodies which have all the characteristics of pre-
cipitins. Opposed to this theory Is the very minute
amount of antigen required to produce a high degree of
itization, and the further fact that although the
ipitin reaction is very clear in the rabbit, the
anaphylactic reaction is much less intense than in the
guinea-pig in w hich there is a very small production of
antibodies of any sort. Many other theories have
: proposed, but as yet none is regarded as entirely
satisfactory, for it seems plain that the cells as well
as the blood and allergenic substance play a role in
tin- phenomenon.
Rklation op Anaphylaxis to Infection and Im-
munity. — The experiments of Vaughan with egg-white
and those of Friedberger with bacterial proteins have
led them to the conclusion that infection and anaphyl-
axis are different expressions of the same proce
Vaughan finds that cleavage products of egg-white
and other harmless proteins are quite as toxic as the
cleavage products obtained from the bodies of patho-
■ bacteria. We might suppose that if egg-white
Id grow and multiply in the animal body, it
would as a result of such growth and subsequent
age by proteolytic antibodies be just as deadly
as the bacilli of the infectious diseases. In fact, in
the invasion of the body by bacteria, the incubation
period necessary for the education of the tissues to
produce antibodies, the destruction of the bacteria
with the simultaneous appearance of symptoms and
lesions,and the storing of the surplus antibodies, we
have an exact if theoretical analogy to our conception
of the processes leading to "serum-sickness." In
other words, the question is whether in bacterial
diseases we have to do with preformed endotoxins or
with the poisonous cleavage-products of a protein
substance endowed with the powers of growth and
reproduction. Rosenau and Anderson, Friedberger,
and many others have shown that bacterial protein acts
like any other antigen in producing acute anaphylactic
-hock, if injected a second time in sufficient quantity.
Rosenow, after much patient work with the pneumo-
coccus has shown that autolytic products of disinte-
grated cocci will cause anaphylactic symptoms in a
tea-pig at the first injection. These facts have led
I i iedberger to hazard the conclusion that anaphylaxis
is only an extreme and acute form of infection, and
infection a mild, protracted form of anaphylaxis.
It cannot be said that this view is as yet justified,
but it is at least an interesting and suggestive
theory.
The exact relation between anaphylaxis and
immunity is not yet clearly understood, although all
workers in the field have recognized that there must
be a close connection between the two, on account of
the many striking analogies, already recounted under
the heading -'Theory of Anaphylaxis" and elsewhere
in this article. The clearest elucidation of the two
processes as part and parcel of the same general
phenomenon has been furnished by von Pirquet.
In his own words, "an immune person does not
become insensible to inoculation, but the time,
quality, ami quantity of his reaction are changed."
He would combine therefore the conceptions ,of
immunity and hypersensitiveness in the one work
"allergy" — or the changed reactivity of an organism
to a second invasion of a foreign antigen. Of all the
infectious diseases conferring immunity, the one best
luted lor experimental and clinical study in man is
COWpoX, or vaccinia. When we vaccinate for I lie
first time, we note a fairly constant symptom-com-
plex, tin the third or fourth day a small red papule
appear- which is the specific la- distinct from the
traumatic) reaction. From the fourth to the sixth day
the middle of the papule bee ! elevated into the
papilla, and is surrounded by a flat, peripheral "areola"
or zone of inflammation. From the eighth to the
eleventh day we see firs! a vesile, then a pustule which
is attended by fever and leucopenia. from tin- time
the reaction subsides, leaving the well-known vaccina-
tion scar. If we revaccinate daily for a fortnight, the
papillae appear in order uninfluenced by each other;
but the "areola" appears on all the vaccination
points simultaneously, i.e. at the time when its
development is due on the first vaccination. From
this time on, no papillse develop; we get another type
of reaction — the "early reaction" — in which the
papule is at its maximum in twenty-four hours, then
disappears. This occurs whenever vaccination is
repeated. Some years later, we get a "torpid early
reaction," or accelerated reaction, in which the
maximum comes on the third or fourth day. Just
as in serum sickness, the altered reaction (allergy),
which follows reinoculation with the antigen, ex-
presses itself temporally in a shortened incubation
period, quantitatively in a heightened intensity of
reaction which is, however, of short duration, and
qualitatively in the kind of lesions produced.
It is interesting at this point to refer to Jenner's
own observation of this phenomenon, recorded in
1 798. He says, " It is remarkable that variolous mat-
ter, when the system is disposed to reject it, should
excite inflammation on the part to which it is applied
more speedily than when it produces the smallpox.
Indeed, it becomes almost a criterion by which we
can determine whether the infection will be received
or not. It seems as if a change, which endures through
life, had been produced in the action, or disposition to
action, in the vessels of the skin: and it is remarkable,
too, that whether this change has been effected by
the smallpox or the cowpox, the disposition to
sudden cuticular inflammation is the same on the
application of variolous matter." This remarkably
clear statement (quoted by Hektoen) probably
records the first observation of allergy in an infectious
disease.
The actual processes underlying these different
types of reaction are described by von Pirquet as
follows: We implant a colony of microorganisms on
the skin. They grow day by day, and on the eighth
i lay there are an enormous number of them. The
contents of the blister will start new colonies on
thousands of other arms. But now the antibody
appears and the colony is attacked and digested, and
a toxic body formed. This is diffused in the neighbor-
hood and we get an intense local inflammation called
the areola. Some of the toxic bodies enter into the
circulation and cause fever. But the microorganisms
are killed and we can no longer vaccinate with the
contents of the now yellow pustule. After two or
three days, the struggle is over, but the antibodies
remain a long time. Let us now- revaccinate. The
microorganisms are immediately attacked and di-
gested — they are given no chance to multiply and
little toxin is binned. This is the immediate reaction.
After a few years, antibodies are no longer present,
but can be formed more quickly than the first time.
This causes the accelerated reaction. A smallpox
germ deposited in the throat of an unvaccinated
individual, multiplies without opposition throughout
the incubation period, and the individual goes through
the whole course of the disease. In the throat of a
vaccinated person, it is overwhelmed by the early
reaction in the first tw r enty-four hours; a slight
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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
redness appears about its disintegrating body, and
that is all.
According to this attractive theory, then, infection
produces sensitization, like the preliminary injection
of horse serum or egg-white. A second inoculation
of the same antigen, whether it be living pathogenic
bacteria, or a tenth of a cubic centimeter uf foreign
serum, produces an allergic reaction, differing from
the first in time, quantity, and quality. The antigen
is broken down with fulminating rapidity, and if the
amount is minute, the reaction is correspondingly
trifling. But if the amount of antigen is large (as
in the guinea-pig experiment) poisonous cleavage
products are liberated en masse, which overwhelm the
organism and produce acute anaphylactic shock.
New light is thrown on that mysterious factor in
infectious disease, the incubation period. According
to the usual theory, microorganisms have to reach a
certain development before toxins enough are produced
to cause symptoms. If this were true, one would
suppose that in a body rendered somewhat immune
by previous infection, microorganisms would grow
more slowly and the incubation period would be pro-
longed. But vaccinia (and serum-sickness) exhibits
just the opposite condition. Von Pirquet concludes
that in most diseases, the clinical reaction is not an
immediate consequence of infection, but a phenom-
enon of a more complicated nature, not explicable
simply by the action of microorganisms and other
foreign substances on the tissues, but involving the
existence of a third factor which appeal's only some
time after the first infection. Thus far antibodies
have been numbered among the protective substances.
Now it is conceived that disease may be due to the ac-
tion of some antibodies and immunity is based, not
on an acquired insensibility to virus, but on an altered
power of reaction toward it.
There are, then, three general theories of immunity
in vogue today: Ehrlich's side-chain theory, Metchni-
koff's phagocytosis theory, and the theory of the ana-
phylactic or allergic reaction. Curiously enough
each one of these apparently divergent theories is
based upon the metabolism of the cell. In the side-
chain theory, it is the hungry receptors seeking a
chemical union with protein food molecules; in
phagocytosis, it is the hungry ameboid cell engulfing
protein food particles; and finally anaphylaxis is an
adjustment to alein food proteins in the sense of a
defence. All three theories are intimately concerned
with protein metabolism. No one theory fully
explains the mechanism of immunity to all diseases.
Each has distinctive features, although all overlap
more or less. The only satisfactory explanation of
the immunity to a certain large and important group
of diseases finds its solution in terms of anaphylaxis.
Lewis Wendell Hackett.
Anaplasia. — This word (from dm, again, and irk&ais
a moulding) is used by some writers synonymously
with anaplasty, having the meaning of a repair of in-
jured parts by means of plastic operation. In 1893
its use in an entirely different sense was introduced by
von Hansemann, who wished to designate by some
specific term the morphological and physiological
differences which exist between the cells of malignant
tumors and those of the normal parent tissue.
The type and character of the parent cells are
usually preserved to some extent in the tumor cells
which arise from them; as, for example, the cells of a
squamous-cell carcinoma of the skin may undergo
a horny change; those of an adenocarcinoma arising
from cylindrical cells are more or less cylindrical in
shape; the cells of an adenocarcinoma of the thyroid
m iv produce a colloid-like substance; metastases of
an adenocarcinoma of the liver may secrete a bile-
like fluid; and the sarcomata arising from the
chromatophores of the skin produce melanin. These
resemblances uf tumor cells to their parent cells are
not so marked as the differences which exist between
them, both in morphological and physiological
characteristics. The latter are shown by striking
variations in size and form; by changes in the finer
structure of the nucleus and cell body as shown by
staining reactions (hyperchromatosis, hypochro-
matosis, etc.); by abnormal cell-division forms; by
the changed chemical character or total absence iif
cell function; by increased vegetative activity(habit
of growth); and by the tendency to undergo degen-
eration. To all of these alterations in cell character
which constitute malignancy von Hansemann would
apply the term anaplasia, as opposed to heteroplasia
and metaplasia. According to his view, the signifi-
cance of these changes must be that the cells of ma-
lignant tumors have lost in differentiation (Entdiffer-
enzierung) and so have acquired the powerof individual
existence. The manner in which the cells have
undergone this change or the etiology of malignant
tumors is not included in the meaning of the term.
There can be no doubt that the use of the term
anaplasia in this application is of great service, and
though von Hansemann's views have "met with
much opposition, it has gained a wide acceptance in
modern pathology. As used now anaplasia em-
braces all these qualities of tumor cells as shown
in their lessened differentiation and increased poirer
of independent existence. Various other expressions
are also in use to indicate the same peculiarities of
tumor cells, such as kataplasia (Beneke), "new cell-
races" (Hauser), "reversion from organotypical
to cytotypical growth" (R. Hertwig). For a fuller
discussion of the problems of malignancy included
under anaplasia see the article on Neoplasms.
Aldred Scott Warthin.
Bibliography.
Von Hansemann: Studien iiber Specificitat, Altruismus und
Anaplasia der Zellen, Berlin, 1S93. Die mikroscopische Diagnose
der bosartigen Geschwulste, Berlin, 1S97.
Anatomical Nomenclature, the Basle. — The expres-
sion BNA is an abbreviated title for the Basle Nomina
Anatomica, or anatomical nomenclature, adopted by
the Anatomische Gesellschaft of Germany, during
their ninth session at Basle, 1895. The list comprises
some 4,500 terms, regarded as the most fitting de-d-
ilations for the various structures of human macro-
scopic anatomy. The terms were selected by a
Commission of Anatomists, appointed six years pre-
viously, by the Gesellschaft, at the instigation of the
late Professor Wilhelm His, for the purpose of revising
anatomical terminology.
The official list is constructed in Latin under the
various headings of Osteology, Myology, S3'ndesmology
Splanchnology, Angiology, and Neurology. A large
proportion of the terms embodied in the list were
culled from the many synonyms already in use in the
standard text-books of gross anatomy, or in anatom-
ical monographs, preference in each case being given
to the shortest and most suitable name for the part.
A few of the terms are new, such being introduced
only in those cases where a search of the literature
failed to reveal a designation deemed proper for the
part under consideration. Only one name was given
to a part, and while the list may in no way be styled
a new nomenclature, it has served to simplify anatom-
ical terminology by greatly reducing the number of
anatomical terms in current use.
The reasons for undertaking a revision of anatomical
nomenclature at the time Professor His brought the
matter before the Anatomische Gesellschaft,
most urgent. Hitherto, there had been no authentic
principles governing the formation and usage of ana-
tomical terms. With the rapid progress of the science
of anatomy and the stimulation of research, in
318
1 ; i : i KliKXCi: IIAXDBOOK OF THE MEDICAL SCIENCES
Anatnmir.il Nomenclature)
the Basle
ope and America, the reduplication of anatomical
rune- had grow a excessive. The naming of a sti
ure was left to tin- choice of the individual investi-
'ator, who was not infrequently ignorant of the work
lone by his fellows in the same field. As a resull
>ach teacher, each school, and each country acquired
i peculiar group of anatomical names. These multiple
is gradually found their way into tin- anatomical
ext-books, each author adopting, or discarding
whatever names he chose. One of the larger standard
ol tin- era contained as many as 10,000
lames, over one-half of which were synonyms, while
, , of the various synonyms employed in
i number of standard works revealed a list of -ohm
mii names. Indeed, for the approximately 500
>. a structures of the brain alone, Professor Wilder
able to collect from the literature a list of no less
■ i mi names.
This cumbersome multiplication of terms was a
jriovous burden to both teacher and student, and
rise to much ambiguity and confusion. The
of double names for each pari in the schools was
isl the rule. Such multiple synonyms as Valvula
coli, vel ileocoecalis, vel Bauhini, vel Tulpi, vel
ipii, wen' not infrequent. Anatomical termi-
■, was necessarily wholly lacking in uniformity
and in any plan of construction. To usage alone
left the final justification of a new term in the
science. Important structures were differently named
in the various countries, the Corpuscula lamellosa
g known as the corpuscles of Vater in Germany
and the corpuscles of Pacini in Italy. Xor, indeed,
i his species of anatomical patois alone national
in extent, but was characteristic of the various
universities. Each great medical school had, in
asure, its own anatomical language, and a
student migrating from one university to another
often forced to acquire a new set of anatom ical
terms.
I Ine of the first anatomists to revolt againstethe
tyranny of multiple anatomical terms was J. Honle,
who. in writing his well-known treatise on anatgmy,
only one name for each part, relegatinfe all
synonyms to the footnote. To his example Provissor
His attributed his conception of an official reacsion
of anatomical nomenclature. Henle further attacked
the use of personal names in terminology and re-
placed them by objective terms, on the ground hat-
the use of such names frequently gave rise to this
torical injustice. His efforts to simplify anatomical
terminology, strangely, only tended to create still
greater confusion, due to the fact that he himself
introduced many new terms, and while his terminology
found favor with many anatomists, others refused to
pt it, and a third group became eclectic, reserving
the right to retain the use of personal names.
Individual endeavor, such as that of Henle, could
not hope to effect a speedy reform in anatomical
nomenclature, yet the efforts of a few pioneers paved
the way for a concerted action on the part of the
anatomical societies. Early in the nineteenth cen-
tury John Barclay, Owen, and Pye-Smith began a
crusade of reform in England, while later in America
(1861) Dr. Leidy, the first president of the American
Association of Anatomists, published a work on
Human Anatomy, in which he eliminated all synonyms
from the text, retaining only such terms, one for each
Mire, as seemed most suitable. Numerous foot-
notes supplied a list of synonyms. The use of proper
names was also much restricted. Unfortunately his
attempt to simplify American anatomical terminology
met with little encouragement. A decade later
Professor Wilder began to advocate a simplification
of anatomical language and called attention to the
special need of a revision of neurological nomencla-
ture. Largely owing to his efforts, Committees on
Anatomical Nomenclature had been appointed by
the American Association for the Advancement of
Science, the American Neurological Society, ami the
American \ o ol Anatomists, prior to the
adoption of the report of the German Commission.
When the AnatOD chafl was founded
at Leipzig, in 1887, one of the firsl matters discussed
was the need of establishing a uniform nomenclal
\ resolution was passed instructing the officers of
the Society to undertake a revision of anatomical
terms. However, a- soon as the task was begun.
numerous unforeseen difficulties presented themselves
and it at once became apparent that an undertaking
involving so much detail would require the coopera-
tion of many anat ists, and a period of se\ oral years,
for its execution. At Berlin in 1889 His brought
these difficulties before the ( lesellschafl and advocated
the formation ol a permanent Commission on Nomen-
clature with the appointment of an editor-in-chief, who
might devote his time a! st exclusively for several
year- to the work of revision. Hi- suggestions were
adopted and the Commission was appointed with
Professor v. Kolliker a- chairman and Professors 0.
Hertwig, His. Kollmann, Merkel, Bardeleben, Toldt,
Waldeyer, and Schwalbe as members.
The two remaining need- of the Commission, viz.,
the securing of an editor-in-chief and the assurance
of financial aid for carrying on the work, were quickly
Professor W. Krause of Berlin accepted the
post of editor. The expenses of the undertaking
amounted to some 11,000 Marks, slightly in excess
of the original modest estimate of 10,000 Marks. To
defray this sum, the Anatomische Gesellschaft voted
3.S00 Marks, the balance being secured by grants from
the scientific academies of Munich, Berlin, Leipzig,
Vienna, and Budape-t.
Before beginning their task the Commission wisely
realized the necessity of limiting the scope of their
undertaking. It was obvious that any attempt to
establish a rigid terminology 7 for structures still the
subject of dispute, could only end in failure. Accord-
ingly the Commission decided to confine its work to
the descriptive anatomy 7 of structures visible to the
naked eye, or at least with the aid of a hand lens.
The designating of the finer structures of microscopic
anatomy was sedulously avoided. While the terms
of the list were to be constructed in Latin, the Com-
mission made it clear that anatomists, who might
accept the terminology, should be left free to translate
these terms into their native tongue.
A further preliminary question of a delicate nature
for the Commission to decide, was to what extent the
nomenclature might assume an international charac-
ter. The Commission attempted to establish clearly
its position on this point. It was granted that the
list was to be a product of the Anatomische Gesell-
schaft, but as Professor His has stated, this Society,
while founded in Berlin, from the first day of its
origin, assumed a character broader than German.
At the time of its organization a small majority 7 of its
members were Germans (145), while the remaining
members (129) came from Belgium, Denmark, Eng-
land, Sweden. Russia, Austria, and France. The
Commission reasoned that the composition of the
Gesellschaft was sufficient cause for establishing an in-
ternational standard of nomenclature. With this end
in view, anatomical terms used in the standard text-
books of anatomy 7 of countries other than Germany
were considered in compiling the lists. Opportunely
a meeting of the Anatomische Gesellschaft conjoint ly
with the section of anatomy of the International
Medical Congress at Berlin afforded the Commission a
means of enlisting the services of such foreign anato-
mists as Sir William Turner, Cunningham, Romiti.
and Leboucq. At a later time Professor Thane of
London was also included in the Commission. Amer-
ica, it is true, was not represented on the Commission,
nor were the representatives of France and England
present at the signing of the report in 1895. Recogni-
tion of the desirability 7 of imparting an international
319
Anatomical Nomenclature,
the Basle
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
character to the -work of the Commission was acknowl-
edged by the action of the Anatomical Society of
Great Britain and Ireland in the appointment of a
Committee in 1S93 to consider adapting the sugges-
tions of the Commission to English needs, while from
America, Professor Wilder had forwarded to the
Commission a series of reports of Committees on
Anatomical Nomenclature of the various scientific
societies.
In order to secure uniformity in the character of
the revised nomenclature, the Commission formulated
certain general rules, which they followed in the
selection of anatomical terms. These fixed principles,
as stated by the Editor, were:
1. Each part of the body shall have one Latin
name; there shall be no synonyms separated by
" sive" or "seu." Each nation using the Latin name
may translate it in the way that seems best.
2. The name shall be as short and simple as pos-
sible, and should recall some point of description, or
distinctive character.
3. No part of the body shall have an unnecessarily
long Latin name.
4. No two parts of the body shall have the same
name unless they are truly homologous structures.
5. The names shall be consistent with Latin gram-
mar and orthography.
6. Personal names shall, as far as possible, be re-
moved from anatomical terms, except where they
actually mark historical observation.
7. In the whole work the Commission shall endeavor
to be as conservative as possible.
8. The same names shall be used for arteries, veins,
and nerves, where they run together; e.g. A. fem-
oralis, V. femoralis, N. femoralis.
9. The same names shall be given to foramina and
to the vessels and other structures which pass through
them.
10. Adjectives shall, as far as possible, be used as
opposites; e.g. profundus and superficialis.
11. Ligaments shall be named according to their
attachments, the final part of the name indicating the
proximal attachment; e.g. sacroiliac, not, iliosacral.
12. There shall be no hybrid names.
While the Commission followed these guiding prin-
ciples as closely as possible, in certain instances, a
deviation from the rules in the selection of a term
seemed advisable. Thus, while such cumbersome
terms as M. petrosalpingostaphylinus could read-
ily be discarded, no good substitute could be found
for so commonly a used term as M. sternocleido-
mastoideus. In a few instances dual terms were
retained, as in the case of Valvula bicuspidalis ve]
mitralis, the latter term being retained out of eon-
cession to the clinicians. Nor did it seem wise in
every case to affix similar terms to neighborhood
structures, such a term as Foramen spinosum being
retained as being preferable to styling it Foramen
meningeum medium by virtue of its penetration by
the A. meningea media.
A systematic plan for the execution of the work to
which the Commission adhered during the early years
of the work, was elaborated by the Editor and sanc-
tioned by the Commission. He suggested a compila-
tion of the lisl of anatomical terms used in a stand-
ard text-book of Anatomy (Gegenbauer's "Lehrbueh
der Anatomie des Menschen" being so employed).
These terms were arranged in vertical columns,
while parallel to them, in other columns, were placed
the various synonyms from a number of other widely
used text-books of anatomy. A copy of this list
compiled by the Editor was sent to each member of
the Commission, with a request that he indicate the
term of his choice for the part, from one of the syno-
nyms submitted, or in case none of the terms seemed
suitable for the part, that he propose a new name.
The lists, along with comments upon the terms, were
then returned to the Editor.
Following this plan, the terms of Myology were first
subjected to the ballot. The result of the first vote was
most gratifying to the Commissioners, since eighty-five
per cent, of the terms considered received a majority
vote, and of this number, more than forty percent,
received an almost unanimous approval. A second
revised list was issued, containing the selected terras
and those still in dispute, together with the new-
names proposed by the members and comments
thereon. Whatever terms the second written bal-
lot left undecided, were finally adjusted in personal
meetings of the Commission. The fact that such
meetings of the Nomenclature Commission were
held during the annual session of the Anatomische
Gesellschaft afforded the Commission an opportunity
of seeking the advice of the distinguished members
of that bod} T . In such manner the terminologv of
Myology was completed at Munich in 1S91 with a
list of 300 accepted terms. At a later session in
Vienna the terms for Osteology and Angiology were
similarly brought to completion.
As the process of balloting by correspondence for
the proper terms of the list progressed, it became
evident that a repeated voting over terms in dispute
gave no more satisfactory results than a single ballot.
Frequently it happened that newly proposed names,
representing the fruit of much thought and special
knowledge, received too scanty consideration, and
were rejected without sufficient testing. In order
to obviate this fault, the Commission, somewhat
hastily, decided that all new terms and comments
should be considered in verbal discussion. This
scheme, however, proved to be wholly impracticable,
owing to the tedious discussions provoked. As a
wise alternative it was resolved to allot the work
under certain headings, in charge of special commit-
tees. At Vienna a committee, consisting of Profess-
ors Merkel, Thane, and Toldt, was appointed to
take charge of Angiology. At a later time Profess-
ors Rudinger, Toldt, and Merkel were assigned to
regional Anatom}', and Professor Toldt was appointed
a committee of one in charge of Syndesmology.
The need of correlation of the work of these special
committees next forced itself upon the Commission.
Since the balloting for the terms had taken place at
different times, and frequently at long intervals, a
certain element of dissimilarity, and in a few instances,
contradictory expressions, had crept into the lists.
In order to adjust these difficulties and to impart
uniformity and logical sequence to the nomencla-
ture, a general editing Committee composed of Pro-
fessors Hi-. Krause, and Waldeyer was appointed.
This Committee soon found its task of smoothing
out inequalities and correcting contradictions a
most arduous one, working continuously for three
years partly by correspondence, and partly by per-
sonal interviews. Frequently authorities were con-
sulted in order to arrive at clearness and unity in
regard to disputed and difficult points in terminol-
ogy. The most perplexing sections of the work
proved to be Neurology and Splanchnology. With
the appointment of a general editing Committee its
original plan of execution was somewhat altered, and
the work much facilitated. The individual mem-
bers of the Commission were invited to forward their
various suggestions and comments for the terms of
the sections under discussion, prior to the first ('al-
lot, in order that such suggestions might receive due
consideration before the voting. After the vote was
taken, the lists were rearranged by the editor and sub-
mitted to the general editing Committee. In this
way the value and precise meaning of each express ion
was subjected to critical examination. In many
instances the bibliography was consulted and dissec-
tions undertaken, to verify the fitness of the decli-
nations for structures in question. The lists, thus
revised, were again submitted to the members of the
Commission for approbation, or further comments,
320
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Anatomical Nomenclature,
the Basle
which in turn received the consideration of the edit-
ing Committee. The final revision of the various
chapters was sent to the members of the Commission
in July, 1894. This revised list was again critically
studied and tested by the members. After a care-
ful consideration of the comments and suggestions
arising from this examination the definitive lis! of
anatomical terms was presented to the Anatomische
Cesellschaft as a whole, for adoption, during the
jion at Basle, 1895.
The task of sweeping out of anatomical terminology
tic great ma" of synonyms, which usage had well
established, was one that presented many difficul-
ties. One of the greatest of these was in respect
to the use of personal names as designations for
structures. The question of eliminating these from
the nomenclature was very carefully weighed by the
Commission. Many convincing reasons were urged
by Professor His against their retention. It was
stated that the use of personal names frequently
rise to historical injustice, the name applied to
a structure not being that of the real discoverer,
hut of some later observer. Personal names of dif-
it anatomists in two or more countries were
frequently chosen for the same structures, the glands
of bieberkuhn in Germany being those of Galeati in
Italy. Moreover, no system had been followed in
I he choice of names of the old anatomists. The
names of such famous anatomists as Harvey and
Vesalius were wanting in anatomical literature,
while the names of Malpighius and Eustachius had
been duplicated.
A more cogent reason for dropping personal names
was found in the fact that a great mass of proper
names had accumulated in modern anatomical
writings, especially in the literature of the specialties,
where frequently names of very questionable scien-
tific importance were encountered.
On the other hand, in favor of the retention of
personal names in the lists, Professor His pointed
out that the use of such names may at times furnish
good mnemotechnic material. It was believed that
the use of such terms as Poupart's, Gimbernat's and
is's ligaments might incite a student to acquire
the meaning of such expressions, whereas his interest
in a Ligamentum inguinale, L. lacunare, or L. ingui-
nale rcflexum, was apt to be less certain. Again the
members of the Commission were dominated by a cer-
tain feeling of piety, which inhibited them from drop-
ping personal names. It was a question in their
minds whether names of the immortals, which for
centuries had served a good and useful purpose in
anatomical literature, should be sacrificed for a prin-
ciple. Moreover, it was doubtless advantageous for
the student in his first semester to encounter such
names as Fallopius, Eustachius, and Malpighius, for
thereby a _ certain historical interest was aroused
which is stimulating.
As a solution of this perplexing question, the
Commission, very wisely it seems, effected a com-
promise in place of arbitrarily banishing all personal
names from the lists. For each structure a material
objective designation was given, and the better known
personal names were added in brackets. Following
the precedent of the Zoological Nomenclature Com-
mission, such names were put in the genitive case.
Further, the use of personal names was much cur-
tailed, being retained only where these were common
to a majority of the national anatomical terminol-
ogies. This mode of treatment, while less simple
than the use of material terms alone, offered the
advantage of leaving to time the final decision as to
which of the two terms would survive.
Another problem which confronted the Commis-
sion was the need of incorporating the terminology
of the medical specialties into their list. The many-
specialists, who had carried on investigations in their
own special fields, notably in Neurology, Otology,
Vol. I.— 21
Ophthalmology, and Laryngology had introduced
itito the literature an anatomical nomenclature whirl,
deviated greatly from the terms used in tin' stand-
ard text-books. A danger had arisen of a veritable
terminological crevice. The question arose should
the ( lommission adhere to the old plan, or should eon-
cessions be made to tin' specialists.' Careful consid-
eration of the matter convinced the members of the
Commission that the nomenclature of the special-
i-t - had arisen through a real need of the same,
the terms of the text-books being no longer adequate.
It was clearly the duty of the Commission i" aco pt
the terms of the specialists, or to supply better ones.
A conference was held with a number of the lead-
ing specialists, active as investigators, and a mutual
adjustment was effected w hereby a full list of the
names of macroscopic structures in these special
regions was to be included in the nomenclature. In
return the Commission was assured that the nomen-
clature of the Anatomische Gesellschaft would be
accepteil as soon as it covered the requirements of
the specialties.
In the course of selecting the list of terms from
the text-books, the Commission encountered many
antiquated and obscure names, some of which \
used by one author in a sense different from that of
another, owing, in certain cases at least, to obscure
or inexact views. The fact was revealed in the dis-
cussions that the members of the Commission them-
selves were frequently at variance regarding the pre-
cise meaning of an expression. In the case of such
ambiguous terms there arose the need of searching
the bibliography, making dissections, and in a few
instances undertaking research, over a given term.
Such investigations led to the introduction of a num-
ber of new terms into the lists, where these were
demanded for the sake of clarity and accuracy. Pro-
fessor His and his colleagues have written explanatory
notes indicating the sense in which these new terms
were employed, such notes being inserted at the end
of the list of terms in the official publication of the
BNA.
With the completion of the work of the Commission,
representing six consecutive years of arduous appli-
cation to their task, the final report was officially
presented to the Anatomische Gesellschaft by Pro-
fessor His at Basle, 1895. The report was unani-
mously adopted by the Gesellschaft. In presenting
their report the Commissioners emphasized the fact
that they regarded their list as only provisional,
and by no means complete. There remained an
undoubted need of a revision of certain gaps in the
lists. Their aim had been to prepare a common
teaching nomenclature, and at the same time to
create a uniform standard, which might serve for
use in anatomical literature, especially that of an
international character. Professor Waldeyer, in his
presidential address at the following meeting of the
Gesellschaft, invited his colleagues to point out
errors and defects in the lists along with suggestions
for improvement and referred to the advisability of
having separate sections of the nomenclature taken
up by the Commission for revision.
The BNA nomenclature may now be justly re-
garded as the standard of anatomical terminology in
the leading anatomical laboratories of the world. The
official list was published not only in the anatomical
journals, but also separately by Professors Krause
and His, in the form of hand-books containing the
list of terms with explanatory notes. The appear-
ance of such widely used atlases as those of Spalte-
holz, Toldt, and Sobotta couched in the BNA terms,
shortly following the report of the Commission,
ensured at once its use in the leading German uni-
versities. Nor was its recognition in foreign coun-
tries long deferred. The Anatomical Society of
Great Britain and Ireland appointed a Committee in
1893 to consider the adaptation of this nomenclature
321
Anatomical Nomenclature,
the Basle
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
to the needs <>f English anatomists. Professor Cun-
ningham introduced the BNA terms in the first
edition of his text-book, published in 1902, adding
separately a glossary of the terms. In America in
1898 the Committee on Anatomical Nomenclature of
the American Association of Anatomists gave an
official recognition of the BNA terminology by a
recommendation of the use of many of its terms, the
Committee, however, in respect of many terms, pre-
ferring mononyms, as suggested by Professor Wilder,
in place of the less simple dionyms of the BNA list.
At a later time Professor Barker in his translation of
Spalteholz's Atlas, rendered the complete list of the
BNA available for students and teachers, while in
a monograph on Anatomical Terminology with
special reference to the BNA, published in 1907, he
made a strong plea for the adoption of the nomen-
clature in its entirety in America. Gradually a ma-
jority of the authors of the leading American anatom-
ical text-books have come to employ the BNA
terminology, either exclusively or in part, some of the
authors preferring the anglicized forms, while others
append the Latin terms in brackets.
The Commission has rendered an invaluable serv-
ice to medical science in establishing an international
code of anatomical terminology and in abolishing a
mass of needless terms. The use of the nomenclature
in anatomical journals has greatly facilitated the
reading of articles published in a foreign country.
It was acknowledged by the Commission that the
terms of research lay wholly beyond their province,
and the right of the investigator to apply special
names to parts which have no designations was
fully recognized. Their aim had been to prepare a
common school speech, free from ambiguous expres-
sions, realizing that research requires a terminology
of its own, which lias no pretension of coming into
school usage. As a result of their efforts the work
of the student has been reduced by at least one-half
with a sparing of the memorizing of over 5,000 names
during his anatomical studies. A further result, of
great importance, achieved through the labors of
the Commission, was the establishment of certain
principles regarding the formation and use of anatom-
ical terms, which will tend to impart uniformity
and simplicity to anatomical terminology, and which
may serve as a basis for future revisions of the same.
Although the advantages to be gained by the adop-
tion of a uniform standard of terminology were read-
ily conceded, it was nevertheless to be expected that
for a time a certain strife must exist between the use
of the older terminologies and the BNA list. The
Commission was fully aware of the impossibility
of forcing any fixed nomenclature, however superior,
either on teacher or pupil, believing that its adoption
must be a matter of gradual growth dependent on
its intrinsic merits. Indeed, among the Commis-
sioners themselves, it was questioned whether a
rigid terminology might not act as a stumbling block
and retard the progress of research. In order to
enlist the good will and cooperation of anatomists
generally in accepting the list, they carefully re-
frained from giving names to structures still under
investigation. Despite the care exercised by the
Commission there has crept into the lists a number of
defects and errors, which have evoked lively criticism,
and have given rise, in certain quarters, to objections,
which have served to retard in some measure a uni-
versal acceptance of the nomenclature. Some of the
objections urged have arisen through a misconception
of the intention of the Commission. The fact that it
has been erroneously styled a new terminology, has im-
peded its adoption on the part of clinicians who have
acquired their anatomical terms from the older text-
books. Yet, as a matter of fact over ninety per cent, of
the terms are already familiar to English-speaking
anatomists, and in the few instances where new terms
have been introduced these are, in much the greater ma-
jority of cases, preferable to the older terms. Another
misapprehension, which has deterred many from
using the BNA list, is the false impression that the
Latin names, as constructed in the lists, were to be
used as such in every day speech. This was clearly
not the purpose of the Commission, it being intended
that the anatomists of the various countries, would
in spoken language, translate the terms into their
native tongue. The fact that the BNA terms more
closely resemble the corresponding English names
than those of any other language, should render them
readily acceptable to English-speaking anatomists.
It has been urged with some degree of justice that
the BNA terms do not always afford the simplest
form possible. In numerous instances dionyms have,
been used where mononyms would seem to suffice.
The use of polynyms had already grown burdensome
to both student and clinician and the tendency, in
daily speech, had been to discard the use of such in
favor of mononyms. Thus one commonly hears
cecum in place of the official Caput ccecum coli, and
cortex rather than Substantia corticalis, while the
popular term appendix would seem preferable to the
more authentic Processus vermiformis. The nomen-
clature Committee of the American Association of
Anatomists have recommended the use of mononyms,
in many instances, as substitutes for the more cumber-
some dionyms of the BNA list. In defense of the
attitude of the Commission on this point, it may be
said that a desire to avoid ambiguity restrained them
from selecting the simplest term in many cases.
Moreover, it was shown that the free use of mononj'ms
would require the coining of many new terms, and
the creation of etymological barbarisms.
Following the critical examination to which the
nomenclature has been subjected since its publication,
it is not surprising that a few inconsistencies, and
inappropriate expressions, have been demonstrated.
The Commission has been accused of deviating from
the principles laid down in the selection of terms,
in the introduction of new, or comparatively unfamilar
names for structures, where the older terms would
seem preferable, notably in the case of the names
given to several of the carpal bones. It was obviously
inconsistent that, while the term maxilla was applied
to the upper jaw and mandibula to the lower, the name
Glandula submaxillaris should be retained. The, term
Bursa mucosa has been pointed out as a misnomer,
since the secretion of a bursa is not mucus, and Bursa
synovialis or serosa lias been proposed as more ap-
propriate. Again the Commission has been charged
with violating the rules that "each term in Latin shall
be philologically correct." Triepel and others have
pointed out numerous etymological defects in the
terminology, and a proposed etymological reform of
the entire list, employing only classical Latin and
latinized Greek expressions, has been instituted by
Triepel. The introduction of many hybrid names
into the lists has been criticized, although it is admitted
by the critics that there is a certain justification for
the use of such hybrid terms as urethralis in place of
the more correct urethricus on the ground of euphony.
Again it may be grammatically proper, but whether
preferable or not, seems doubtful, to use carpiaeus,
or carpicus, for carpeus, and coccygicus for coccygcus.
It has been stated with respect to certain adjectives
in the list ending in -icalis that there is correctly no
such termination and that such terms as A. umbilicalis
and M. lumbricalis should be A. umbilicaris and M.
lumbricosus. Another defect is the undifferentiated
use of the ending -ideus. A number of anatomists
hold the opinion that the ending -ides for the Greek
ending -sidris should remain in anatomical ter-
minology, the term Os hyoides being preferable to
the BNA term Os hyoideum. Some would prefer
the writing of anulus in place of the less correct
annulus, while the term antibrachium should be
more properly written antebrachium.
322
Kl I IMM.XCK HANDBOOK OF THE MEDICAL SCIENCES
Anatomy, History of
It [a admitted that the UNA nomenclature does
,,,,t tneel the need of comparative anatomy. Most
of the expressions, especially those for muscles
been constructed in application to human anatomy
and hence are misleading for vertebrate anatomy.
Thus the use of the terms M. pectoralis major a
minor would be erroneous if applied to the relative
proportions of those muscles in the vertebrates,
in, from the view point of morphology, the BNA
grouping is at times quite artificial. As pointed out
Professor McMurrich certain of the facial muscle:
have been grouped as a M. quadrants labii superioris
credited with three heads of origin, which have
elsewhere been more properly regarded as distinct
muscles. A revision of the BNA list to render it
applicable to vertebrate anatomy is highly desirable.
The appointment of an International Commission on
logical Nomenclature has already proven a rec-
ognition of this need.
There has been, it is stated, a certain reluctance
on the part of some American ami English anatomists
ept the BNA nomenclature, for the reason
that it is the product of a German organization, and
uch is not adapted to the needs of English-
ting anatomists. However, as has already been
pointed out, the Anatomische Gesellschaft might
fairly claim to be international in its composition and
the Nomenclature Commission embraced representa-
tives from several countries. America was not
represented on the Commission, doubtless due to the
that anatomical laboratories had not yet attained
a high degree of organization, and but few American
anatomists attended the meetings of the Gesellschaft
at the time of the formation of the Commission. In
the various international nomenclature committees
which have been formed since then, American anat-
omists have obtained full representation. Moreover,
in defense of the initiative taken by Germany in under-
taking a revision of terminology of an international
character, it would seem probable that at the time the
reform was instituted, no other country could have
provided so distinguished a group of anatomists,
who might devote so much of their time for so long
a period to the undertaking. The scientific world.
which recognizes no national boundaries is under
great obligation to the Anatomische Gesellschaft
for initiating terminological reform, and even should
the nomenclature established by it not prove the ideal
one, the obvious benefits gained for anatomical
science through the general adoption of it as the
international terminology, would seem to offset any
sacrifices attendant upon the relinquishing of a few-
national colloquialisms.
The ultimate result of the efforts of the Anatomische
llschaft toward terminological reform has been
broader in extent than the mere production of the
BNA nomenclature. The BNA list of terms has
been welcomed by anatomists as providing the best
common anatomical terminology yet presented.
Further than this the work of the Commission estab-
lished a basis for future and more comprehensive
revisions of anatomical terms. Since the presenta-
tion of the Basle report a number of Nomenclature
Committees of truly international character have
been formed. Some years ago an International Com-
mittee was appointed to revise Myological Nomencla-
ture, with a view of coordinating, if possible, the
comparative and human anatomical terminologies.
Professors McMurrich and Harrison were made the
American representatives. As yet no report of the
Committee has appeared. At the third meeting of
the Commissionfor Brain Investigation, appointed by
the International Association of Academies, at Vienna.
1906, a committee for the revision of neurological
nomenclature was formed, with Professor Waldeyer
as chairman. During the second International
Congress of Anatomists at Brussels, 1910, Professor
Minot, on behalf of the American Association of
Anatomists, presented a recommendation for the
formation of an International Committee to revise
embryological nomenclature and prepare a li-t of
standard terms. Pi M chairman) and
Mall represented America on the I ommittee. With
the cooperation of these various nomenclature com-
mittees, revising and elaborating the work of the B
Commission as they will, the establishment of a
uniform international standard of terminology for
tin' various anatomical would seem ftdly
assured. Benson Amhkose Cohoe.
BlBLIOGRAPHT.
Annahme der Nomenklatur durch dii '-haft.
Anat. Ariz., Bd. X.. Erganz., S. L61, 1895
v. Bardeleben, K.: Einige Vorschlage zur Nomenklatur. Anat.
Am., D.I. xxiv., S. 301-304, L904
Barker, L. F.: Anatomical Terminology with Special Reference
t.. the UNA. Blakiston, Phila., L907.
Chaine, J.: Reforme de la nomenclature myologique. Anat.
Any, , Bd, xxvii., Erganz.. S. 38-39, ton.-,.
genbauer, C.: Bemerkungcn zur anatomiechen Nomen-
klatur. Morphol. Jarhbuch, Bd. XV., S. 151, 1S98.
Bis, W.: Die anatomische Nomenklatur. Nomina anatomica.
(Reprinted from the Arch, f. Anat. u. Physiol., Anat. Abth.,
Leipzig, 1895. Supplement-Band.)
Krause, \V.: -Die anatomische Nomenklatur. Internat. Mo-
natsschr. f. Anat. u. Physiol., Bd. jr., S. 313, 1893.
Spitzka, E. A : Review of Dr. Barker's Book. Bulletin of the
Johns Hopkins Hospital, Vol. xviii.. No. 195, 1907.
Triepel, H.: Die anatomischen Nanien, ihre Ableitung u.
iche. 2 aufl. Wiesbaden. 190S.
Triepel, H.: Die anatomische Nomenklatur. Ergebn. d. Anat.
u. Entwickl., Bd. xvii., S. 531-554, 1909.
Triepel, H.: Nomina anatomica mit Unterstutzung von Fach-
philologen bearbeitet. Wiesbaden, 1910.
Triepel, H. : Merkblatter zur anatomischen Nomenklatur. Anat.,
Anz., Bd. xxxviii., S. 161-165, 1911.
Yiorordt, H. : Bemerkungen zu BNA. Anat. Anz., Bd. xiii.,
S. 1S1-1S3, 1S97.
Waldeyer, W.: Eroffungsrede, 11 Vers. d. Anat. Gesell., Anat.
Anz., Bd. xiii., S. 2-3. 1S97.
Wilder, B. G.: The Fundamental Principles of Anatomical
Terminology. Med. News, Phila., Dec. 19, 1S91.
Wilder, B. G.: Some Misapprehensions as to the Simplified
Nomenclature of Anatomy. Proc. of the Amer. Assoc, of Anat.,
X. Y . 1895, pp. 35-39.
Report of the Majority of the Committee on Anatomical Nomen-
clature. Proc. of the Amer. Assoc, of Anat., 11th session, N. Y.,
1S9S.
Anatomy, History of. — Considering the necessity
of the anatomical sciences as a basis for the proper
study of the healing art, and the high position assigned
them in modern times, it may seem strange that their
early development was slow, and the knowledge of the
ancients concerning the structure of the human body
crude and superficial. The principal cause of this
was the prevalence of animistic ideas, it being thought
that extraneous spirits inhabited or controlled the body
in some mysterious way. Involuntary movements,
such as the pulsation of the heart and arteries, the
twitching of muscles, the phenomena of respiration
and bodily heat, were all considered indubitable signs
of the presence of such spirits, to which were ascribed
most cases of disease and disordered action.
After leaving the body the psychical entity that ani-
mated it was thought to maintain some occult relation
to it; hence the corporeal remains were either preserved
with pious care, or burned or entombed to prevent their
suffering insult or injury that might affect the career of
the spirit in the other world. Mingled with these
superstitious ideas were others derived from horror of
death and repulsion from corrupting flesh. Contact
with a dead body was usually held to be a defilement
requiring long purification, and to attempt to in-
spect its internal structure was a sacrilege meriting
the severest punishment. Dissection was, under
such circumstances, practically impossible. It is
certain that but few writers of antiquity were able to
avail themselves of this method of research.
The sources of information were therefore indirect.
323
Anatomy, History of
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Animals killed either for food or sacrifice, the occasional
examination of persons severely wounded or suffering
from eroding diseases, the noting of the effects of putre-
faction which displayed the deeper structures, es-
pecially the bones, were the usual means employed
for the investigation of the human body. In Egypt,
it is true, bodies were eviscerated for the purpose of
preserving them as mummies; but this appears to
have been done by a low class of servants under
the direction of priests who regarded the interests of
the spirit in the other world as the only essential, and
who therefore gave no thought to exact anatomical
knowledge.
Yet among the ancient Egyptians are found some
of the earliest attempts at recording anatomical
data. They were acquainted with the heart, the
lymphatic glands and the crystalline lens. The
Ebers papyrus, of about 1550 B.C., and said to be the
oldest complete book extant, relates to the healing
art and contains incidental allusion to the structure
of the body. Vessels and nerves are together des-
ignated as "metu"; of which four are distributed
to the nostrils, four to the temples, four. to the head,
two in each hand and foot, etc. The heart is regarded
as the center of the vascular system, and vessels con-
taining blood, air, water and other fluids pass from
it to all parts of the body. Vital spirits are said to
enter one nostril and penetrate to the heart; an idea
which was to have a great effect upon anatomy and
physiology as far down as the seventeenth century.
Similar determinations, of no greater value, are found
in papyri of a somewhat later date.
Contemporary with the Egyptian culture, or
possibly anterior to it, was that of Chaldaea and
Assyria from which the Phoenicians and Hebrews
derived much. One of the contributors to the
Ebers papyrus is stated to be from Byblus, a town of
Phoenicia. Certain cuneiform inscriptions indicate
that the situation of the vessels of the neck was known,
as they describe the compression of these structures
to relieve the pains of circumcision. These inscrip-
tions refer to the heart as the seat of the mind, the
liver as the central organ for the blood.
The anatomy of the Hebrews was probably derived
mainly from Chaldean, Assyrian, and Egyptian
sources. The principle of life was by them believed to
reside in the blood (Gen. ix. 4; Lev. xvii. 11), which
was accordingly forbidden as food and used as a pro-
pitiatory offering. The heart was supposed to be the
seat of the understanding, courage, and love; to dilate
with joy, contract with sadness, harden or soften with
the passions. These expressions, which have become
wholly figurative in modern times, were formerly
believed to be literally true. The later Talmudists
had some anatomical knowledge of the female geni-
talia, the oesophagus, the lungs, the kidneys, the spinal
cord, and the cauda equina. One of the rabbis, at
the close of the first century, is said to have boiled a
body for the purpose of obtaining the skeleton. A
fabulous bone, "luz," was thought to become the
seed of the body from which it is to be renewed at
the resurrection.
The early writings of India contain no anatomical
knowledge except names of a few parts of the body.
Somewhat later (900-200 b.c.) there are rude attempts
at the enumeration of structures. To what extent
these enumerations are based upon actual examina-
tion and misinterpretation of anatomical facts it is
impossible to say. In them the primitive elements
of the body are air, bile, and phlegm, air having its
seat below the navel, the bile between the navel and
the heart, the phlegm above the heart. Seven
organic products were believed to be formed from
these primitive elements: watery chyle which in the
liver and spleen forms blood, from which arises flesh
which forms cellular tissue, from whence comes bone
which generates marrow, which gives origin to semen
and menstrual blood. The ancient Hindoos are
324
said to have practised dissection, it being held lawful
to pursue such investigations for scientific purposes
though under many limitations and restrictions; but
the sculptures of the rock-cut temples of Elephanta
and Ellora show ignorance of the anatomy of muscles.
Later authors appear to have had a vague idea of the
circulation of the blood, as they state that the watery
chyle circulates through the vessels and irrigates the
system as water does a field.
The Chinese have not, even at the present day, any
exact anatomical knowledge. The tracing of their
crude notions back to the mists of the past is of purely
archeologic interest, and it is difficult to say whether
the alleged great antiquity of some of their medical
writings is based upon authentic facts. They
considered the elements of the body to be air, water,
"metal," and "wood"; the liver to be the seat of the
intelligence, the seat of life to be in the middle of the
breast. Arteries and veins were not separately
distinguished, but some notion of a circulation or
translation of the blood appears to have been ad-
vanced, as it is stated that it completes a course
throughout the body fifty times in twenty-four hours.
In rare instances only was dissection allowed. It is
alleged that in the fourth century a.d. forty corpses
of decapitated persons were turned over to phy-
sicians for dissection, and that in the eighteenth
century the emperor Khang-hi, inspired by the Jesuit
fathers, had the anatomical works of Dionis and
ThomasBartholin translated into Chinese.
The Japanese in matters of anatomy copied from
the Chinese. Their older writings are curious mixtures
of fact and error. They teach that the heart contains
blood, rules all the other viscera, and is connected
with the liver, lungs, spleen, and kidneys; that blood
is prepared in three "combustion organs" of rather
mythical character, perhaps the thoracic duct, the
pancreas, and the lacteals. They assert the structure
of the lungs to be like that of a honeycomb, and state
that they contain a nourishing gas which penetrate
the whole body outside the vessels that carry the
blood. The brain, the spinal cord, and the marrow
are said to be of one nature, the brain having the
highest rank. The seat of the soul is stated by most
authors to be the heart, as it has been seen in some
animals to beat after the severing of the head from
the body. Others place it in the brain, the spleen,
the lungs, the kidneys, or the liver. The nerves are
often confounded with the tendons, often described
as tubular canals. In the middle of the eighteenth
century, a physician named Yamawaki obtained per-
mission from his prince to dissect a body, an illegal
act that could be done only under powerful protection.
He published his observations and declared that the
older teaching should no longer be thoughtlessly
followed. Dissection was thereafter surreptitiously
practised, and very accurate wooden models of the
skeleton were made. About 1775 the Dutch edition
of an anatomical work by Kulmus, Professor at
Dantzig, was translated into Japanese.
It is among the Greeks that we first meet with a
knowledge of anatomy that can be called scientific.
With keen and active intelligence they examined and
speculated upon all things in the world around them.
Prepossessed with the anthropocentric theory of the
universe, they attained only a partial and distorted
view of natural phenomena, but often showed aston-
ishing powers of generalization in speculative theories.
Among them arose the group of so-called "natural
philosophers," at the head of whom we find Pytha-
goras (584-504 B.C.). He attempted to explain
natural phenomena by means of harmonic numbers
which he considered as actual entities having myste-
rious powers, the elements of the body being comprised
in the number 10, each single number (1+2+3+4)
having therein a counterpart. He was the first to
deny the spontaneous generation of animals, holding
that all life must spring from germs preexisting in the
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Anatomy! History of
semen which, formed from the brain of the male,
combines with moisture from the brain of the female,
Ml | is t In' perfected foam of (he blood. This idea is
perhaps connected with thai of the origin of the god-
dess of generation, Aphrodite (aas' work into Latin, by Constantinus Afer, a
Benedictine monk {circa 1080), is probably the
work on anatomy in that Language (Hyrtl).
The leavening influence of the crusades now began
to be felt. The uniting of the scattered peoples of
Western Europe into vast armies that made long
journeys by land and sea, and came in contact with
nations of totally different culture and habits of
thought, had great effect in c billing the small,
warring, feudal factions into larger social units more
susceptible of advancement, in opening new avenues
of com rce, in diffusing a knowledge of t he learning
of the East, and in bringing about a revival of intel-
lectual activity. New universities were founded
throughout Europe; at Bologna in 11 10, at Padua in
1228, at Salamanca in 123'.), at the Sorbonne in 1253.
Others whose foundations dated back to the Roman
period received new accessions. Among the latter
were Salerno and Montpellier, at each of which an
active medical school was established. At Salerno
was seen the first symptom of a revival of practical
anatomy, for the Emperor Frederick II. (1212-12.">(l)
made a law in 1240 that no one should practise
surgery without having been previously examined in
anatomy, and provided that a dissection of the
human body should be made at Salerno once every
five years, inviting physicians and surgeons from all
parts of the empire to witness it. It has been
erroneously stated that the bull, dc sepulturis, of Pope
Boniface, issued in 1300, was an interdict against
dissection; but it was really intended to prevent the
gruesome practice of dismembering and boiling dead
crusaders, "more teutonico," for the purpose of more
easily transporting their bones to their native land.
The bodies of the Emperor Barbarossa, of Saint
Louis (King Louis XL of France), and of many
nobles were treated in this manner. The Senate of
Venice, in 1308, decreed that a human body should
be dissected annually. It is uncertain to what
extent these dissections were carried, but it is prob-
able that only the larger viscera were examined.
Among the products of the school of Salerno that
have survived are the "Anatome Porci" of Copho,
and the anonymous "Demonstratio Anatomica."
These are both based wholly upon dissection of
animals.
There is evidence that at this period autopsies were
occasionally held to determine the cause of death,
whether by poisoning or otherwise. It is also said
that the bodies of those who had been hanged were,
in Italy, not infrequently given over to physicians
for dissection. Occasionally bodies were stolen for
anatomical purposes.
It is at about this time that occurred the first
attempts at pictorial representations of bodily
structure. These are found in a translation of Galen
made by Nicholas Regio and published at Dresden
in the fourteenth century. Two manuscripts on
anatomy by Mondeville and Magister Ricardus that
have survived from the school of Montpellier also
contain rude drawings of structures.
The credit of first establishing systematic public
demonstrations of anatomy belongs undoubtedly to
Mundinus (Raimondo de Luzzi, Mondino, 1275-1326),
who taught at Bologna. Not content with expound-
ing Galen, Abbas, and Avicenna, he brought the
science back to the correct path of ocular investiga-
tion. At least three bodies of women were publicly
dissected by him, and there is reason to believe that
the number was considerably greater. He is the
author of a small work known as the "Anathomia
327
Anatomy, History of
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Mundini," that was circulated extensively in manu-
script before the invention of printing, and afterward
ran through at least twenty-three editions. Although
very incomplete and containing numerous errors, it
was used as a text-book for two hundred years. It
is very difficult to read, as much of the nomenclature
is borrowed directly from Arabian authors. The
abdomen appears as the "myrach," the peritoneum
the "cyphach," the omentum the "zirbus," the
sternum "the shield of the mouth of the stomach."
Some of his appellations are still used: as "nucha"
for the nape of the neck, "saphena" for the great
superficial vein of the thigh. His anatomy is crude
and incomplete rather than positively erroneous.
He held that the body has three cavities (ventres):
the head, containing animal members; the thorax,
spiritual members; the abdomen, natural members.
His anatomy of the heart and of the pulmonary
circulation is fairly accurate as he follows Galen.
In view of the imperfect and incomplete character
of this treatise of Mundinus, it is difficult to under-
stand its great influence upon the anatomical instruc-
tion of that age. It was, however, the first work
since Galen avowedly based upon personal inspection
of the human body, and it appealed to the medieval
spirit of curiosity that now began to manifest itself.
The same impulses that led Marco Polo to the terri-
tories of the Great Khan and impelled the alchemists
to new discoveries in their search for the transmuta-
tion of metals, animated many physicians of that
time in their examination of the body of man. A
zeal for anatomical studies arose, first in the Italian,
afterward in the French and German universities.
At Mundinus' own university of Bologna definite
rules for dissection were established. At Venice
(1308), Florence_(13S8), Padua (1429), also at Ferrara
and Pisa dissection was either required or allowed as
an aid to medical instruction. Pope Clement VII
(1523-24) granted it at Rome. At Montpellier in
1376 or 1377 the medical faculty obtained from the
Duke of Anjou a regular license to dissect the cadavers
of criminals, which was successivelv continued by the
kings of France (Charles VI., 1396; Charles VIII.,
1496). In Prague dissection was practised from the
very foundation of the university in 134S, and a
building was given for that special purpose in 1460.
At Vienna dissection was practised as early as 1404,
and made a definite part of the medical curriculum
in 1433. Pope Sixtus IV. granted special authority
for dissections at Wittenberg in 14.82 and it was
practised at Tubingen in 1485. The first anatomy
act in England was passed in 1540, allowing the
company of barbers and surgeons of London four
bodies annually for dissection. In Paris we hear of
it as early as 1478 and Moreau says it was customary
to make four dissections annually. In 1483 the
Paris Faculty decreed that graduates in medicine
should be required to have anatomical knowledge.
No doubt the actual number of dissections was
greater than is shown by these scattered records.
Yet this was nowhere carried on with the care and
precision that characterize work in modern schools.
The freeing of muscles, vessels, and nerves from the
tissues that envelop them seems not to have been
understood. Usually the great cavities of the body
were opened and the principal viscera therein con-
tained were displayed and demonstrated. Slices
were removed from the cadaver by a razor in the
hands of an attendant. The modern methods of
injection and preservation were, of course, unknown;
and a cadaver was soon a mass of disgusting and
noxious putrescence. There was as yet no approach
to exact and complete anatomical investigation.
That anatomy was but of slight assistance to either
medicine or surgery is amply shown by the records of
the time. Indeed, it fell into such disrepute that
Paracelsus (Theophrastus Bombastus von Hohenheim,
1 193-1541) declared it to be useless to know the
internal structure of the body, that a knowledge of
the shape or situation of the lungs, heart, or stomach
was of no value in the diagnosis or treatment of dis-
ease. In 1525 he burned the works of Galen and
Avicenna before his pupils at Basle, denouncing
these teachers as blind guides. This was at the close
of an address in which he denounced scholasticism
which he felt was retarding the progress of true
science. He said "I would admonish you to put
aside for awhile the mere dreams and opinions of
others who think by rote and not by experience. Of
what use is the rain that fell a thousand years ago?
We are more interested in that which falls to-day."
Some of the doctrines of Paracelsus reappear at later
periods. He considered the body to be a microcosm
representing the entire external universe, formed
from preexisting and indestructible germs (Weis-
mann's germ plasm), and governed by astrological
influences, the sun affecting the heart, the moon the
brain, Mercury the liver, etc., etc. The functions
of the body he supposed to be carried on by the
archcens, a sort of dcus in machina, that resided in
the belly. He made many other fantastic specula-
tions, especially in therapeutics and appears to be
the original author of the homeopathic doctrine of
" like cures like."
Among those who carried on the work started by
Mundinus and somewhat extended the domain of
anatomy are:
Gabriele de Zerbi (1468-1505), professor at Padua,
Bologna, and Rome, who first separated the organs
into systems, described the musculature of the
stomach, and the puncta lachrymalia. He knew
that the tunica vaginalis testis is derived from the
peritoneum.
Achillinus (Alessandro Achillini, 1463-1512), pro-
fessor at Bologna and Padua, author of a commentary
on Mundinus, who discovered the malleus and the
incus, the labyrinth of the ear, the patheticus nerve,
the ileocecal valve, and the entrance of the bile duct
into the duodenum.
Alessandro Benedetti (1460-1525), professor at
Padua in 1490, afterward at Venice, built the first
anatomical amphitheater. His demonstrations were
public and he complains of the "numerous populace"
that crowded to them. He wrote a work on anatomy
that is one of the very best of the period.
Berengarius Carpensis (Jacopo Berengario Carpi,
1470-1530), professor at Pavia and Bologna, author
of a commentary on Mundinus. He showed the
mythical character of the rete mirabile which Galen
had described as existing on the internal carotid
arteries (as in the herbivora), and was the first to
deny that orifices existed in the interventricular
septum. He stated that he had dissected more than
a hundred cadavers, but does not say that these were
all human.
Marcus Antonius (Marc Antonio della Torre, 14S1-
1512), professor at Padua and Pavia, the pupil of
Lionardo da Vinci who is said to have designed plates
for his work. Lionardo was himself an anatomist
fully equal to any of the pre-Vesalian epoch. He
made many dissections and carefully reproduced
them in drawings that show a great deal of anatomical
knowledge. William Hunter says: " I expected to
find in the drawings of Lionardo da Vinci at most
only the anatomical indications indispensable for a
painter in practising his art; but to my great astonish-
ment I discovered that Lionardo had studied anatomy
as a whole and that very profoundly. When I
consider the care with which he studied every part
of the human body, I am persuaded that he ought to
be considered the best and greatest anatomist of his
epoch." He seems to have come nearer to the
circulation of the blood than any of his contempora-
ries. "The heart," he says "is a muscle of great
strength, much stronger than the other muscles.
The blood that returns when the heart opens again
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REFERENCE HANDBOOK OF TIIF. MEDICAL SCIENCES
Anatomy, History of
j, not the same as that which closes tin 1 valves." It
should I"' remembered thai Raphael, Michael Angelo,
Bandinelli, Pollajuolo, Verocchio, and Donatello all
studied anatiitiiy and left anatomical drawings,
Concerning Michael Angelo, the slanderous story was
circulated that he had practised vivisection of a
criminal in order to gel the expression that ho desired
to portray in a picture of the crucifixion.
Vidus Vidius (Guido Guidi, 1545-1569), physician
to Francis [., and professor at Talis and Pisa, whose
name is retained in the Vidian canal and t ho Vidian
nerve; Guintherus Andernacensis (Gtinther von
lernach, 1487-1574), professor at I.ouvain and
Paris; and Jacobus Sylvius (Jacques Dubois, 1478-
1555), professor at Paris, are all chiefly famous as
being the instructors of Vesalius. Gunther had both
\ esaiius and Servetus as prosectors in his laboratory
at the same time. His description of the valves of
the heart is good, and he appears to have been the
first to discover that both air and blood undergo
changes in passing through the lungs. Sylvius
fly improved nomenclature, assigning designa-
tion- to muscles and vessels, distinguishing voluntary
from involuntary muscles, and demonstrating more
by personal dissection than was done in other schools.
In his little "Introduction to Anatomy" he says:
■■ 1 would have you look carefully and recognize by
eye when you are attending dissections or when you
see anyone else who may be better supplied with
instruments than yourself. For my judgment is
that it is much better that you should learn the
manner of cutting by eye and touch than by reading
and listening. For reading alone never taught any-
how to sail a ship, to lead an army, nor to com-
pound a medicine, which is done rather by the use of
one's own sight and the training of one's own hands."
fie discovered valves in some of the veins, but appears
to have had no idea of their function.
The time was now ripe for a new advance. The
invention of printing and consequent general dif-
fusion of ancient literature, the discovery of new
countries and continents, the progress of invention
and the flourishing condition of pictorial and plastic
art, created an intellectual activity that would no
longer brook the restraints of schools and the un-
supported dicta of the ancients. The power of
tradition, which had weighed like an incubus upon
anatomical teaching for over thirteen hundred year-,
was now to be rudely shaken. There arose a group
of anatomists who were to pursue their work again
in the proper spirit of free inquiry and to institute for
the first time in the history of the science of careful
examination of the human body made with thorough-
ness and skill. The chief of these was Andrew
Wesel, more commonly known by his Latin ap-
pellative of Andreas Vesalius, who was born at
Brussels, December 31, 1514. He was the son, grand-
son, and great-grandson of distinguished physicians,
a fact of which he was justly proud. He showed a
taste for anatomical investigations at an early age,
and after an excellent training in Latin, Greek,
and perhaps in Arabic, at the university of Louvain, he
went to Paris to work in the laboratory conducted
by Vidius and afterward by Sylvius at the school
founded in 1.330 by Francis I. His description of the
way in which anatomy was pursued there shows the
state of teaching at that time. The demonstrations
were mostly upon animals, and upon those rare
occasions when the human body was examined
it was hurried over in three lessons, the teacher
merely opening the great cavities and so hastening
over the demonstration that "more anatomy might
be learned in the shop of a butcher than in such a
dissecting room." Except the eight muscles of the
abdomen which were badly mangled and improperly
prepared, not a muscle was demonstrated, nor were
any bones shown, much less were nerves, veins, and
arteries properly dissected and displayed.
At odd times Ve aim haunt'-,! tin- city Cemeti ii'
to procure chance hour- turned up by t he spade of the
Sexton. He early noted errors in the description "I
Galen and Mundinus. Returning to Louvain he con-
ducted anatomical demonstrations there, and pos-
Sessed himself, it is said, of an entire human skeleton
by remaining all night beyond the city gates and
robbing the gibbet of a bnd\ partially destroyed by
birds. Jle afterward went to Italy, and received, in
1537, at twenty-three years of age, the appointment
of professor of anatomy at Padua, already famous
for its anatomical instruction. II. n- he at once
achieved a striking success. His demonstrations
were crowded; the clergy, the laity, even women
thronging to hear him. He remained in Italy seven
years, delivering courses in I'isa and Bologna as well
as at Padua, a proceeding rendered possible by the
short duration of each course, viz., seven weeks.
While not employed in teaching he gave his time to
the composition of his great work, " De Huniani
Corporis Fabrica, Libri VII.," the first attempt at a
complete exposition of the structure of the human
body.
In this we find the result of his own personal re-
searches, a careful and generally accurate description
of the anatomical features of man made for the first
time from actual inspection. As Vesalius himself
says, it is an attempt to demonstrate the structure of
man upon himself. Galen's many errors, caused by
his almost exclusive study of inferior animals, were
unsparingly noted. Excellent plates made from
drawings of preparations illustrated the work. These
were so good that they were often ascribed to Titian,
but they were probably the work of Stephen von
Calcar, one of Titian's pupils, with perhaps some
aid and advice from the master and an occasional
drawing from Vesalius himself, who was skilful with
the pencil.
From this epoch-making work modern anatomy
may be said to have its birth. It is, however, by no
means free from errors, both those due to hasty
preparation, and those arising from the preconcep-
tions then current. Vesalius still supposed that
mucus passed through the holes in the cribriform
plate, that the tubular nerves distributed animal
spirits, etc. Many of his errors were pointed out by
his contemporaries
This new departure should be considered as belong-
ing to the movement of the age. As has been already
noted, the world was becoming impatient of tradi-
tionary authority and seeking for facts by personal
observation and research. Vesalius' great work
appeared in 1543, in the same year that Copernicus
published his treatise "On the Motions of the Heav-
enly Bodies"; it was in 1521 that Luther made his
memorable appeal before the Diet of Worms, and in
1534 that he completed his translation of the Bible.
The adherents of ancient tradition did not yield
without a struggle. Vesalius was denounced by
many, his former teacher Sylvius calling him an
impious madman whose breath poisoned Europe.
The errors of Galen which Vesalius had pointed out
were explained in the most grotesque manner, either
by supposing a corruption of Galen's text, or by the
hypothesis that the human body had changed since
Galen's time. The seven pieces of the sternum which
Galen had described (from apes) were supposed to
indicate how much larger and more developed the
thorax was in Galen's time; the curvature of the thigh
bones, not seen in modern man, was said to be their
natural free condition before they were straightened
by the wearing of tight breeches. More important
were criticisms directed toward Vesalius' own demon-
strations by Eustachius, who pointed out a number of
errors, and thoroughly disapproved of the conduct of
Sylvius. Vesalius seems to have taken this opposition
very much to heart. He had previously resigned his
chair, and now he went to Madrid, where, in the gloomy
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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
court of Philip II., he found a most uncongenial
atmosphere. He was surrounded by enemies who
attempted to stop his work by the power of the In-
quisition. Philip asked from the University of
Salamanca an opinion as to the permissibility of
dissection, and the reply of the learned doctors was
that since it is useful to man it may be allowed (1556).
Restless and ill at ease, Vesalius wished to return to
his chair in Italy, now vacant by the death of Fal-
lopius. He was destined never to do this. Making
a voyage to Palestine in the fulfilment of some vow,*
recalled while there by the Senate of Venice to re-
sume his chair, he was shipwrecked on the island of
Zante, and suffered so much from exposure that he
died there, October 15, 1564. He was one of the great
pioneers and pathmakers of science, worthy to rank
with Copernicus and Columbus. Anatomy has never
lost the impulsion due to his arduous efforts. He
found it a mass of crude speculations based on
ancient authority, he left it a recognized science hav-
ing for its basis actual observation of structure.
■ Vesalius was by no means alone. Two other great
figures stand out at this epoch, Eustachius (Barto-
lommeo Eustacchi, 1520-1574), professor of an-
atomy at Rome, and Fallopius (Gabriele Fallopio,
1523-1562), professor at Ferrara, Pisa, and Padua.
It is to Eustachius that we owe the first idea of in-
vestigating the tissues, also the conception that to
understand adult structures we should examine the
fetal ones. To correct the current errors in Vesalius
and others, he prepared a great illustrated work
on the controversies of anatomists, but it was never
published, and the plates that he had made for it at
great expense were long supposed to be lost, but were
finally discovered in the Vatican library and presented
by Pope Clement XI. to Lancisi, who published them
in 1714. They were the first copper plates used for
anatomical illustrations, and show that their author
had anticipated many of the discoveries of his
successors. The Gasserian ganglion and the pan-
creatic duct are clearly shown, and the ciliary muscle
not only figured but given its modern designation.
The name of Eustachius is preserved in the Eustachian
tube, said to have been first discovered by Alcmreon,
and the Eustachian valve of the fetal heart mentioned
previously by Jacobus Sylvius. He first described
the membranous cochlea and the tensor tympani
muscle, the origin of the optic nerve, the suprarenal
capsules, and the ventricles of the larynx.
Fallopius was especially renowned for his exact
description of the organs of hearing. He discovered
the facial canal and its hiatus, the communication of
the mastoid cells with the middle ear, the fenestra
ovalis, the chorda tympani, the aqueductus vestibuli,
and the lamina spiralis. He gave the membrana
tympani its present name and named the oviducts
(previously discovered by Herophilus) the tuba'
seminales. The inguinal ligament (Poupart's) was
first described by him, as also the hymen, the clitoris,
the seminal vesicles, and the uriniferous tubules. He
also described the ileocecal valve, which was, however,
probably known to Achillinus. He discussed the
development of bones and teeth, and knew the ganglia
of the spinal nerves.
In their zeal for knowledge the anatomists of that
age are reputed to have not infrequently overstepped
the bounds of common humanity. Vesalius, following
the example of Herophilus, is said to have vivisected
criminals, and the records found in the criminal
archives of Florence (1545-1570) show beyond dis-
pute that it was by no means uncommon to send
living persons to Pisa "to be made an anatomy."
While this language seems to indicate that such
* The report that he was condemned to death by the Inquisition
for opening by accidenl the body of a living man, and that his
sentence was by Philip commuted t<> a pilgrimage, appears to be
wholly without foundation, unsupported by the records of the
Inquisition or of 1 he royal archives.
subjects were dissected alive, there is, on the other
hand, some evidence to show that they were first
executed by smothering or otherwise.
Many other almost equally famous men contrib-
uted to the anatomical knowledge of the period.
Among these are the following:
Servetus (Miguel Serveto, 1509-1553), a Spaniard
from Villanova, in Arragon, burned at the stake by
Calvin, at Geneva, for heretical opinions. He was the
first clearly to describe the pulmonary circulation and
the change from venous to arterial blood that occurs
in the lung. This description occurs in the rare work
" Christianismi Restitutio," published by him at
Vienne in 1553. In this he clearly states that air
mixed with blood passes from the lungs to the heart.
"A pulmonibus ad cor non simplex aer sed mixtia
sanguine mittitur per arteriam venosam." He had,
however, no idea of the greater or general circulation.
Columbus (Matteo Realdo Colombo, 1494-1559),
a bitter opponent of Vesalius, and who immediately
succeeded him at Padua and afterward taught at
Pisa and Rome, dissected with great assiduity,
completing at least fourteen bodies in a year. He
also ransacked old charnel houses for bones and is
said to have compared about half a million of skulls.
He was an ardent investigator, demonstrated ex-
perimentally the lesser circulation, perhaps with
knowledge of the prior work of Servetus, and had
an accurate idea of the functions of the valves of
the heart.
Ingrassias (Giovanni Filipo Ingrassia, 1510-15S0),
professor at Naples, of high rank as an osteologist,
who discovered the stapes and studied the sphenoid
and ethmoid bones.
Cananus (Giambattista C'anano, 1515-1579), one
of the earliest to mention the valves of the veins
(1547).
Coesalpinus (Andreas Cfesalpini, 1519-1603), the
first to use the term circulatio in speaking of the move-
ment of the blood. He seems to have anticipated
Harvey in holding that the blood returns from the
general tissues to the heart by the veins alone. He
lacked, however, the precise demonstration which
characterizes Harvey's work.
Arantius (Giulio Cesare Aranzio, 1530-1589),
professor at Bologna, who discovered the ductus
arteriosus, the corpora Arantii, named the hippo-
campus major, carefully described the gravid uterus,
which he considered a muscular organ, and first spoke
of a separation of the maternal and fetal blood.
Coiterus(VolcherKoyter, 1534-1600), of Groningen,
who investigated the osteology of the fetus and the de-
velopment of the bones.
Varolius (Constanzo Varolio, 1543-1575), pro-
fessor at Rome, who made special researches into the
brain and nervous system, describing the base of the
brain and the apparent origin of the cranial nerves.
His name is preserved in the pons Varolii.
Bauhinus (Caspar Bauhin, 1560-1624), professaj
at Basle, who made improvements in terminology,
(The discovery of the ileocecal valve, ascribed to him,
is apparently due to Achillinus.)
Spigelius (Adrian van den Spieghel, 1578-1625), of
Brussels, who made a special study of the liver, one of
whose lobes still bears his name.
Fabricius ab Aquapendente (Girolamo Fabrizio,
1537-1613, so called to distinguish him from Fabriciua
Hildanus, a celebrated surgeon of the period), who was
the successor of Fallopius at Padua, and worthily
maintained the reputation of that celebrated school.
He erected at his own expense an anatomical amphi-
theater which still remains. It is a small dark pit
with seats risintr almost perpendicularly about it,
excluding the light so that all dissections must have
been by candle light! It was here that Harvey
learned anatomy ami obtained from Fabricius the
germs of the knowledge which was to result in the
discovery of the circulation of the blood. Fabricius
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Anatomy, History »t
was the first to demonstrate in a complete manner
the valves of the veins. , The first mention of these i~
by Stephanus (Charles Etienne) of Paris in 1545, who
, to them as "apophyses membranarum," in-
tended to prevent the regurgitation of the blood.
Sylvius i 1555) noted them in several veins, Eustachius
in the coronary vein (1563). Vesalius seems not to
have realized their importance, but figures them in the
hepatic veins. Fabricius, however, wrote a cum;
treatise upon them ("De Venarum Ostiolis," 1603
and .stated that they prevent the overdistention of
Is when blood passes from the larger to the small-
er veins. He also .studied the development of the
human fetus and of the embryo chick, tho muscular
of the bladder, tho esophagus, stomach, and intes-
tines, particularly the appendix vermiformis. He was
leeded at Padua by C'asserius (Giulio Casserio,
1561-1616), who paid especial attention to the organs
of voice and hearing and discovered the stapedius
muscle. The musculo-cutaneous nerve of the arm is
sometimes called the nervus perforans Casserii.
The zeal for investigation instituted by Vesalius and
carried on by his contemporaries and immediate
was undoubtedly a great advance over the
ignorant apathy that preceded it, but it was not so
ij a new movement as a revival of an old one.
The anatomy of that time was, after all, the anatomy
of the Greeks, carried to a greater degree of detail, it is
true, but marred by the same teleological errors. The
spiritualistic theories of Hippocrates, Aristotle, and
Qalen still prevailed and blinded the eyes of anato-
mists to the true significance of structure. The
doctrine of the tissues, hinted at by Aristotle, and
dimly groped after by Eustachius and Fallopius, had
borne as yet no fruit. The development of the embryo
had been but little studied and its details were im-
perfectly known. In osteology and arthrology the
advances were greatest, the general features of the
■s, joints, and ligaments being well described; but
their nomenclature was as yet undeveloped, they being
mated in each region by numbers. In the
vascular system the veins were considered the most
important vessels, it being supposed that the blood in
them had an oscillatory movement which the valves
modified without absolutely controlling its direction.
The heart had been fairly well described, but as no one
had shown experimentally the impossibility of regur-
gitation of blood into it from the aorta and the pulmon-
ary artery, it was still supposed to be a sort of mixing
reservoir for the blood and animal spirits. The
permeability of the interventricular septum was still
in dispute, it being held necessary for the mixing of
the blood. The powerful muscular character of the
heart was still unrecognized, and though the lesser or
pulmonary circulation had been mentioned by
Bervetus and Columbus, it was not generally ac-
cepted. The lymphatics, although seen and vaguely
mentioned by several ancient authors, were
not understood.
The macroscopic anatomy of the brain was not yet
well known; the ventricles were supposed to be the
reservoirs of the vital spirits, and the nerves to be
tubular in character. The distribution of the cranial
nerves was not clearly made out.
In splanchnology vague ideas prevailed. The liver
and spleen were thought to be potent organs for the
elaboration of blood, which was made in them as fast
as it was distributed by the heart through the veins
and arteries to be poured out into the substance of
the organs. The pancreas, although discovered by
Herophilus, was overlooked, as it is evident that
\ esalius mistook for that organ the collective mesen-
teric glands. The ovaries were believed to produce a
female semen.
Anatomical instruction was still carried on mainly
by demonstrations by the professor. The prosectors
usually made dissections in sight of the pupils, the
professor sitting opposite and with, a little wand
pointing oui the part described. The muscles
dissected in one day, the contents of the head, chi t,
and abdomen in a second, the bones and ligaments in
a third. It was not usually practicable to extend this
lime on account of the rapid decay oi tie- body. As,
however, the whole day was occupied by each demon-
tration, the work was nut as superficial as might at
first appear.
Another great advance was now made in a domain
which, although physiological in its scope, yet reacted
powerfully upon anatomy by affecting conceptions of
bodily structure. This was the careful inductive
demonstration (commonly called discovery) of the
circulation of the blood made by the renowned
William Harvey who was born April 1, l~>7s. He
studied at Cambridge and Padua, graduating from
both universities in lfi()2. In Italy he became ac-
quainted with the views of Fabricius whose pupil he
was, as to the wide distribution of the valves of the
veins, and those of Columbus regarding the pulmonary
circulation. It was not, however, until lie had made
many vivisections and studied the movements of the
heart in many living animals, under varying conditions,
that he attained to a correct idea of the double circuit
made by the blood.
Harvey began to teach the new doctrine in his
lectures at the Royal College of Physicians as early
as 1615, but did not publish them until 1028, when
appeared, at Frankfort, his "Exercitatio Anatomica
de Motu Cordis et Sanguinis in Animalibus" (An
anatomical treatise on the movements of the heart
and the blood in animals). In this he frankly breaks
with traditional teaching: " I profess to learn and
teach anatomy not from books, but from dissections;
not from the suppositions of philosophers, but from
the fabric of nature."* Showing that the anatomical
arrangement of the valves of the veins and of the
heart necessarily implies a movement of the blood
from the veins toward the heart and from the heart
into the arteries, he demonstrated such movement by
a compression of veins and arteries and by various
other experiments in living animals, making an ear-
nest plea for comparative anatomy: "Had anatomi-ts
only been as conversant with the dissection of the lower
animals as they are with that of the human body, the
matters that have hitherto kept them in a perplexity
of doubt would, in my opinion, have met them freed
from every kind of difficulty." For the first time we
see doubt cast upon the doctrine of "spirits." Says
Harvey: "We are too much in the habit of worship-
ping names to the neglect of things. The word blood
has nothing of grandiloquence, about it, for it signifies
a substance which we have before our eyes and can
touch; but before such titles as spirit and innate heat
we stand agape."
The new doctrine was at first universally rejected,
especially in Italy where most of the preliminary
discoveries had been made that led to Harvey's con-
elusions. As in the case of Vesalius, the innovator
was greeted with abuse and detraction instead of
demonstration and legitimate argument. Harvey
received this, however, with a singularly calm and
judicial spirit. He says: "To return evil speaking
with evil speaking I hold to be unworthy in a philoso-
pher and searcher after truth. I believe that I shall
do better and more advisedly' if I meet so many indica-
tions of ill-breeding with the light of faithful and con-
clusive observation." The only opponent he deigned
to answer was Jean Riolan (Riolanus, Jr., 1.577-1657),
professor at Paris, so renowned for his acerbity in con-
troversy that it was said of him that he would rather
give up a friend than yield an opinion. Harvey's
* In the possession of the Royal College of Physicians of London
are preparations of tin- blood-vessels, mounted on boards and show-
ing the aortic valves, that are said to have been prepared by Har-
viv when a student in Italy and used for demonstration to his
classes. Hyrtl believes them to be the oldest anatomical prepara-
tions extant.
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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
reply was judicial and complete, but failed to con-
vince Riolan, who obtained a decree from the Faculty
at Paris forbidding the teaching of the new doctrine,
and opposed it up to the time of his death. Harvey
lived to see his views almost universally accepted,
dying in 1657, a few years before Malpighi discovered
the capillaries and thus placed the anatomical basis of
the circulation beyond cavil (1661).
Harvey's work called more attention to the heart,
and many points in its gross anatomy were now estab-
lished. Among those who worked to this end may be
mentioned Richard Lower of London (1631-1691,
tuberculum Loweri), Raymond Vieussens(1641-1715
or 16, fossa ovalis), professor at Montpellier, Nils
Stensen (Nicholas Stenonis, 1638-16S6), professor at
Copenhagen, who worked at the musculature and
looped fibers, and Adam Christian Thebesius (1686-
1732), who discovered the foramina Thebesii.
As a consequence of the doctrine of the circulation,
the distribution of blood-vessels was more accurately
studied. A passage in Sylvius is sometimes cited to
show that he suggested injections, but it is clear that
he could not have made any effective use of them.
The first to do this was Stephen Blancaard, of Middle-
burg, Holland (1650-1702), who, in 1675, succeeded
in injecting the blood-vessels. Others obtained great
success with this method, especially Frederick Ruysch
(1638—1731), professor at Amsterdam, whose prepara-
tions were justly famous. It is to him we owe the dem-
onstration of the vascular distribution in the choroid
of the eye (tunica Ruyschiana =choriocapillaris).
Using fine injections he found vessels in every part
of the body in such numbers that he inclined to the
belief that the body was mainly composed of them,
"totum corpus ex vasculis."
Closely associated with the anatomy of the blood-
vascular system is that of the lymphatics. These
structures were probably seen in goats by Aristotle
and Herophilus, but as their course and termination
were not determined, the remarks of those authors
concerning them were overlooked or misunderstood.
Eustachius saw and described the thoracic duct in the
horse, supposing it to be a vein for the nourishment of
the thorax. The chyliferous lymphatics were first ob-
served in 1622 by Gaspare Aselli (1581-1626), professor
at Pa via, in the mesentery of a dog lately fed. Misled
by the prevalent conceptions as to blood formation, he
thought they could be traced to the liver. His dis-
covery was not published until 1627, and the next
year such vessels were demonstrated in the mesentery
of a criminal two hours after death by Fabrice de
Peiresc, a senator of Aix, to whom Gassendi had com-
municated Asellius' discovery. In 1647, Jean Pecquet
(1622-1674), a student at Montpellier, accidentally
discovered the thoracic duct in a dog and traced it
through the diaphragm to the receptaculum chyli
(reservoir of Pecquet). It was still considered a vein,
though further research showed its connection with
the mesenteric glands. The distinction between the
lymphatics and the mesenteric veins was first made
by Nathanael Highmore (1613-16S4), of Shaftesbury.
Jan Van Home (1621-1670), professor at Leyden was
the first to observe the thoracic duct in man, though
Olaus Rudbeck (1630-1702), professor at Upsala,
noted it about the same time. The latter also dis-
covered the general lymphatics, distinguishing them
as vasa serosa in 1651, their present name being given
by Thomas Bartholin (1616-1680), professorat Copen-
hagen, who greatly extended the knowledge of them.
Finally Anton Nuck (1650-1692), professorat Leyden,
invented the method of injecting these vessels with
mercury and traced them to nearly all parts of the
body.
It was at about this period that anatomical science
obtained great assistance by the invention of the
microscope. As an instrument of research the simple
microscope was not used until the seventeenth
century, although the magnifying power of lenses
seems to have been known in remote antiquity. The
greater power of the compound microscope invented
about 1608 by Hans and Zacharias Janssen, of
Middelburg, Holland, still further stimulated inves-
tigation and led to the discoveries of Malpighi,
Leeuwenhoek, Redi, and others. The imperfection
of the instrument so greatly affected its utility that
many anatomists distrusted the results obtained
from its use. After many attempts and partial
successes by others, Chevalier of Paris (1824) and
Amiei of Modena (1827) finally succeeded in correcting
chromatic and spherical aberration, thus producing
an instrument by which minute structure can be
accurately investigated.
The immediate result of microscopical investigation
was, on the one hand, greatly to extend the knowledge
of structure, and, on the other, to introduce novel
ideas regarding generation and the diffusion of animal
life. Marcello Malpighi (1628-1694), professor at
Bologna, Pisa, and Messina, a man of great scientific
force, laid the foundations of modern botany, of
histological anatomy, and of embryology. His
discovery of the capillaries in the lung of the frog
has already been mentioned. Molyneux (1683) and
Leeuwenhoek (1688) almost immediately extended
this by finding them in the extremities of lizards and
tadpoles. Malpighi discovered the red corpuscles
of the blood in 1665 and thought them to be fatty
globules. He was, however, anticipated in this by
Johannes Swammerdam (1637-1680) who not only
saw them but correctly described them in 1658.
Malpighi published the first accurate account of the
consecutive development of the chick, carrying his
investigations as far as the imperfect instruments
and methods of his time would permit. He greatly
advanced the knowledge of glands, showing the
structure of acini and ducts, demonstrated the glomer-
uli of the kidney and the splenic corpuscles which
still bear his name, and by inflating the air vesicles
showed the glandular structure of the lungs and the
impossibility of air passing into the vessels by
mechanical means. Misled by his imperfect instru-
ments and crude methods of preparation he endeav-
ored to show that the brain also has a glandular
character. Having cooked the organ he thought
that the gray matter appeared on examination to be
composed of minute spherules connected with the
fibrous central portion. He assumed that these
spherules secreted the nervous fluid which was dis-
tributed by the nerves. This accorded with the
prevalent ideas and greatly retarded a true apprecia-
tion of the structure of the brain.
Many other anatomists added to our knowledge of
glands: Francis Glisson (1597-1677), professor at
Cambridge, gave a description of the liver that is the
basis of our knowledge at the present day; Johann
Georg Wirsung, professor at Padua in 1642, discovered
in man the pancreatic duct, alleged to have been
previously found in the fowl by his pupil Moritz
Hofmann (1621-1698), afterward professor at Altorf;
a discovery that retarded rather than advanced
anatomical science, for the pancreas was supposed
to be a lymphatic gland and the duct a lymphatic
leading from the intestine to the liver, and thus were
confirmed erroneous views of lymphatic distribution;
Thomas Wharton of London (1610-1673) wrote of
the nature and classification of glands, and discovered
the duct of the submaxillary gland that bears his
name.
At Paris a remarkable advance was made by the
establishment by Jean Riolan, Jr., of the Jardin du
Roi, afterward the Jardin des Plantes, which was,
in effect, a biological laboratory where various prob-
lems of human and comparative anatomy could be
studied. Jean Guichard Duverney (1648-1730) was
an able demonstrator there, so popular that noblemen
flocked to hear him. He discovered the vulvovaginal
glands (in the cow), to which Caspar Bartholin's
332
REFERENCE HANDBOOK OF THE MEDICAL SCIENt ES
Anatomy, History of
name was afterward attached. H>' also confirmed
the existence of the bulbourethral glands, first
discovered by Mery (1645-1722) and named after
nglish anatomist Cowper.
\1, ixis I.ittrc i Hi.")S-17'_'(i) described the urethral
elands that bear bis name, and Martin Naboth
(1675-1721) the glands of the neck of the uterus
and the closed follicles of the same region. Lorenzo
Bellini (1643-1704), professor at Pisa, examined
, - fully the structure of the kidney (uriniferous
tubules). Thomas Bartholin (1616-1680), professor
at Copenhagen, one of the most distinguished anatom-
ists ef the seventeenth century, discovered the duct
of the sublingual gland which joins Wharton's duct,
while the ducts of that gland that open separately
into the mouth were found by August Quiriu Bach-
i (Rivinus, 1652-1723), professor at Leipsic.
The duet of the parotid gland, seen and described as
I iment by C'asserius, was first recognized as a duct
by Walter Needham, of London, in 1655. Nils
sen i Nicholas Stenonis, 1638-1(386), professor
ipenhagen, mentioned it in his inaugural thesis in
, and its discovery is often assigned to him.
Stensen was one of the most able thinkers of his time.
He held that in order to understand the function of
organs we must first determine their structure, and
that no accurate knowledge of the brain can be had
until we understand its conducting tracts. He
declared, contrary to the prevailing opinion, that
petrifactions are not mere erratic freaks of nature,
but the remains of plants and animals that formerly
lived. The glands of the intestinal tract were
investigated by Johann Conrad Brunner (1653-1727)
and Johann Conrad Peyer (1653-1712); those of the
eye-lids by Heinrich Meibom (1638-1700), professor
at Helmstadt; while Conrad Victor Schneider (1614-
1680), professor at Wittenberg, demonstrated the
true nature of the lining membrane of the nasal
fosse, and thus overthrew the ancient doctrine of the
tion of mucus (pituita) by the brain and of the
cerebral origin of catarrhal disorders. Antonio
Pacchioni(1665-1726), professor at Rome, discovered
the bodies that bear his name, situated near the
superior longitudinal sinus; and the synovial fringes
and so-called synovial glands were described by
Clopton Havers (1692).
The Pythagorean and Galenical doctrine that the
embryo is formed from two kinds of semen, generated
respectively by the male and female, was generally
held. Harvey, following in the footsteps of his
master Fabricius, investigated the course of develop-
ment not only in fowls but in mammals, and published
(1651) a treatise on development in which he formu-
lated the famous proposition that the egg is the
primary stage of development for all animals. The
original phrase is, "Ovum esse primordium commune
omnibus animalibus," afterward currently abbreviated
as, "Omne vivum ex ovo." According to this view
the ovum is the essential element in the generative
process. This belief was shaken by the discovery,
in 1(>77, by Johann Ham, a pupil of Leeuwenhoek, at
Leyden, of the spermatozoa, which were at once
accepted by many as the true generative elements,
and were even considered to be minute but completely
formed creatures, possessing in miniature all the
organs of the adult. There thus arose two schools,
the Animalculists and the Ovists, that respectively
maintained the efficacy of the male and female
products. Nathanael Highmore (1613-1684), a phy-
sician of Shaftesbury, England, investigated the
testicle, the seminal ducts, and the epididymis.
His name is preserved in the corpus Highmorianum
(mediastinum testis) and the antrum of Highmore
(maxillary sinus). Wharton described the round
ligament of the uterus as the excretory duct for the
female semen, but the question of this hypothetical
product was finally settled by Caspar Bartholin, who
correctly described the functions of the vulvo-
vaginal glands. The mammalian ovum eluded
research for a long time. The ovisacs (Graafian
follicles) were described by Etegnier de Graaf (1641
1673), who says that they were known and mentioned
by Vesalius and others. He supposed them at first
to be ova, though he ei m later to have had a correct
idea of their nature. When Naboth discovered the
closed follicles of the luck of the uterus, he too
supposed that he had found the ova (nvula Nabothi).
It is said that Van Borne I 1621-1670), professor
at Leyden, saw the ovum in Kills, but it was not
definitely and unquestionably recognized until von
Baer demonstrated it in L827. Nicolas Andry do
Boisregard (1658-1742) was the first to note the
entrance of a spermatozoon into an ovum, and
believed that it did this in order to feed. Antonio
Vallisneri (1661-1730), professor at Padua, held, on
the contrary, that the ovum was necessary for
generation, and supposed the spermatozoon to be
unessential. Needham first showed that the fetus
was nourished by maternal blood.
In the nervous system considerable advances were
made during this period. Although Harvey stated
that he was unable to discover the animal spirits,
yet he does not seem to have been able wholly to free
himself from the influence of the prevailing doctrine.
Ren£ Descartes (Cartesius, 1596-16.50,) the eminent
mathematician, held that although the soul was im-
manent throughout the whole body, it must be
specially centralized in the pineal gland, that being
the only unpaired organ of the brain and situated so
as effectually to control the animal spirits contained
in the ventricles. He held that the brain is the
seat of sensation, motion, and thought, sensation
being due to impulses transmitted to that organ by
nerves, motion to the contraction of muscles induced
by impulses also transmitted by the nerves. He seems
to have been aware of reflex action, noting that sen-
sation may cause motion independently of the will.
He thus anticipated discoveries made nearly two
hundred years later, and was the first to attempt to
explain the phenomena of life by purely physical
causes. He was a warm adherent of Harvey's
doctrine of the circulation, though he would not
admit that the blood was impelled by the action of the
heart. Johann Jacob Wepffer (1620-1695) was the
first distinctly to deny that spirits were generated in
the cavities of the brain. Pacchioni considered the
dura mater as an organ for effecting the circulation of
the spirits, and provided it with three muscles and four
tendons.
Francois de le Boe (Franciscus Sylvius, 1614-
1672), professor at Leyden, carefully studied the
brain and gave true ideas of its interior spaces. His
name is preserved in the aqueduct, fissure, fossa, and
artery of Sylvius. The fifth ventricle which he
discovered is sometimes called the Sylvian ventricle.
Raymond Vieussens (1641-1715), of Montpellier,
also investigated the brain. He was the first to
describe the anterior pyramids of the medulla oblon-
gata, the olive, and the centrum ovale. His name
remains in the valve of Vieussens or anterior medullary
velum. Duverney described the decussation of the
pyramids and the connection of the jugular sinuses
with the jugular vein; while Humphrey Ridley
(1653—1708) described the restiform body and the
circular sinus. Malpighi recognized the functional
importance of the gray matter of the brain, and
Burrhus (1616-1695) showed that one-fourth of the
cerebral substance was a spermaceti-like fat. Much
advance was made by the investigations of Thomas
Willis (1622-1675), professor at Oxford, who showed
that the brain gradually increases in complexity as we
ascend the animal series, and considered that only
by comparative studies could its anatomy be prop-
erly understood. He renamed and rearranged the
cranial nerves, separating the nervus intercostalis or
sympathetic from the vagus. In his enumeration he
333
Anatomy, History of
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
made ten pairs, including the first cervical nerve, and
classing as single pairs the auditory and facial, and the
glossopharyngeal, vagus, and spinal accessory. He
described the optic thalamus and the corpus striatum.
Osteology continued to be assiduously cultivated.
It is from Ole Worm (158S-1054), professor at Copen-
hagen, that the Wormian or sutural bones are named;
and Clopton Havers (1692), an English physician,
demonstrated the structure of bone (Haversian canals
and systems). The structure and action of muscles
were specially investigated by Stensen, by Borelli
(1608-1679), the celebrated mathematician, and by
Hooke. (1635-1703), who was the first to recognize
the primitive fibrillar.
Knowledge of the viscera was essentially advanced
by John Mayow (1643-1679), of Oxford, who was the
first to recognize the true function of the lungs; by
Theodor Kerckring of Amsterdam (1640-1693), who
described the valvuke conniventes (plicae circulares
BNA) of the intestine; by Jacques Benigne 1 Winslow
(1669-1760) of Paris (foramen of Winslow, posterior
ligament of knee joint), and by James Douglas (1675-
1742) of London (Douglas' pouch of peritoneum,
semilunar fold, etc.).
The eye was specially examined by several investi-
gators, who considered it because of its interest as an
optical instrument. Among these we may mention
Johann Kepler (1571-1630) the astronomer, who
demonstrated the optical properties of the crystalline
lens and showed that it is not the seat of vision, as was
held by Hippocrates; Christoph Scheiner (1575-
1650), who demonstrated the image on the retina and
studied the movements of the pupil and the mechanism
of accommodation; Descartes, who compared the
eye to a camera obscura and suggested that accom-
modation for near vision was effected by changing the
figure of the lens; and Edme. Mariotte (1620-16S4),
who discovered the "blind spot" of the retina.
Another great result of the introduction of the mi-
croscope was a vast increase in the knowledge of
living things. The source of life and the "vital
principle" had been favorite subjects for speculation
among the philosophers and poets of antiquity, and
the generation of living from non-living matter was
held to be demonstrated by many ordinary phe-
nomena, such as the appearance of maggots in putrefy-
ing meat and of other insect larva? in stagnant water.
Aristotle even held that tadpoles and snakes were
generated from the mud of the Nile. As the laws of
development were more carefully studied this
"generatio oequivoca" was controverted, especially,
in the case of the chick, by Harvey and Fabricius.
Francesco Redi (1626-1694), professor at Pisa, by a
scries of well-conducted experiments, showed that
meat did not produce maggots when protected from
flies by means of gauze. The doctrine, discarded
for the higher forms of life, was, however, revived by
the discoveries of the microscope. Antony van
Leeuwenhoek of Delft (1632-1723) discovered that
stagnant water and infusions containing animal or
vegetable matter swarmed in a few days with minute
forms of life, the "infusoria." Nicolaas Hartsoeker
(1656-1725) extended these researches and held that
the air was filled with animalculce that settled upon
plants and from them passed into infusions. This
view, afterward conclusively demonstrated by Spal-
lanzani, became known as "panspermatism" and is
the forerunner of the modern "germ theory."
The eighteenth century was distinguished rather
for its work in elaborating and defining what had
previously been discovered than by any great ad-
vances in anatomical science. A few remarkable
men appeared who advanced generalizations that
were afterward to bear fruit, but they were in advance
of their time and had but little influence upon their
contemporaries. The microscope was still very
defective and felt to be a wholly untrustworthy
instrument when used with the higher powers.
Speculation was rife, and in the absence of direct
observation philosophers held the field. Of these
should be mentioned Leibnitz (1646-1716), who
shares with Newton the renown of inventing calculus.
He supposed the universe to be composed of monads,
minute, invisible, intelligent constituents of all
bodies and beings, that in the human body are gov-
erned by a central monad, the soul; as the universe
is governed by a central monad, God. He was a firm
believer in the uniformity of action of natural causes
and the author of the celebrated aphorism, " Natura
mm facit saltum." Like Paracelsus, Georg Ernst
Stahl (1660-1734) scorned anatomy and physiology,
holding the soul, which eludes investigation, to be
the supreme principle. This doctrine was termed
"animism." Friedrich Hoffmann (1600-1742), pro-
fessor at Halle, taught that the medulla oblongata is
the chief reservoir of collier, an extremely volatile
principle circulating through the vessels and nerves.
David Hartley (1705-1757) considered the white
medullary substance of the brain as an organ for the
secretion of thought, and explained mental processes
as caused by minute vibrations (vibratiuncles) of
particles in the nerves. Cabanis (1757-1808) had a
similar idea, which he expressed rather grossly, com-
paring the brain to the stomach, sense impressions
to food, thought to excrement, etc. Theophile de
Bordeu (1722-1776) considered the stomach, heart,
and brain as the "tripod of life," regulating the other
organs. Finally, there should be mentioned among
these speculative philosophers Lorenzo Oken (1779-
1851), who held that the entire organic world origi-
nated from sea slime formed of microscopically
minute vesicles. This is apparently an adumbration
of Bathybius and the cellular theory, but appears to
be only a chance hit not derived from observation.
Oken also independently worked out a theory of the
veretebral character of the skull, but many of his
speculations were wild and absurd.
It is in this century that we first see the influence
of speculative ideas concerning the relation of the
structure of man to that of other organisms — ideas
which have had a powerful effect upon modern ana-
tomical science. The collection of materials in the
field of biology had become so vast that some system
of classification became necessary. Steps toward this
were first taken in the realm of plants by John Ray
(1628-1705), who revived the Aristotelian idea of
genera and species and established, as criteria for
species, immutability of form and non-fertility with
other species. Tournefort (1656-1708) gave a clear
definition of a species as individuals having some dis-
tinct characteristic, and of a genus as a collection of
species resembling each other in structure. It was,
however, Karl von Linne 1 (Linnaeus, 1707-177S), of
Rashult in Smaland, Sweden, professor at Upsala,
who, by inventing the binomial nomenclature and
applying it widely to all known species of animals
and plants, finally established firmly the idea of
the immutability of species. He even extended
his system of classification to diseases, of which he
described three hundred and twenty-five genera.
His earlier view was that all the species of plants
and animals were immutably created at the be-
ginning of the world, but in his later works he ap-
pears to admit a certain amount of variation. In the
classification of Linne man was placed at the head of
the order Primates, comprising also apes, lemurs, and
bats. The recently discovered orang was classified
in the same genus with man as "Homo silvestris,"
and the great naturalist declares himself unable to
discern any character by which the great apes can be
made genericallv distinct from man. The race of man
himself, Homo sapiens, he subdivided into six groups:
H. fcrus (savage); H. americanus; H. europceus; H.
asiaticus; H. asser(negroes) ; H. monstrosus (abnormal).
The great rival and contemporary of Linne 1 was
George Louis Leclerc de Buffon (1 707-1 7S8), director
334
REFERENCE HANDBOOK <»!•' THE MEDICAL SCIENCES
\ li:itom> '. Illstnry of
if the Jardin du Roi at Paris, and a very prolific
.vriter in all domains of natural history. At Brsl
Buffon agreed with Linne - a- to the immutability of
species, but in his studies of comparative anatomy
met with many difficulties, and soon admitted thai
uany variations may arise through changes of climate,
uod, etc.; that t he least perfected species disappear:
finally he even hinted at the possibility that all
ies of animals were derived fr a common stock.
While he by no means clearly worked out these ideas,
contain the germs of the doctrine of adaptation
the survival of t he tit test, and it is evident that he
realized that genera and species are merely human
ons made for convenience in classification.
In like manner we may discern in Maupertuis (1698-
. president of the Berlin Academy and a cele-
d mathematician and astronomer, an approach
ome modern theories of heredity and variation.
Il<' held that all matter has psychic qualities, that the
particles of the embryo retain and transmit impressions
derived from their parents, chance combinations pro-
ducing differences which accumulate and thus form
new species. It was Charles Bonnet (1720-1793)
who lirst advanced the view that animals can be
arranged in a graded series with man at the head.
His conception of the series was that it was necessarily
linear. Erasmus Darwin (1731-1S02), the grand-
father of the great naturalist, anticipated some of the
- that afterward made his grandson famous.
He showed that the structure of animals changes be-
se of their exertions, that many of these changes
are transmitted to posterityl transmission of acquired
characters), and that many anatomical features of
man indicate that his primitive attitude was quadru-
pedal. Reasoning from such data, he maintained that
all warm-blooded animals may have arisen from a
single living filament which improved and transmitted
its improvements to posterity.
The poet Goethe (1749-1S32) was also famous for
his morphological researches. Besides the remark-
able contribution to botany in which he advanced the
thesis of the metamorphosis of leaves into parts
of the flower and fruit, he also suggested that the
skull of vertebrates is composed of modified vertebrae.
He recognized the importance and significance of
vestigia] structures and predicted that a premaxillary
bone would be found in the human fetus.
Widely different from these philosophers who sought
to explain the complicated structure of man by the
at ions of natural forces, were the views of the
eminent philosopher and metaphysician Emmanuel
Kant (1724-1804), who held that a great gap neces-
sarily exists between organic and inorganic matter,
and that while in the latter natural causes prevail, the
former is the product of preordained intention, be-
yond the power of man to comprehend.
Closely allied with these theories of the relation of
the structure of man to that of other animals are
others regarding his individual deve'opment. The
imperfections of the microscope and of technical
methods prevented an accurate determination of the
earlier embryonic stages, and it was imagined that all
details of the completed structures are prefigured in
the impregnated ovum. This necessarily involved
the conclusion that the successive generations of
offspring must also be prefigured in the same manner.
Burden accordingly declared that the semen of Adam
must have contained the archetype of all mankind.
The whole of the past and present organic life of the
globe was held to have been contained in miniature in
the first created beings, the successive individuals
merely developing by growth from these preformed
and structurally complete miniatures. This is the
celebrated theory of preformation or encasement (cm-
boitcment) which has profoundly interested biologists
for the past one hundred and fifty years. It was to
this unfolding that Bonnet applied the term evolution,
a meaning widely different from that now in common
use. Tin' great weigh) of authority at lirst favored
this view, ami the celebrated Albrechl von Haller
1708— 1777), professor al Berne and Gottingen, a most
learned and acute observer, whose reputation v. a
greal that he practically controlled the scientific
thought of the latter half of the eighteenth century,
i alculated the number of i a ed in the
ovary of Eve, the mother of mankind, placing it at.
about 200,000,000,000.
In opposition to this is the theory of post -format ion
01 i pigenesis advanced by Hippocrates and Aristotle,
according to which the human body develops from a
structureless blastema by successive stages not qi
sarily resembling the adult individual. This view
was revived by Caspar Friedrich Wolff (1733-1794),
who published, in 17.V.I, his now celebrated thesis,
"Theoria Generationis," which contained an account
of accurate observations showing that the organs
of the body are not preformed in the fetus, but devel-
oped from membranous sheets (the blastodermic
membranes of later embryologists) which are them-
selves composed of globules or vesicles (cells). These
ideas were not accepted by the anatomists of his day.
Opposed to them was the great authority of Haller,
who declared, "Nulla est epigenesis," and they were
quite forgotten until fifty years later when Meckel
called attention to them. Wolff's name remains to
us in the Wolffian bodies or primordial kidneys.
It was from Haller that the doctrine of the vital and
animal spirits finally 7 received its coup de grace. By a
series of most carefully conducted experiments he
showed that there exists in living tissues a property
of motility independent of the nervous or vascular
systems. This he termed irritability. Haller is often
justly termed the father of physiology, which he him-
self loved to call living anatomy. His works abound
in most excellent anatomical observations. He was
an indefatigable worker, dissecting as many r as four
hundred bodies in the space of seventeen years. He
classified structures according to their properties and
thus paved the way for Bichat. Many structures
have been at one time or another named after him.
He was the first to describe the pes hippocampi.
The doctrine of spontaneous generation continued
to be discussed. Antonio Maria Valsalva (1666-1723)
professor at Bologna, a pupil of Malpighi and a teacher
of Morgagni, finding that living forms still appeared in
liquids that he had heated and then enclosed in vessels,
concluded that they must have originated from the
liquids themselves; but this was overthrown by the
experiments of Lazzaro Spallanzani (1729-1799),
professor at Reggio, Modena, and Pavia, who repeated
the experiments with careful precautions and failed
to produce life. It was to this observer that we owe
the demonstration that the spermatozoa are the con-
stituents of semen essential to fertilization. He
showed that the fluid obtained by filtering semen has
no effect, also that no exhalations from semen can
cause impregnation. Thus were overthrown some
of the more fanciful hypotheses of generation.
Throughout the eighteenth century we find isolated
attempts at generalizing the complicated structures
of the body under a few categories. Almost equally
famous with Haller for his erudition was Hermann
Boerhaave (1668-1738), professor at Leyden, a
skilful anatomist who discovered the sudoriparous
glands of the skin, and held that the elementary
structures composing the body are vessels and fibers.
In Andreas Bonn (173S-181S), professor at Amster-
dam, we discern a decided advance. He endeavored
to show that ail structures can finally be reduced to
membranes. Of these he made four classes: (1) the
tectorial — skin, mucous membrane, etc.; (2) fibrous —
fascia and aponeuroses; (3) synovial, and (4) serous.
The real founder of the science of general anatomy
was, however, Marie Francois Xavier Bichat (1771-
1S02) who, by his philosophical insight and great
energy in research, demonstrated the existence of the
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Anatomy, History of
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
tissues of the body in a complete and definite manner.
Distrusting the microscope, he made his distinctions
by the chemical, physical, or vital properties of each
tissue — i.e. by its behavior with various reagents;
by its color, density, etc.; or by its alterations in
health and dN^ase. Of these tissues or tissue systems
he made twenty-one, such as the cellular, the osseous,
the fibrous, the arterial, etc. As these tissues are
everywhere the same, their diseases must be identical,
hence this separation is a proper foundation for
pathological anatomy. He considered life to be the
composite effect of the separate interaction of the
forces resident in these tissues. He died at the early
age of thirty-one, from overwork and disease con-
tracted in the putrid dissecting rooms of his day,
having effected the greatest advance in anatomical
knowledge made since the time of Vesalius.
The anatomy of diseased organs was, prior to
Bichat, specially investigated by the illustrious
Giovanni Battista Morgagni (1682-1771), who may
be said to be the founder of pathological anatomy.
He was likewise an ardent investigator in the normal
field, as will appear from the large number of struc-
tures that bear his name; as the caruncula Morgagni
(middle lobe of prostate), frenum Morgagni (near
ileocecal valve), fossa Morgagni (navicular fossa of
urethra), hydatids of Morgagni (on fimbria of
Fallopian tube), columns of Morgagni (in the rectum),
etc., etc.
Closely allied to pathological anatomy is surgical
anatomy, which made many important advances.
John Hunter ( 172S— lTO^), an indefatigable investi-
gator, is said to have dissected some thousands of
bodies. It is to him that we owe a demonstration
of the ease with which collateral circulation is estab-
lished after ligation of vessels, and the reparative
significance of inflammation. He also appears to
have been aware of the law of recapitulation in em-
bryology, by which the fetus of an animal successively
passes through forms resembling creatures below it
in the animal scale. During thirty years he worked
at collecting a museum illustrative of comparative
and human anatomy and pathology, which finally
comprised some fourteen thousand specimens. It is
still considered one of the best extant. It is from
him that is named the canal traversed by the femoral
artery under the adductor magnus.
Other workers in surgical anatomy were Antonio
Scarpa (1752-1832), professor at Modena (Scarpa's
triangle, fascia, nerve, ganglion, etc.); Franz Caspar
Hesselbach (1759-1816), professor at Wiirzburg
(Hesselbach's triangle); Antonio de Gimbernat
(latter part of 18th century), professor at Barcelona
(Gimbernat's ligament-ligamentum lacunare BNA).
Certain beginnings were now made in the study of
the comparative anatomy of the races of man. Pieter
Camper (1722-1789), professor at Amsterdam,
Franeker, and Groningen, was a widely learned man;
at once an anatomist, a zoologist, a geologist, and an
artist, he published in almost every branch of natural
history essays remarkable for their originality and
research. He was the first to show that the hollow
bones of birds are connected wdth their respiratory
apparatus, and wrote an important memoir on the
anatomy of the orang, showing that that animal
could not be considered as degenerated from man, as
had been supposed by some. Noticing that painters
took no pains to depict the special physiognomy of
the races of mankind, he began to study racial types
and invented the celebrated "facial angle," formed
by a plane tangent to the most prominent points of
the forehead and face and another drawn through the
auditory openings and the ate of the nose. He found
that this angle gradually decreases as we descend
througli the animal kingdom, and concluded that the
different races of mankind might be distinguished by
it. A wider examination has shown that this view
is incorrect, but the method instituted by him of
336
measuring portions of the skull by means of angles
has been extensively used in other directions.
Another famous angular measurement was that of
the occipital angle of L. J. M. Daubenton (1716-1799)
the curator and almost the creator of the splendid
museum of the Jardin des Plantes. This was intended
to measure the inclination of the foramen magnum
which also varies very much in the animal scale, and
has relation to the erect position of the body.
The comparison of crania was systematically pur-
sued by Johann Friedrich Blumenbach (1752-1840)
professor at Gottingen, who prescribed for the exam-
ination of skulls certain positions that are still in use.
He possessed a very large collection of crania, and made
important generalizations regarding the races of men.
While considering these as very numerous, he grouped
them in five principal divisions, to which he applied
designations that held for more than a century. Three
of these he considered primary: the Caucasian, Mon-
golian, and Ethiopian; two secondary or intermediate:
the American and Malayan.
Logically connected with this, although not devel-
oped until early in the nineteenth century, was the
curious doctrine widely known as "phrenology,"
though its founder, Franz Joseph Gall, of Baden
(1758-1828), called it "organology." Gall was by
no means ignorant of the gross anatomy of the brain,
but he knew nothing of its histology and supposed
the white substance to be equally active with the
gray in intellectual processes. Noticing the conver-
gent fibers of the corona radiata, he conceived the idea
that the brain was a series of pyramidal "organs''
whose bases were superficial and whose apices were
deeply buried in the medulla oblongata. These
organs correspond to supposed functions of the mind,
concerning which he appears not to have had any well-
digested philosophical ideas. He believed that he
had demonstrated that the organs varied in size
and external prominence in different individuals to
such an extent that character and mental aptitudes
could be told by palpation of the protuberances of
the cranium, due allowance being made for the natu-
ral bony prominences common to all skulls. Gall
described twenty-seven organs, his pupil Spurzheim
added ten more, and his followers in this country
increased these by six, making a total of forty-three.
When the nerve cells were discovered and it was
seen that the gray matter was the effective working
element of the brain, and that the surface projecting
externally was only a small portion of the cortical
area, phrenology had no longer a satisfactory reason
for existence as a doctrine. However, it retained a
considerable vogue for a time, being especially diffused
by peripatetic lecturers whose influence in spreading
among the people a knowledge of the physical basis
of mind was often considerable.
A correct appreciation of some parts of the body was
now greatly aided by the advancement of chemistry.
Oxygen was discovered by Priestley in 1774. Its
true significance was not, however, understood until
the demonstrations of Lavoisier (1743-1794), who
showed its importance in combustion and respiration.
Antoine Francois de Fourcroy (1755-1809) was the
first to investigate the composition of organic prod-
ucts, and William C. Cruikshank (1745-1800) dis-
covered urea.
The delimitation of the organs of the body in the
living, which may be said to be an anatomical art,
was now much advanced by the invention of per-
cussion by Joseph Leopold Auenbrugger (1722-1S09),
a physician of Vienna.
The advances made in the knowledge of the grosser
structures were rather refinements upon what was
already roughly sketched out than incursions into
new fields. Josias Weitbrecht (1702-1747) was the
author of a celebrated treatise upon syndesmology
that contains the elements of our knowledge of
ligaments to-day. Exupere Joseph Bertin (1712-
REFEKKNCK HANDBOOK OF THE MEDICAL SCIKNCES
Anatomy, History of
1781), an academician of Paris, described the ilio-
femoral ligament, the sphenoidal turbinated bones,
and the septa of the kidney. Bernhard Siegfried
Ubinus (Weiss, 10 { .)7-177(>), professor at Leyden,
itly improved myology by the publication of
ni'licvni plates showing the muscular system
lm ,st carefully delineated. He was also the first to
demonstrate by injections the relation between the
[at ystems of the mother and the fetus.
In the vascular system considerable advances were
made. Gilbert Breschet (1784-1845) described the
veins and canals of the diploS; William Hunter
(1718-1783). brother of John and lecturer at Middle-
go pital, demonstrated the arrangement of the
lymphatics and showed them to be absorbents. He
llso the author of a paper on the anatomy of the
id uterus which is the basis of all subsequent
descriptions. It particularly notes the changes in the
cavity and the formation of the decidua. He care-
fully described the descent of the testes, and his name
is often coupled with the round ligament of the uterus
ami the gubernaculum testis. William Hewson
(1739-1774) also contributed to knowledge of the
ils and lymphatics, tracing them in birds,
3, and reptiles. Paolo Mascagni (1752—1815)
fessor at Siena, Pisa, and Florence, published
studies of the lymphatics which were after-
ward continued by Vincenz Frohmann (1794-1837),
professor at Heidelberg and Louvain.
In the realm of the nervous system considerable
lines were made. Giovanni Maria Lancisi
1654-1720), the teacher of Morgagni and physician
to I he Pope, described more carefully than had been
■ before some features of the brain (nerves of
Lancisi = longitudinal striae of corpus callosum).
Alexander Monro I. (1097-1767), one of Boerhaave's
favorite pupils, professor at Edinburgh, gave an
excellent description of the bones and nerves; but
his fame was eclipsed by that of his son, Alexander
Monro II. (1733-1817), also professor at Edinburgh,
who was especially noted for his work in the anatomy
> >f the brain (foramen of Monro = foramen inter-
ventriculare, sulcus of Monro = sulcus hypothal-
amicus). He was the first to attempt a description
of all the bursa? mucosae of the body. Felix Vicq
d'.Vzyr (174X-1794), an academician of Paris, demon-
strator at the Jardin du Roi, and excellently versed
in comparative and veterinary anatomy, also studied
the brain and added to our knowledge of the minute
structure of the white and gray matter (line and
bundle of Vicq d'Azyr). Johann Christian Reil
1 1759-1813) first described the insula or island of Reil.
Luigi Rolando (1773-1831), professor at Turin,
distinguished himself by careful researches in both
the brain and spinal cord (fissure, gelatinous sub-
stance, and tubercle of Rolando).
The cranial nerves received renewed attention.
It was Johann Jacob Huber (1707-1778), professor
al Gottingen and Cassel, who clearly pointed out the
error of Willis in placing the suboccipital nerve
among the cranial nerves, though Haller also com-
mented upon this. Carl Samuel Andersch (1732-
1777) distinguished from each other for the first time
the ninth, tenth, and eleventh nerves, and discovered
the petrous ganglion. Samuel Thomas Sommering
(1755-1830) is credited with being the first to sepa-
rate the facial and the auditory nerves, thus estab-
lishing the twelve cranial nerves as we now enumerate
them. This enumeration, however, was really first
definitely proposed, in 1794, by Johann Christoph
Mayer (1747-1801). The little intermediary nerve
that makes the tale of the cranial nerves absolutely
complete was first described by Heinrich August
Wrisberg (1739-1808), professor in Gottingen, who
also made other discoveries, his name remaining in the
medial cutaneous nerve of the arm, in the cuneiform
cartilages of the larynx, and in a small ganglion in the
substance of the heart.
Vol. I.— 22
Johann Friedrieh Meckel (1721-1771), the In I
in a succession of famous anatomists of the name,
professor at Berlin, gave especial attention to the
trigeminus and facial nerves and was the first to
describe the sphenopalatine and submaxillary
ganglia and the space in the dura mater that con-
tains the semilunar ganglion of the trigeminus. The
latter struct ure appears to have been firsl recognized
as a ganglion by .1. Lorenz Gasser, of Vienna, about
17"i(l. Meckel had previously described it as a
tenia nervosa, and Vieussens as a plexus ganglioni-
formis, and Eustachius had figured it in his cele-
brated plates. It was named by Hirsch as the gang-
lion Gasserianum, in honor of his illustrious master.
The tympanic nerve and the superior ganglion of
the glosso-pharyngeal nerve were first described by
Johann Ehrenritter (about 1775), professor at Vienna,
although from the exact researches of L. L. Jacobson
(1783-1843), professor at Copenhagen, the nerve
usually bears his name. To the latter author is
also ascribed the discovery of the vomeronasal
organ in the nasal fossa- of the sheep and of its
vestiges in man.
A physiological discovery of much importance in the
elucidation of the anatomy of the nervous system was
that of the distinction between the motor and the
sensory roots of the spinal nerves made by Georg Pro-
chaska, (1749-1S20), professor at Prague. This was
afterward clearly established by Magendie (1783-
1855) and by the Edinburgh anatomist, Sir Charles
Bell (1774-1S42), who also showed conclusively
the motor function of the facial nerve. The long
thoracic nerve is often called the external respira-
tory nerve of Bell.
In the anatomy of the viscera there should be men-
tioned the investigations of Lorenz Heister (1083-
1758), professor at Altorf and Helmstadt, who dis-
covered the spiral valve in the neck of the gall-bladder;
Antoine Ferrein (1693-1709), professor at Paris,
who investigated the kidney and the organs of voice;
Joseph Lieutaud (1703-1780), who described anew
the bladder, mentioning for the first time the trigone.
He was famous in pathological anatomy, publishing
a work based on the examination of twelve hundred
bodies. Johann Nathanael Lieberkiihn (1711-1765)
was famous for injected preparations and made
some excellent observations on the minute anatomy
of the intestinal mucous membrane, including the
villi and glands. Johann Christian Rosenmiiller
(1771-1820), professor at Leipsic, investigated the
nasal fossce and the annexes of the uterus. The
anatomy of the vocal organs was also investigated
by Denis Dodart (1634-1707), who held that the
voice was caused by a vibration of the air in the larynx,
while Ferrein held that it was due to a vibration of
the vocal chords. Giovanni Domenico Santorini
(1081-1737) also paid especial attention to the
organs of voice, to the emissary veins of the cranium,
and to the muscles of the face (corniculate cartilage
of the larynx, emissaria Santorini, musculus riso-
rius Santorini of the face).
The anatomy of the eye was especially enriched by
important discoveries during this period. Francois
Pourfour du Petit (1604-1741) paid especial attention
to the lens and described the zonular spaces in the
suspensory ligament, often called the canal of Petit.
Jacob Hovius, a Dutch anatomist (about 1702),
appears to have discovered the choriocapillary layer
of the chorioid, afterward accredited to Ruysch
(tunica Ruyschiana). He also described the vena?
vorticosas. Eberhard Jacob von Wachendorff dis-
covered the pupillary membrane in 1740, though it
is possible that it may have been previously known
to Albinos. Jacques Rene 1 Tenon (1724-1816), an
academician at Paris, described the fascial attach-
ments of the eyeball more accurately than had been
heretofore done (capsule of Tenon = fascia bulbi,
space of Tenon = interfaseial space). In some cases
337
Anatomy, History of
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
controversies arose as to priority of discovery: the
separable posterior elastic layer of the cornea, which
was apparently seen and described by Benedict
Duddell, an oculist of London in 1729, was rediscovered
by Jean Descemet, professor at Paris (1732-1810),
and at about the same time by Pierre Demours
(1702-1795), demonstrator at the Jardin du Roi.
The most important treatise on the anatomy of the eye
that appeared during the 18th century, and the basis
of all that has since been published, is that of Johann
Ciottfried Zinn (1727-1759), professor at Gottingen
(zonule of Zinn = ciliary zonule, ligament of Zinn =
common tendinous ring of ocular muscles). Felice
Font ana (1730-1805), professor at Pisa, described
the attachment of the iris and the trabecular tissue
since known as the spaces of Fontana (spaces of the
angle of the iris BNA). Johann Gottfried Berger
(1059-1736) was probably the first to indicate the
existence of the orbicular fibers of the iris.
The profound and exact researches in the anatomy
of the internal ear made by Domenico Cotugno (Cotun-
nius, 1736-1822), professor at Naples, were probably
the most significant of any made in this region during
the century. He also investigated the pathological
anatomy of the skin, and was the first to demonstrate
by boiling the existence of albumin in urine. His
name remains in the liquor of Cotunnius or perilymph,
the aqueduct of Cotunnius (aqueductus vestibuli),
and the nerve of Cotunnius (nasopalatine nerve).
The great advance in the anatomical sciences during
the nineteenth century has been primarily due to
what may be termed their secularization, that is to
say, to the extension of research by placing it in the
hands of all students inclined to pursue it. At the
beginning of the century the old method of teaching
by means of demonstration was still almost every-
where pursued. Students were rarely able to dis-
sect, and the procuring of bodies for anatomical
purposes was beset with difficulties. In 1S27 the
University of Edinburgh, with nine hundred students,
made dissection compulsory, and this excellent
example was immediately followed by London, Liver-
pool, and Dublin.
In consequence of this the demand for human
cadavers was greatly increased and the price so en-
hanced that unscrupulous persons were tempted
to procure them by surreptitious means. Grave-
robbing, hitherto exceptional, now became common,
and in every large city where medical schools flourished
there became established a set of ruffians who
made it their business to supply dissecting tables
with bodies ruthlessly torn from the graves to which
they had been consigned by sorrowing friends. The
large iron cages built over many graves and the for-
midable enclosures of cemeteries of this period in
England and Scotland testify to a widespread fear,
and a glance at the literature of the early part of
this century will show what an effect this ghastly
practice had upon the popular mind. It would be
easy to give many authentic examples which were
not confined to disreputable law-breakers; for, led by a
youthful love for adventure or perhaps in some cases
by a real zeal for knowledge, bands of students and
even of professional men broke into cemeteries and
violated graves. The law required of medical practi-
tioners a competent knowledge of anatomy, and yet
denied them the means necessary for attaining it.
The absurdity of such a position was not realized
until the shocking disclosures of the trial of Burke
and Hare at Edinburgh in December, 1828. It
was shown that these scoundrels had murdered at
least sixteen persons for the purpose of selling their
bodies. Similar cases were those of Bishop and
Williams, executed in London in 1831. Bishop had
followed his nefarious trade for twelve years, and had
sold to the colleges at least five hundred bodies, some
of which were doubtless those of murdered victims.
The excitement occasioned by these trials led to a
parliamentary inquiry and the passage of the War-
burton anatomy act, August 1, 1832, which legalized
dissection under certain restrictions and provided
for turning over to the medical schools the bodies of
unclaimed paupers. Upon the continent of Europe
similar regulations had already been for some time
established.
The cooperation of a large number of additional
workers led to greater precision in all anatomical
work, to the accumulation of a vast body of additional
facts, and finally to a more comprehensive and satis-
factory generalization of the principles that underlie
and affect anatomical structure. The idea of the
filiation and progressive development of all organic
beings — considered a wild and unsubstantial hypothe-
sis_ during the eighteenth century — has constantly
gained in weight and force by increasing knowledge
of existing forms — comparative anatomy; of extinct
forms — paleontology; and of individual development
— embryology. This increase in knowledge has been
greatly aided by improvement in the microscope,
which has become an efficient and reliable instrument
of research, and by the application of chemical
and mechanical methods to the preparation of (is-
sues for microscopical examination, which met I:
are grouped together under the term of microscopical
technology.
Fragments from the writings of some of the ancient
philosophers, notably Empedocles and Democritus,
show that ideas of adaptation and mutability of
forms had occurred to them. So, too, we find traces
of such speculations in the writers of the last century:
Buffon, Erasmus Darwin, and Goethe. These ideas
were developed into a coherent system by Jean
Lamarck (1774-1829), professor of natural history
at the Jardin des Plantes and one of the most acute
minds of his age. His force as a naturalist will be
appreciated when we recall that we owe to him the
division of animals into vertebrates and invertebrates,
and also the separation of the groups Crustacea,
arachnida, and annelida. He invented the term
biology for the sciences of life, though Treviranus
suggested it during the same year (1802). In his
" Philosophie zoologique" is first scientifically stated
and systematically supported the mutability of species
and their origin by adaptation. Lamarck thought
that such changes were caused mainly by the needs
of the animal and the use and disuse of organs, be-
coming cumulative in the race by the transmission
of acquired characters. For these changes three
factors — space, time, and matter — are requisite;
and these are produced by nature in unlimited
quantities, hence the multiplicity of organic forms.
He was the first to conceive the ancestral record of
man as a branching tree instead of a series of ascend-
ing steps. The formation of the lowest animal
from mucilaginous matter was suggested by him,
prior to Oken's sea-slime theory.
The views of Lamarck, although widely accepted in
a modified form by the naturalists of to-day, were
very coldly received at that time. This was largely
due to the powerful opposition of Georges Cuvier
(1769-1832), professor at the Musee d'Histoire Nat-
urelle at Paris, and the foremost naturalist of his time.
He greatly advanced knowledge of both living and
extinct forms of animal life and has been called (he
founder of comparative anatomy and of paleontology.
From a modern point of view his work is most con-
tradictory. While he founded a true natural system
in zoology, showing that the forms of the animal
world may be reduced to a few distinct types, he yet
upheld the absolute fixity of species. While investi-
gating fossil remains with an ardor and success
never before equalled, he advanced the theory that
all organic living forms had been repeatedly wiped
out of existence by unexplained cosmic catastrophes.
In opposition to the epigenetic views of Wolff and
others, he also upheld the evolution of the embryo
338
REFERENCE HANDBOOK OK Till': MEDICAL S< II \< is
Anatomy, History nf
•om a preformed miniature. Throwing the weight
f his great influence against the development theory,
e was able, owing to the lack of data, to discredit
almost wholly, and to control the trend of biolog-
■al thought, until after the middle of the century.
A growing revolt against this domination was, how-
ver, caused by the advances of knowledge. Gott-
["reviranus of Bremen t,1777) a remarkable ape-like skull associated with
bones of the cave bear; at La Naulette, in Belgium,
near Dinant, a fragment of a human jaw of very low
type, together with bones of the mammoth and
woolly rhinoceros; and in 1886, in the grotto of Spy,
bank of the Orneau River, in Belgium, were un-
earthed two skeletons associated with similar bones
of extinct animals. Other discoveries of like nature
were made in Kent, England, near Prague, in Mor-
avia, in the Balkan peninsula, in Bohemia, at many
places in France, in the pampas of South America
and in Patagonia, the latter being associated with
the huge carapaces of the glyptodon. The most
remarkable find of all was, however, that of Dr.
Eugene Dubois, who during explorations in Java
(1890-1S95) discovered a fossil skull cap, a femur, and
two molar teeth embedded in rock and associated
with the remains of extinct animals belonging to the
Pliocene epoch. These remains appear to be transi-
tion forms between those of the higher apes and the
lowest existing men.
At the time of Darwin the intimate structure of the
cell was little understood or considered, but the re-
searches of Oscar Hertwig, van Beneden, Flemming,
and man}' others have shown the great importance
of this branch of anatomical inquiry, and it is about
the problems here found that the principal discus-
sions of more recent times have been raised.
In 1S66 the lowest form of a cell was considered to
be simply a mass of structureless protoplasm endowed
with vital properties, the cell membrane and the
nucleus having been successively dismissed as non-
essential elements. Protoplasm was considered as a
homogeneous, semi-fluid substance, with little or no
trace of organization, whose chemical constitution
was only approximately known, but was believed
to I"- highly complex. S • daring spirits ventun d
to surmise that it might be possible to produce pro-
topla in iii i he chemical laboral ory.
The elaborate investigations of recent jreai have
shown the futility of such a pretension, indicating
that protoplasm has an almost inconceivable insta-
bility, that it differs in composition in different o
in different parts of the body, and under different
stimuli. The substance of which it is composed are
among the most complicated known to chemistry,
and there is reason t<> suppose that in the living body
it is much more unstable than in tlie cadaver. There
appears to be a wide distinction to be made between
those organic bodies thai an- products of secretion
and excretion such as sugar, starch, and urea, and
the organi ed bodies such as the different proto-
plasms that are produced by the slow and peculiar
processes of biotlC growth.
The morphological character of protoplasm has
also been found to be much more complicated than
had been supposed. First granules were observed,
then striations, then vacuolizations. The appear-
ances being often contradictory and varying much
with varying conditions, it is not surprising that they
have led to diverse views as to its structure. These
are by no means settled as yet, but they may be
succinctly grouped as follows:
1. The reticular theory, first brought clearly for-
ward by Karl Heitzmann (1830-1896) in 1873, and
still maintained, under various modifications, by a
great number of cytologists. According to this all
protoplasm is composed of two substances: a more
solid network — the cytoreticulum or spongioplasm,
and a more fluid interstitial substance — the cyto-
lymph, hyaloplasma, or enchylema. The granules
observed in cells, when not foreign inclusions or
masses of dead protoplasm, are the intersections of
this network. There is no doubt but that the great
majority of cells, when fixed by the usual methods
and treated with staining reagents, show some traces
of such a reticulum.
2. The filar theory, advocated by Flemming (1887),
who by studying cells unaffected by reagents concludes
that they are structurally composed of free thread-,
the cytomitom, not combined into a reticulum but
often containing numerous nodosities.
3. The granular theory, first brought forward by
Arndt, and afterward advocated by Altmann (1S87).
This supposes protoplasm to be formed of granula-
tions embedded in a homogeneous basis substance.
These granules, Altmann's bioblasts, are held to be
themselves morphological units of a still lower order
than the cells. Special means of preparation are
required to demonstrate them.
4. The alveolar theory of Biitschli (professor at
Heidelberg, 1S89) and his school, who hold that the
structure of protoplasm is like that of a fine viscous
froth or foam, that is to say, composed of alveoli
with extremely thin walls. This structure is be-
lieved to be a physical consequence of the peculiar
conditions of tension and surface flow possessed by
the substance, and may be imitated by emulsions of
thickened oil and various salts. This view attempts
to explain the appearances of the other theories
either by the optical conditions under which the
alveoli are viewed or by the reaction of the reagents
employed. To demonstrate the alveoli in perfection
the protoplasm must be living and the best attain-
able optical conditions secured. Under such cir-
cumstances they are seen actively to change their
forms and relations to each other, these phenomena
being so swiftly evanescent that it is impossible
accurately to represent them in a camera drawing — ■
while the hand is tracing one part another is rapidly
changing.
Attempts have been made to reconcile these con-
341
Anatamy, History of
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
flirting views. Kolliker considered that the different
appearances are due to different states of develop-
ment of the protoplasm. In young eells he supposes
it to be homogeneous and without strueture, formed
of a mixture of various substanres possessing different
degrees of contractility and solubility in acids. In
such a medium vacuoles will sooner or later appear.
If these are numerous and small the structure of the
protoplasm will be alveolar; if the walls of the alveoli
break it becomes reticular; if the threads of the retic-
ulum break it beromes filar. Doubtless this view
may assist us in certain interpretations, yet it must
be said that recent observations tend to show that
even the earliest ovum does not possess a homogene-
ous structure.
Among the differentations of the protoplasmic
mass of the cell the nucleus has been the most sueces-
fully investigated. Flemming was the first to show
that it contains several substances, one of which,
from its affinity for coloring matters, he named chro-
matin. The phenomena of indirect cell division
(mitosis, karyokinesis) were first connectedly observed
by • Anton Schneider in 1873, although Balbiani
and others had previously noted separate stages.
The nuclear reticulum which plays so important a
part in this process was first noticed by Frommann in
1865. The fragmentation of this into separate sec-
tions or chromosomes was shown by Balbiani and
Carnoy. These again are separable into granular
bodies, to which the name of chromomeres has been
given by Fol (1891). Other investigators who have
greatly advanced the knowledge of this process are
Strasburger, Boveri, Oscar and Richard Hertwig, van
Beneden, and Rabl.
The great advance made in theoretical chemistry by
the atomic theory of Dalton (180S) is well known.
Although atoms and molecules have never been seen,
the hypothetical constitution of bodies supposed to
be formed by them is now definitely stated and pre-
dirted. The signal success of this theory has led to
similar speculations regarding the constitution of pro-
toplasm. The first of these was that of Niigeli, who
in 18S4 propounded his micellar hypothesis. Accord-
ing to this, protoplasm is composed of an immense
number of "micellae," elementary units of a crystal-
line character, far beyond the limits of microscopic
vision. As molecules are formed of atoms, so micellae,
units of a next higher order, are formed of molecules.
The peculiar physical properties of protoplasm, its
imbibition of water, etc., are explained by the arrange-
ment and affinities of the micellae.
The hypothesis of Nageli has led the way to a num-
ber of others of a similar character by De Vries,
Wiesner, Haeckel, Hertwig, Roux, and Weismann.
These have generally been directed toward explaining
by this means the phenomena of heredity. By a
series of beautiful experiments (1884) Oscar Hertwig
has apparently succeeded in showing that the phys-
ical substance upon which this transmission of
characters depends is the chromatin found in the cell
nucleus.
Starting with this for a basis Weismann, in various
publications from 1875 to 1894, has propounded an
elaborate theory by which he attempts to explain
the phenomena of hereditary resemblance. Accord-
ing to this, the chromatin is a structure of almost
inconceivable architectural complexity. In his sys-
tem Weismann, following Nageli, names it "idio-
plasm," and supposes it to be composed of groups
called "ids," corresponding to the chromomeres seen
under the microscope. During the segmentation
of the ovum or any other cell division, these ids also
divide, so that they are distributed to each cell
throughout the body. The ids are themselves com-
posed of lesser units called "determinants," because
they determine the histological character of the cells
within which they dwell. There are as many kinds
of determinants as there are parts of the body cap-
342
able of being different. Determinants are themselves
compound, being composed of "biophores," or ulti-
mate units that control the vital activities of the cell.
In the segmentation of the ovum certain of the cells
divide so that each division retains exactly similar
determinants and thus remains equal in capacity to
the original ovum. Such duplicative division pro-
duces the tissue denominated "germ plasm" found
in the nuclei of the germinal cells of the ovary and
testis. Other of the cells divide by a differer,
division by which determinants of different kinds
are sorted out, grouped together, and relegated to
different cells. These are the somatic or body o
from which the general tissues of the body are formed.
Since the germ cells and body cells separate at the
earliest stage, no modification of the latter can affect
the germ plasm, hence it is denied that characters ac-
quired by the body cells can be transmitted to the off-
spring.
The arrangement of the determinants by which
bodily characters are affected is caused by architect-
ural peculiarities inherent in the original ovum and
spermatozoon. There is contained within each fecun-
dated ovum an entirely closed system of interrelated
units that can develop only in a predetermined
manner. We have here a reappearance, under a new
form, of the theory of preformation sustained by
Haller and combated by Wolff.
Closely connected with this is His's theory of ger-
minal foci (1S74), which supposes that within the
protoplasm of the egg the different parts of the
adult body are prelocalized and distinct, although
not yet formed. To this view many eminent anato-
mists and embryologists have adhered, but recent
experiments of Hertwig, which show that when the
segments of a dividing ovum are shaken apart each
may develop into a complete individual, appear to
have dissipated these ingeniously devised theories
as a puff of wind lays prostrate a house of cards.
Among the most ardent and indefatigable investi-
gators in the domain of general anatomy during the
nineteenth century should be mentioned Jacob Henle
(1809-1S85), professor at Zurich, Heidelberg, and
finally at Gottingen. He was among the first to
realize the importance of the cell theory and did much
toward its establishment. He also advanced what
may be called the modern theory of pathological
processes, holding that they are merely modifications
of those of health.
Albert von Kolliker (1817-1905), professor at Zurich
and Wiirzburg, also had great influence upon research
in both general anatomy and embryology.
In comparative anatomy should be mentioned
Richard Owen (1S04-1892), the author of a curious i
theory of the vertebral origin of the skeleton, Thomas
H. Huxley (1S25-1S95), who by his writings and
researches greatly furthered the doctrine of devel-
opment by descent, and Carl Gegenbaur (1826-1908),
at Heidelberg, whose researches upon the morphology
of the head and limbs are justly famous. In tie
paleontological field great advances were made by
the discovery in America of fossil deposits of large
extent, and of importance far surpassing anything
hitherto known. These were especially investigated
by Joseph Leidy (1S23-1891), professor in the
University of Pennsylvania; by O. C. Marsh (18
1899), professor in Yale University; Edward D. Cope
(1840-1S97), professor in the University of Penn-
sylvania; Henry F. Osborn (born 1S57), professor in
Columbia University; and G. Baur, professor in the
University of Chicago. They have thrown great
light upon human anatomy by confirming in a
striking degree the theories of development and the
morphological laws controlling the formation of the
human body. The anatomy of the head, of the teeth,
and of the vertebral column have been especially
elucidated.
The advancement of embryology has been greatly
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Anatomy, History of
.icicd by the anatomists whose names have been
ilready given, and also by Johannes MUller (1801-
S58), professor at Bonn and Berlin, one of the most
earned men of his day, who especially studied the
levelopment of the genital organs, the glands and
he peritoneum; and by Francis M. Balfour (1851-
1882), professor at Cambridge, whose tragic death
,n the Aiguille Blanche of the Alps was a great loss
,i science. An important advance in the establish-
nent of the phyletic history of man and other ani-
mals was made in 187-1 by Ernst Ilaeckel (born Is:: I),
ifessor at Jena, who attempted to show that all
mimals possessing a food sac or intestinal cavity
descended from a common ancestor (as yet hypo-
thetical), the Gastrcea, and that this is represented
mbryological development by a stage which may
rmed the gastrula, formed by the invagination
il the blastodermic vesicle or blastula. This, the
elebrated gastrwa theory, aroused violent opposi-
tion from the opponents of the development hypoth-
n is now quite generally accepted.
The details of the intracellular phenomena of the
fecundation of the ovum were first observed by Oscar
Hertwig in 1N75, in the transparent eggs of the sea
urchin.
In osteology during the century there should be
noted the work of John Goodsir (1S14-1S67) on the
structure and development of bone, the discovery of
the lacuna? and canaliculi by Purkinje, and that
of the osteoblasts by Gegenbaur (1864). William
Sharpey (1S02-18S0) did much to increase the knowl-
edge of the structure and development of bone, as
also did Oilier and Robin in France and H. Muller,
Gegenbaur, and Kolliker in Germany. The archi-
tecture of the spongy tissue of bones received especial
attention from Jeffries Wyman of Harvard University
and from H. von Meyer of Zurich. The develop-
ment of limbs in vertebrates has been studied by R.
Wiedersheim of Freiburg, the form of the skull by
R. Virchow of Berlin, and Welcker of Halle, the
general morphology of the skull by Gotte of Stras-
burg, and Gegenbaur (1SS7). The vertebral column
has been investigated by Cunningham of Dublin and
Edinburgh, by Merkel and Henke.
Arthrology has made important advances in pre-
cision and knowledge of the mechanism of joints.
Especially worthy of mention are the works of Meyer
of Zurich, Braune of Leipsic, Morris of London,
Heiberg of Christiania, and Bigelow and Dwight of
Boston. Bland Sutton, of London, has investi-
gated the nature of ligaments, Bernays, of St. Louis,
the development of joints.
In myology the minute anatomy of muscle has
received particular attention, but cannot yet be said
to be settled, as a knowledge of the intimate structure
of protoplasm is as yet imperfect. Bowman, in
1M0, was the first to throw any clear light on the
subject. He was followed by Leydig and Cohn-
heim. Afterward Krause (1S6S) brought forward
his theory of "muscle caskets," Hensen showed new
details, and Merkel, Engelmann, Rollett, and Ranvier
respectively advanced their views. The general
morphology of the muscular system has been ad-
vanced by the researches of Huxley, Humphry of
Cambridge, and Gegenbaur: the study of muscular
anomalies has been pursued by Wenzel Gruber,
Theile, Wood, Macalister, Struthers, Chudzinsky,
Testut, and Ledouble. Special groups of muscles
have also received attention, Fiirbringer studying
those of the larynx and of the shoulder, von Bardele-
ben and Cunningham those of the hand and foot,
Ruge those of the face.
In the earlier part of the century the structure of the
capillaries was not understood, it being believed that
they were interstitial lacunae without walls. The
demonstration of their independence and continuity
was first made by Treviranus in 1836. The endothe-
lium of the blood-vessels was first demonstrated by
llenle in 18158. Johannes Muller made important
discoveries in the vascular system, especially that
of the helicine arteries of erectile tissue, in 1835.
The study of the formed elements of the blood has
greatly advanced, but still leaves much to be desired.
The blood platelets (hematoblasts or third corpus-
cles) were first discovered by Max Schultze in 1865,
and were afterward studied by Bizzozero, Hayem,
and Pouchet. Ehrlich (1891) carefully studied the
white corpuscles and separated them into varieties
that appear to be of great value in pathological anat-
omy. Neumann and Malassez have investigated
the origin and formation of the red blood corpuscles.
Other angiological studies of note are those of His
and Bernays on the development of the heart, of
Braune on the venous system, and of Bardoleben,
Thoma, and Bonnet on the variations in the struct-
ure of the vascular walls. Heubner (1872) greatly
elucidated the vascular distribution in the brain.
A profound study of vascular anomalies has been
made by W. Krause.
The lymphatics, formerly believed to originate from
the interstitial spaces of connective tissue (Ludwig,
Brtickc), were shown by Recklinghausen, Kolliker,
and Ranvier to form a closed system. The true nature
of the lymphatic glands has been elucidated by the
labors of His, Klein, Ranvier, and others. Impor-
tant investigations into the origin of the lymphatics
have been made by P. C. Sappey (1810-1896),
professor at Paris, and by Ranvier; in this country
by Sabin and Huntington. The connection of the
serous cavities of the body with the lymphatic system
has been studied by Schweigger-Seidel, Klein, Tour-
neux, and Kolossow. The lymphatic tissue of the
throat (pharyngeal tonsil, etc.) has been the object
of research by Killian, Stohr, Flesch, and others; and
von Davidoff and Klatsch have shown that the lym-
phoid tissue of the intestine, the mesenteric glands and
the spleen are all developed from the intestinal epithe-
lium, a conception which Stieda has extended to
the thymus gland. Finally Heidenhain has demon-
strated the wandering of leucocytes throughout
glandular tissues.
The convolutions of the brain were thought by the
earlier anatomists to be arranged without definite
order, being compared to the irregularities of the coils
of the small intestine. In 1855 Gratiolet (1815-
1865), by a careful comparative study of the brains of
man and animals, showed that the apparently con-
fused complexity can be reduced to a comparatively
simple plan. This was further developed by Pozzi,
Leuret, Ecker, Giacomini, and others.
Closely connected with this is the discovery, first
made by Broca, that certain motor and sensory
activities can be located in definite areas of the cere-
bral cortex. He noted that the loss of articulate
speech known as aphasia is usually associated with a
lesion of the left third frontal convolution (Broca's
convolution). This doctrine has been greatly ex-
panded by the experiments of Fritsch and Hitzig,
Ferrier, Charcot, Horsley, and many others, and
has become of great diagnostic value. It will be per-
ceived that it only superficially resembles the older
doctrine of Gall and Spurzheim.
The nerve cells in the brain and spinal cord were
probably first mentioned in 1S33 by Christian Gott-
fried Ehrenberg (1795-1876), professor at Berlin.
They were better described, however, in 1836, both
by Gabriel Gustav Valentin (1810-1883), professor at
Berne and Johannes Evangelista Purkinje (17S7-
1869), professor at Breslau and Prague, from whom
are named the cells or corpuscles of Purkinje in the
cerebellum. They were for some time misunderstood,
Magendie, in 1839, describing them as infusoria.
Their nervous character was established in 1844 by
Robert Remak (1S15-1865), professor at Berlin,
who at the same time suggested their connection with
nerve fibers.
343
Anatomy, History of
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
The first to note the axis cylinder process or axone
of nerve cells appears to have been Rudolph Wagner
(1805-1864), professor at Gottingen, but its true
nature was first shown by Otto F. K. Deiters (1S34-
1863), professor at Bonn, in 1S65. Although unable
to demonstrate its actual continuity with the axis
cylinder of a nerve fiber, he gave to the process the
name by which it is generally known and also named
the protoplasmic processes or dendrites. The con-
nection of nerve cells with nerve fibers remained for
some time obscure. Counting experiments instituted
by Benedict Stilling (1S10-1S79), of Kassel, showed
that at the level of the second cervical nerve there are
found not more than half the number of fibers that
reach the cord by the posterior nerve roots.
Since the direct methods of anatomical research
failed to resolve the complex architecture of the
nervous system, recourse was had to the indirect
methods of physiological experimentation, patholog-
ical lesions, and embrvological development. In
1S33 Marshall Hall, of London (1790-1857), first
clearly demonstrated reflex movements and the in-
dependent action of the spinal cord and the medulla
oblongata already surmised by Descartes. As early
as 1839 Nasse snowed that wdien a nerve is cut its
peripheral end degenerates, and in 1S50 this was more
carefully studied by Augustus Waller (1S16-1S70),
who showed that it is always the end that is detached
from the nerve cell that perishes, and that when the
posterior root of a spinal nerve is severed between its
ganglion and the cord, an area of ascending degenera-
tion will ascend to the cord. In 1852 Ludwig Tiirck,
of Vienna (1810-187S), showed that a descending
degeneration might occur from a lesion of the cord.
Following these were similar experiments by Burdach,
Goll, Charcot, Vulpian, Kahler and Pick, Gowers, and
many others, showing the results of lesions of the
brain or cord in producing degenerations.
Connected with these are the experiments instituted
by Bernhard von Chidden (1824-1886), professor at
Munich, which showed that when, in a young animal,
a nerve root or nerve tract is torn away or injured,
the group of cells with which it is centrally connected
suffers atrophy. Among the experimenters in this
line of work there may be mentioned Hay em, Forel,
and von Monakow.
Many investigators had noticed in sections of the
brain and cord a difference in coloration between
fetal and adult structures which varied with advanc-
ing growth. It was Paul Flechsig, of Leipsic, who
first showed that this was due to the fact that different
groups of fibers develop their myeline sheath at
different epochs, and that by this means certain
fiber systems can be made out that correspond in
general to the results obtained by degenerations.
Improvements in technical methods have made this
means of research comparatively easy, and such in-
vestigations of the nervous system have been carried
on by Bechterew, Edinger, Darkschewitch, and
others.
Observations in the comparative anatomy of the
nervous system have also led to important results.
In this field should be mentioned the names of
Theodor Meynert (1S33-1S92), professor at Vienna;
Mathias Duval, professor at Paris; and E. C. Spitzka,
professor at New York.
By a combination of these methods there was
gradually evolved a general idea of the architecture of
the central nervous system. This was, however,
necessarily somewhat vague and indefinite as long as
the minute anatomical relations could not be actually
demonstrated. Power to do this was at last obtained
by the improvement in technical methods which
made it possible to demonstrate the finest ramifi-
cations of the nerve cells. Hence arose the neurone
theory as advanced by Ramon y Cajal, van Gehuchten,
LenhossiSk, and supported by Kolliker and Waldeyer.
According to Joseph von Gerlach (1820-1896), the
protoplasmic processes of cells unite in a fine anasto-
motic network upon which all sensory impressions
are discharged and from which, in some mysterious
manner, all motor impulses originate. This doctrine
was opposed by His (1886) on embryological grounds,
by Forel (1887) on pathological grounds. The new
methods of staining showed that nerve fibers are
merely elongated processes of nerve cells. This led
to the conception that the nervous system is composed
of histological units (termed neurones by Waldeyer)
which may comprise a cell body with its extensions,
the protoplasmic processes, the axis-cylinder proc-
esses, the nerve fibers, and end organs. These units
are held to be substantially independent of each
other, never uniting to form a plexus. This view,
which has been used with great success to explain the
architecture of the nervous system, is now accepted
by most histologists. It should be noted, however,
that the recent investigations of Apathy (1S97) on
the earthworm and leech seem to show that it may
require some modification.
The internal structure of the body of the nerve o I!
has also received much attention and is still under
discussion. Remak and Max Schultze considered it
fibrillary with interstitial granules. Franz Nissl, by
peculiar methods of staining, thinks that he has
shown that the structure is not fibrillary, but that
two substances exist, one being masses of stainablc
granular substance (Nissl bodies, tigroid substance),
the other unstainable. He considers that different
types of cells exist distinguishable by the arrangement
of these substances.
The finer anatomy of the organs of special sense is
almost wholly the work of the nineteenth century.
The development of the eye has been most carefully
investigated by Hatschek, Ayers (of Cincinnati), and
Kupffer, and the curious discovery was made by
Ahlborn (18S6), Rabl-Ruckhard, and Spencer that
the pineal body is a vestige of an eye that occurs in
some reptiles. The anterior limiting layer of the
cornea was discovered by Sir William Bowman (1816-
1892), professor at London; the scleral sinus (canal of
Schlemm) was first described by Schlemm (1830), but
was previously known to Albinus, as appears from a
catalogue of his preparations. The ciliary muscle
was first demonstrated as such (in the sheep) by
William Clay Wallace, of New York (1835). Bruckc
(1S46) and Bowman (1847) afterward described it.
Even the deep circular fibers whose discovery is
usually ascribed to H. Miiller appear to have been
seen by Wallace. The action of the muscle was first
correctly described by Helmholtz (1851). A contro-
versy of long standing regarding the existence of a
dilator muscle of the iris appears to have been
settled affirmatively by the researches of Kolliker,
Retzius, and Juler. The structure of the lids, the
lacrymal apparatus, and the retina was specially
studied by H. Miiller (Midler's muscle, Mailer's
fibers). The layer of rods and cones (Jacob's mem-
brane) was discovered by A. Jacob, of Dublin, in
1S19, the visual purple by Boll in 1876. Recently
important comparative studies of the retina have
been made by W. Krause and Ramon y Cajal.
The complicated anatomy of the ear has been the
object of research by a great number of observers,
only a few of whom can be mentioned here. The
membrana tvmpani has been carefully investigated
by O. Shrapnell (1832), Jos. Toynbee (1851), Rudingei
(1S67), and Prussak (1868); the anatomy of the
auditory ossicles and the mechanism of their move-
ments has been elucidated by Helmholtz (1868); the
Eustachian tube has been specially studied by
Rudinger, Huschke, and Kolliker; the membranous
labyrinth by Botteher, Henle, and Hyrtl. The organ
of Corti was discovered by the Marchese di Corti in
1851. Additional details of its structure were estab-
lished by E. Reissner (1854), M. Claudius (1856).
O. Deiters (1S60), and Hensen (1863). Special
344
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Anderson Mineral Springs
memoirs on the anatomy of the car have been written
l,v Ku.liiiH'T, Wharton Jones, Ayers, and Retzius.
' \. in ihc organ of smell, the olfactory cells were
described by Max Schultze in 1862, although
they were probably seen previously by Ecker and
Eckhardt. The tracing of the olfactory fibers has
been effected by the labors of Kelliker, van Gehuch-
ten and Ram6n v Cajal. The general anatomy oi
the passages of the nose has been carefully studied by
Zuckerkandl.
The taste buds of the tongue were discovered by
Schwalbe, of Strasburg. in isii7, and at aliont the
same time by Loveh, of Christiania.
The tactile corpuscles of the skin were first seen by
Meissner and Wagner in 1852, the end bulbs by W.
Krause and Kolliker 1 1850- 1858). Pacini discovered
the corpuscle's that bear his name in 1836, and they
described by Vater somewhat later (1841).
Other nerve endings recently described are those of
Golgi in tendons (1878), those of Ruffini in the fingers
(1893), and the "muscle spindles" of Kiihne and
others found in the substance of muscle.
Most of our accurate knowledge of the minute
iv of the viscera was developed during the
nineteenth century. Space does not permit a
detailed account of the discoveries, but mention
lid be made of the work of Neumann, Lent, and
Rose upon the teeth, and the attempts of Ryder,
iorn, Cope, and others to obtain from paleonto-
logical and other evidence a connected account of
the mechanics of their development; of the work of
Flemming, of Kiel, upon the principles of gland con-
struction; and that of Heidenhain of Breslau upon the
anatomy of the pancreas, the salivary and peptic
glands." Investigations of the development of the
peritoneum by Toldt, His, Treves, Brosike, and
others have greatly aided our comprehension of that
plicated structure. The liver has been specially
investigated by Kiernan, Hering, Heidenhain, and
Kanvier, and in the anatomy of the kidney great
advances have been made. Henle described the
loops of the uriniferous tubules that bear his name
in 1862, Ludwig and Heidenhain have done much in
elucidating the structure of the tubules, and Disse
has studied the changes of the epithelia during
tion.
In the generative organs of the male researches in
spermatogenesis have been carried on by La Valette
St. George, Nussbaum, Flemming, Hermann, and
Minot. In the female organs Pfliiger and Waldeyer
have investigated the structure of the ovary and the
development of ovules, and Nagel has given the first
exact description of the human ovum. The situation
of the pelvic organs has been carefully determined by
B. Schultze and Waldeyer, and an exhaustive exami-
nation of the human placenta has been made by
Minot. Frank Baker.
Anderson Mineral Springs. — Lake County, Cali-
fornia.
Location. — Twenty-one miles from Calistoga,
five miles from Middletown, and ten miles from the
Great Geysers.
Access. — By stage from Calistoga and Clovendale.
The worshipper at nature's shrine, the lover
of grand and varied scenery, will find all that
can be desired at the Anderson Mineral Springs.
The mountain stage ride is one of the most picturesque
in the State. The ever-changing picture of hill and
dale, of forest and shrubbery, and of brooks with
ferns and mosses forms one of those pleasing pano-
ramas which the spectator loves to recall in after days.
The springs with the hotel and cottages are located in
a cosy nook in a large canon surrounded by forests
abounding in picturesque waterfalls. The cool,
leafy dells and the profound silence and solitude of the
dense forests form an ideal combination to at I ract the
early morning rambler. The atmosphere hen' is
balmy and exhilarating and free from humidity.
Fish and game abound all the year round. The
accomi lations offered to guests are excellent, and
\ isitors come by the thousand to enjoy the numerous
advantages of the spot. There are nine important
springs. The principal drinking-spring, known as the
Cold Sulphur, is located about 250 yards from the
hotel. It »;e .-.nil.. I'd ic 1 1; n ,: :..
and found by him to have the following composition:
One United States Gallon Contains:
Solids. Grains.
Sodium chloride. 1 -09
Sodium carbonate. . '' -''
Sodium sulphate 6. 18
Potassium salts Traces.
Magnesium carbonate 11 .73
Magnesium Bulphate 16.95
I 1 1, i inn carbonate 20.40
Calcium sulphate 9.10
Ferrous carbonate 0.46
Arsenious salts Traces.
Silica 2.45
Organic matter Traces.
Total 77 . 03
Cub. in,
P , f Carbonic acid gas 243 50
aseS I Sulphurated hydrogen 4-20
This may be characterized as a saline sulpho-
carbonated water. It has been found very beneficial
in chronic skin diseases of strumous and syphilitic
origin. In liver, stomach, kidney, and bowel troubles,
in uterine and ovarian engorgement, and in glandular
congestions, the water has also proved to be of much
value. It is aperient, diuretic, and alterative in its
action.
The "Sour Spring" is one of the few California
mineral springs containing free sulphuric acid. Its
sour taste was formerly supposed to be due to alum,
but the following analysis by Mr. George E. Colby, of
the California State University (1889), shows that no
alum is present:
One United States Gallon Contains:
Solids. Grains.
Sodium chloride . 08
Sodium sulphate . 49
Potassium sulphate ®'„
Magnesium sulphate 4.76
Calcium sulphate 2.07
Ferric sulphate . 63
Aluminum sulphate* 7.11
Boric acid (with spectroscope) Strong test.
Lithium (with spectroscope) Well-marked test.
Ammonia (manganous sulphate) . 33
Silica 3 - 94
Organic matter Traces.
Total 20.28
A considerable quantity of free sulphuric acid was
also revealed by the analysis. The temperature of
the water is 64.3° F. It possesses tonic, astringent,
and gently laxative properties, and has proved bene-
ficial in hemorrhages from the lungs, menorrhagia,
and dyspepsia. .
Another valuable water is the " Iron Spring. 1 he
following is Mr. Colby's analysis, made in 1S99:
* A microscopic examination of the residue obtained by slow
evaporation fails to show characteristic crystals of alum.
345
Anderson Mineral Springs
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
One United States Gallon Contains:
Solids. Grains.
Sodium chloride 0.18
Sodium bicarbonate 0. 19
Sodium sulphate 3.42
Potassium sulphate 1 . 17
Maunesium sulphate 7.36
Calcium sulphate 10.88
Calcium phosphate 0.15
Ferrous carbonate 1.18
Alumina 0.93
Boric acid (with spectroscope) Strong test.
Lithium (with spectroscope) Well-marked test.
Manganous carbonate 177
Silica 4 . 22
Organic matter Small quantity.
Total 31.45
Free carbonic acid gas, 25. SO cubic inches.
Temperature of water, 124° F.
This is a mild calcic-chalybeate water. It possesses
tonic and slightly laxative properties, and is useful in
anemia and chlorosis and in conditions requiring
restorative agents.
Among other valuable springs in this group may be
mentioned the "Cosmopolitan," an excellent drinking
water, but possessing slightly laxative properties; the
"Bellmer" Spring, a light saline-sulphur water; the
"Magnesia Spring" (known also as "Father Joseph's
Spring"), a rich saline water having valuable laxative
properties; and the "Hot Sulphur and Iron" or bath-
ing spring. These last waters have a temperature of
14.5.5° F., and have been found very beneficial in rheu-
matism, chronic joint swellings, constipation, and skin
diseases. It is claimed that the inhalation of the hot
sulphurous steam of- this water is highly useful in cases
of chronic bronchitis, incipient phthisis, and catarrhal
affections of the nose and throat. There are good facili-
ties for bathing. The incrustations formed by the hot
sulphurous vapors on the surrounding rocks are
gathered and powdered and used in cases of chronic
nasal catarrh, as well as for acute coryza and phar-
yngitis. This powder represents all of the solid
mineral ingredients found in the water.
The pine forests, elevation, and climate are of
undoubted value in many subacute and chronic
diseases. Emma E. Walker.
Andral, Gabriel. — Born in Paris, France, on Novem-
ber C, 1797. He took his medical degree in 1821.
In 1830 he was made Professor of Internal Pathology
at the Faculty de M<§decine; and in 1839 he accepted,
as the successor of Broussais, the Chair of General
Pathology and Therapeutics. He performed the
duties of the latter professorship, during a period of
twenty-seven years, with such distinction that he was
spoken of on all sides as one of the celebrities of
French medicine. He was also one of the attending
physicians of La Charity Hospital. In 1S66 An-
dral retired from practice and from his professorial
duties. He died on February 13, 1S76.
Andral 's lectures were characterized by the ex-
traordinary clearness with which he described all the
phenomena of disease; and this same characteristic
will be found to exist in his published writings.
Of these the two most celebrated are: "Clinique
Medieale," Paris, 1823-1S27, five volumes; and
"Traite d'Anatomie Pathologique," Paris, 1X29,
three volumes. A. H. B.
Andre, Nicholas. — Born in Dijon, France, October
15, 1704. He practised for years in Paris and
vicinity, serving as surgeon to the Maison royale
de Saint-Cyr and as charity surgeon to the parish of
Versailles. His chief claim for recognition rests upon
the fact that he invented urethral bougies. Trea-
346
Uses published: "Dissertation sur les maladies de
l'uretre qui ont besoin de bougies"; "Observations
pratiques sur les maladies de l'uretre, et sur plusieurs
faits convulsifs, et la gudrison de plusieurs maladies
chirurgieales, avec la composition d'un remede propre
a r ^:--: • -> ■,*-♦■
• ! Wt--'. i> ••
m
Fig. 198. — The Spinal Cord from a Case of Pernicious Anemia,
Showing the Microscopic Appearances of the Gray Mutter in the
Section Shown in Fig. 197. The small veins are surrounded by
distended perivascular spaces and one of them is filled by a
recent thrombus.
The word "febrile" it will be remembered was in-
corporated into one of the many descriptive names
given this disease. It is well to remember that fever
is not an uncommon associate of the more advanced
stages of pernicious anemia. It is impossible to state
any symptom-complex, even in the fairly well ad-
vanced stage of the disease. The important point,
here, then, is that many other conditions are suspected
before pernicious anemia is thought of. This can-
not be emphasized too strongly — a heart lesion or
nephritis or both, in the majority of cases, are thought
to be the real malady. Perhaps there are two reasons
for this — first, because of the signs pointing to both the
heart and the kidneys, and second, because it is
hard for the physician to believe that one can walk
about with a blood count of two and one-half million
349
Anemia, Pernicious
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
cells. The asthenia is usually taken to mean cardiac
incompetency but it is often the only symptom of a
profound toxemia with a red cell count of a little over
2,000,000 and the physician is thrown off the right
track by the fact that the patient "walked in."
This feature of the disease is probably due to the
fact that the destructive process has worked grad-
ually. A healthy individual whose blood is re-
duced suddenly by hemorrhage to 2,000,000 is pros-
trated. Here is another evidence that the disease is
of long standing before symptoms develop. It per-
haps also shows that the reserve power of the blood,
like that of many other organs, is considerable.
Though there are symptoms in the advanced cases
pointing to the heart (palpitation, dyspnea), these are
not as marked as in primary cardiac disease, because
the patient with pernicious anemia rarely attempts
violent physical effort. .Some patients become very
irritable and being unwilling to seek medical aid as
they "feel perfectly well," it is through a member of
the family that the report of this irritability reaches
Fig. 199. — The Spinal Cord from a Case of Pernicious Anemia,
Showing Combined Degeneration of the Posterior and Lateral
Tracts. The direct pyramidal tracts are also considerably degene-
rated.
the physician. This indefinite group then com-
pletes the symptoms of the early and advanced stage.
Vertigo, headache, numbness and tingling of the
extremities may be complained of, and in the late
stage of the disease symptoms referable to the lo-
comotor apparatus may be present. The patient
may stagger slightly, the Romberg symptom being
present in some cases, so that tabes and multiple sclero-
sis are diagnosed without the blood condition being
suspected. Such cases have had the diagnosis of
pernicious anemia made at autopsy only. Hemor-
rhage from the nose and other mucous membranes is
not common. Even at the late stage asthenia stands
out as the distinctive feature but this, like many of the
associated symptoms, is quite compatible with other
suspected pathological conditions, especially cardiac
and renal disease. Perhaps a distinctive feature is to
be found in the fact that these people even after or
during a second or third paroxysm of profound
anemia often insist upon continuing at work or
business and declare they "feel quite well." This
is unlike the cardiac or renal case. There are then
no symptoms peculiar to pernicious anemia.
Physical Signs. Early Stage. — As with symptoms
we know practically nothing definitely of the early
signs of pernicious anemia.
Advanced Stage. — When, however, the patient
begins to fail he seeks medical aid. This may be
during one of the paroxysms of profound blood defici-
ency, at which period a positive diagnosis can be
made by the blood picture. If, however, the patient
is seen between such paroxysms he may present fea-
tures of a secondary anemia, such as occurs from any
of the common causes — neoplasm, nephritis, cardiac
disease, etc. The retention or excess of fat will be an
important sign. The patient looks ill — very ill — yet he
is fat; the fat can often be picked up from the abdomen
in thick folds. The shoulders, the thighs, and the hips
are well rounded out with fat. There may be small
aggregations of fat in the abdominal wall and about
the back and neck, which might be mistaken for
metastases from a malignant growth. A wasting
disease (especially portal cirrhosis) in those who have
been obese but who are beginning to lose flesh, will
sometimes present this appearance of fatness, but
such cases usually show the lineae atrophica? in the
skin of the hips and shoulders and axilke, due to the
loss of the underlying fat. Pernicious anemia patients
are well rounded out with fat even at death. This
point has not been sufficiently emphasized in the
clinical description of this disease. In marked con-
trast with this plump body is the yellow white color,
which gives at once the impression that the individual
is ill; the yellow tinge may be detected in the con-
junetme and by pressing a glass slide upon the lips.
The appearance is not, as a rule, that of jaundice; one
must look closely for the yellow color, compare it with
a normal skin, and so convince himself that it is not
the dough white of chronic Bright's, the brown white
of cachexia, or the light yellow of hepatic disease.
The blue veins stand out markedly in the yellow
white skin; the conjunctiva? as mentioned above show
a light yellow tinge, this differing from the blue
white sclera of chlorosis which resembles the white of a
hard-boiled egg. The conjunctiva; in chronic Bright's
have a pearly whiteness and do not show any yellow
tinge. A fairly plump but ill-looking individual with
a yellow white skin, slightly yellow tinged conjunctiva,
complaining of an undefined sense of weakness, but
who is able to walk about and insists on continuing
with his business (provided this does not involve
more than ordinary physical effort) is one in whom
pernicious anemia should be strongly suspected. It
is between paroxysms, when the blood picture is not
typical, that these clinical features are of great value
in detecting pernicious anemia.
The heart examination reveals very little or no
displacement of the impulse or enlargement of the
heart, but the systolic thrust may be rather widely
distributed and fairly forcible. The blood pressure
is exceptionally low. At times there may be an
acceleration and slight irregularity of the heart. The
systolic impulse may be quite marked at the base of
the heart and in the arteries of the neck. The jugu-
lar pulsations are visible but are not systolic in time
(negative pulsation). This combination of pulsa-
tions requires careful analysis — at times with the
sphygmograph — in order that very misleading con-
clusions be not accepted. Their explanation has been
set forth by many observers, but neither experimental
nor postmortem findings have placed these explana-
tions beyond the realm of theory.
To one not familiar with the blood in this disease it
might be inferred that a blood examination would at
once settle the diagnosis. The whole blood picture
will be discussed later, but it is well to state here that
all the foregoing symptoms and signs may be present
and yet the blood present a reduction only in the
hemoglobin and red cells, an irregularity in size and
shape and a high color index and possibly an increase
in the small mononuclear cells. In other words, the
blood, if seen between the paroxysms of profound
anemia, is by no means distinctive. The high color
index and the increased small mononuclear percentage
would be in favor of the diagnosis of pernicious anemia,
and should prompt the physician to keep the patient
under close observation. The paroxysmal character of
the blood changes in this disease is frequently over-
looked and cannot be too emphatically insisted upon.
350
REFERENCE HAXDBOOK OF THE MEDICAL SCIENCES
Anemia, Pernicious
\ systolic murmur is usually hoard along the .sternum,
,i the apex or above the clavicU — often at all these
es with equal intensity. Diastolic murmurs are
r ,l,.,l, but their cause is a matter of surmise a no
ms postmortem have been found to account
o. Extreme dilatation is rare and tricuspid
insufficiency is uncommon.
It will be seen that the physician could very res son
ably take the dyspnea and asthenia to mean a failing
compensation in a heart too damaged to produce e\ i-
dence of valve lesion. Cases of pernicious anemia are
frequently sent to the hospital with this diagno
lungs with the exception of an occasional pleural
effusion are negative. The liver may be just palpable,
spleen is usually not palpable. The urine is
usually pale, normal in quantity, varying in specific
gravity, and shows serum albumin, distinct trace,
with finely granular and hyaline casts. Examination
of the eye-grounds may reveal large hemorrhagic
3 (flame spots) though personally I have not seen
these except in the far advanced cases. In fact hem-
orrhages (petechias, epistaxis, etc.) are not common
until very late in the disease, then they may be exten-
sive and occur on any of the serous or mucous sur-
3, This, together with slight edema of the extrem-
(usually legs, but sometimes hands, very rarely
face) and occasionally the serous effusions above
referred to and the signs in the heart almost uniformly
to ih" overlooking of the blood condition. If
pallor of the skin has been noted by the physician
he is apt to dismiss this with the statement "second-
ary anemia." It is well to emphasize this, for scarcely
a year passes in a hospital service without the cardial'.
renal, or, as will be seen presently, the nervous signs
and symptoms masking the blood condition and
deferring the diagnosis to a week or more after the
patient's admission and even till his autopsy, as not
Infrequently occurs, when the nervous symptoms
have been those most evident.
In the gastrointestinal tract the absence of hydro-
chloric acid (achvlia) in the gastric contents is an
early and fairly constant finding. This occurs with-
out 'reference to the symptoms and its significance
i< by no means understood. One is tempted into
theoretical explanations which are without foundation
in clinical, experimental, or postmortem evidence
\s a clinical sign, in pernicious anemia, it is very con-
i. but with regard to the stage or severity of the
disease it vields us no information.
The changes in the nervous system (spinal cord)
have been so constant that some writers have incor-
porated these into a definition of the disease. In the
ion on pathology in this article will be found
photographs of sections of the cord illustrating the
histological changes which occur. At what stage in
the disease these changes occur is difficult to deter-
mine. Clinical manifestations are very variable.
The tingling and numbness observed early have been
attributed to the action of toxins upon the cord.
There may be paresthesias and spastic paraplegia and
signs of multiple sclerosis and of tabes, the two latter
diagnoses being made at times without pernicious
niia being discovered till autopsy. There may
aNo lie practically no neurological features clinically,
vet extensive cord destruction be found at autopsy.
That these cord lesions cannot be produced by
ischemia alone seems proven. It is therefore reason-
able to conclude that the destruction is rather the
result of a toxemia than of an anemia, and that the
cord, like the blood and other tissues, is a victim in
the general destruction.
In the late stage of the disease these neurological
features may eclipse all others and the case may go
to autopsy as exclusively a tabes, a multiple or
lateral sclerosis, etc. Neurological features being
present or absent and the diagnosis of pernicious
anemia having been made, there may develop slight
delirium but the asthenia is now so profound that this
i> never active. The patient usually sinks into coma,
in which he may remain for two or three days when
death takes place.
There are no complications of this di \ny
feature such as hemorrhage, eord lesions, etc., which
might lie considered a- a complication is attributed
to the hemolytic and toxic action of the undiscovi
poison assumed to be the active agent in the di •
Relapses and Duration. — A most important
feature of the disease is « tendency t" improvement
with subsequent relapses. The number of relapse i
patient may go through would appear to be limited
in the majority of eases to three. After two
ysms of profound anemia, one has grave doubts re-
garding the outcome of the third. These may be
spread over one year or five, seven, or ten years. I
have seen no case last beyond five years. When a
patient dies, apparently in the first paroxysm, it is
difficult to say whether he has not "worked through"
former attack's without consulting a physician. The
blood changes during and between these attacks will
be now considered.
The Peripheral Blood. — (For a study of the bone
marrow see "The Bone Marrow" under "Pathology"
in this Article, p. 347.) An individual presenting some
or all of the above symptoms and signs may be in one
of several degrees of blood destruction when the physi-
cian sees him. The most distinctive of these are
the following:
I. / ,ind Interparoxysmal Stage. — Moderate
reduction of hemoglobin (oligochromemia) and red
blood cells (oligocythemia) (3,500,000). Color index
high. Variations in size and shape (anisocytosis) of
the red blood cells. Variations in the intensity of the
staining of the red blood cells (polychromatophilia).
Increase in the percentage of small mononuclears
i lymphocytosis).
;
1904
Sept.
Oct.
Nov.
I>ec.
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H^MOGl-OBllC RED CORPUSCLES:
WHITE COHPUSCLES-
Fig. 200. — The Blood Chart of a Case of Pernicious Anemia as
Observed in 1904. The highest lymphocyte count (October 3
1904) was 37 per cent., with a polynuclear neutrophile count,
on the same date, of 55.6 per cent, ' Normoblasts were usually
present; and reached 34 in a slide on October 10, 1904. At this
time 9 meftaloblasts were also found, but thereafter nucleated
red cells were not seen. See subsequent findings on Fig. 201.
II. Anteparoxysmal and Postparoxysmal Stage
(shortly before "and shortly after a paroxysm). — Oli-
gocythemia and oligochromemia marked (2,500,000).
Red cells appear deeply stained. High color index.
Anisocytosis. Lymphocytosis. Polychromatophilia.
i Iccasional nucleated red cells (normoblasts).
III. Paroxysmal Stage. — Oligocythemia and oligo-
chromemia profound (1,500,000). Color index high.
Anisocytosis. Ervthroblasts numerous. Normoblasts
and large nucleated red cells (megaloblasts) present.
Karyokinetic figures may be seen.
IV. Profound Degree of Paroxysmal Stage. Such
as usually precedes a fatal termination. — Oligocy-
351
Anemia, Pernicious
REFERENCE HANDBOOK OF THE MEDCAL SCIENCES
themia profound (1,000,000 or less). Oligochromemia;
hemoglobin may be too low to estimate. High color
index. Anisocytosis marked, stippling. Polychro-
matophilia. Erythroblasts often entirely absent.
Megaloblasts may be present. Free nuclei may be
present. Lymphocytosis.
If a case, presenting either I or II, be carefully
£
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Apr.
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Fig 201 — The Blood Chart in same Case (as shown in Fig. 200) in 1909. The highest lympho-
cyte count was 43 per cent. (July 25, 1909) ; the polynuclear neutrophile count, at the same
time, was 38 per cent. Nucleated red cells were a constant feature, megaloblasts preponderating.
followed, sooner or later a paroxysm will occur and III
will be observed. Figures 200 and 201 show the blood
course of a case over a period of five years. The
clinical error is in failing to follow carefully the case
which presents the apparently unimportant anemia
seen in I. In I, the high color index, the anisocyto-
sis and the lymphocytosis should arouse suspicion of
pernicious anemia. Myelocytes may occur at any
stage, but there is nothing significant in their presence.
The blood plates are said to be increased,
but this is not a constant finding.
From what has been said and from these
charts it will be seen that the diagnosis is
not to be made upon the presence of
nucleated red cells alone. This must be
emphasized, for cases of pernicious anemia
are frequently overlooked during the in-
tervals between paroxysms because the
physician considers the erythroblast an
essential feature of the blood of pernicious
anemia.
Under what circumstances then are
nucleated red cells present or absent in
pernicious anemia? Nucleated cells may
be entirely absent in: (1) The interparox-
ysmal period. (2) The latter part of a
parox3'siii, when the blood has increased
one to two million cells. (3) The early or
mild paroxysms. (4) The graver stages
of the disease and in the later paroxysms;
in these stages the erythrogenetic centers
would seem to have been overwhelmed.
It is well to warn against a poor nuclear
stain which fails to bring out the nuclei,
thus giving the impression of no nucleated
red cells. The nuclei of the white cells
will show whether or not such a stain has
been used. Lymphocytes may be mis-
taken for erythroblasts. (See also below.) Nu-
cleated red cells are usually present: (1) During
the gravity of the paroxysm; in the profound
stages the megaloblast preponderates; as the red
blood count begins to rise the normoblast usually
preponderates. (2) At the beginning of the parox-
ysm.
352
It will therefore be seen that the characteristic
features of the blood in pernicious anemia are:
1. Red cell reduction (oligocythemia) constant.
2. Hemoglobin reduction (oligochromemia) constant.
3. High color index constant. •
4. Nucleated red cells (erythroblasts), gigantoblasts,
megaloblasts, normoblasts, microblasts inconstant.
5. Anisocytosis, giganto-
cytes, mcgalocytes, normo-
cytes, microcytes, poikilocytee
constant.
6. Polychromatophilia in-
constant.
7. Normal or low white
count constant.
8. Deep staining inconstant.
9. Stippling inconstant.
The nucleated red cell, if
present, may be an expression
of the stage and severity of
the disease but never an essi «-
Hal feature on which to base
the diagnosis. One may go
further and say that though
the nucleated red cells may be
present, unless the other char-
acteristics above enumerated
white corpuscles .. are also present the diagnosis,
pernicious anemia, cannot be
made. Nucleated red cells,
then, are distinctive of a grave
anemia only. To determine
the type of the anemia in which such cells are found
the other clinical and blood features of the case must
be taken into account. The small lymphocytes may
be mistaken for a nucleated red cell. It is some-
times quite difficult to determine, certainly, which
cell one is dealing with, but it is safer to decide iu
favor of the leucocyte. The karyokinetic figures seen
n the red cell nuclei are of more interest at present to
the hematologist and the biologist than to the clinician.
s
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RED CORPUSCLES -
- WHITE CQREUSCLES —
Fig. 202. — The Blood Chart of a Case of Pernicious Anemia. The microscopic
examination was typical of pernicious anemia. The highest lymphocyte count
was 58 per cent. (July 18) ; the polynuclear neutrophile count on the same date
was 25 per cent. A strking feature was* the absence, for the most part, of
megaloblasts. Normoblasts were constantly observed, although not in great
numbers. In September, 1909, this case developed marked neurological symp-
toms and was treated exclusively in his final illness for these. Pernicious anemia
was detected at autopsy and his early record (given here) in an other hospital
was looked up. He died December, 1909, in his third paroxysm (probably).
This is true also of the extruding and free nuclei. I
have never found free nuclei without nucleated red
cells as well. The stippling, polychromatophilia, and
deep staining of the red cells are important but not
constant features.
The blood crisis occasionally occurs in this disease.
Within a few hours there may be a shower of nucleated
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Anemia, Pernicious
red cells, mostly normoblasts. The striking point
aboul this crisis is the sudden appearance and dis-
earance of these cells in the periphereal blood.
es, as described by \ on Noorden in 1891 , are
,, n also after profound hemorrhage from traumatic
other causes. There are many theories regarding
the phenomenon, but as yet none of these is sup-
ported by substantial evidence.
It is important to remember thai :
1. Pernicious anemia may occur without nucleated
ills.
2. Nucleated red cells occur more commonly in
this than in any other anemia.
,:. Nucleated cells occur in other diseases than
pernicious anemia.
I. rhe normoblast is the commoner of the nucleated
red cells and its presence either in excess of or to
the exclusion of megaloblasts warrants a better
osis.
5. The presence of many gigantoblasts and me-
galoblasts is of grave significance.
ii. Nucleated red cells occur in showers, which may
appear and disappear suddenly.*
7. The presence of megaloblasts is strong evidence
of pernicious anemia, but must be taken together
with other blood features.
s. Small mononuclears may be mistaken by ex-
perienced observers for nucleated red cells.
Diagnosis. — The diagnosis has been considered
to a large extent in describing the blood picture.
ere are a few conditions, however, which should be
cially mentioned here, namely: (1) Secondary
anemia, especially in the profound stages: (2) Unci-
naria anemia (uncinariasis, hookworm disease, anky-
lostomiasis); (3) dibothriocephalus anemia.
1. Secondary Anemia. — One should remember
that it is generally admitted that a toxin is the factor
in the causation of all anemias, barring only that due
to traumatic hemorrhage, which might be considered
in a class by itself. So far as we know the most
destructive of such toxins is that associated with
pernicious anemia. It therefore is a matter largely
of degree of destruction, when comparing the anemias,
as is the case when considering purpura. Occasion-
ally an anemia due to the toxin of a known disease,
nephritis, carcinoma, portal cirrhosis, tuberculosis,
etc., will reach a stage when the erythrogenetic areas
would seem to fail to respond to the demand for new
cells and the blood features of pernicious anemia will
begin to appear. Rarely, however, is the picture
identical and certainly never is this so in the early
stage. The ravages of the primary disease will
usually have manifested themselves by the time the
blood takes on the features of pernicious anemia.
Oligocythemia and oligochromemia are rarely as pro-
found and the color index is rarely above O.S and
usually about 0.5. Polynuclear leucocytosis is com-
mon and there is a greater tendency to poikilocytosis
than to variation in size. That is, megalocytes and
macrocytes are uncommon. It must be remembered
that nucleated red cells may be found in the severer
M;iges of secondary anemia and that the cell most
commonly found is the normoblast. Perhaps the
most important differential feature is the absence, in
secondary anemia, of a paroxysmal tendency. The
anemia may be profound, but- is more apt to have
become so after long periods of stationary character-
istics in which there has been no disposition to im-
provement. The person presenting the emaciation
* Export hematologists may observe a blood and report no nu-
cleated red cells in a specimen in which a house officer will find
many such cells. Each may be quite correct owing to the "show-
ering" tendency of the normoblasts. It is well, however, to
uric such a blood as soon as possible after such an erythro-
blastic finding is reported, in order to determine whether lympho-
have been mistaken for red cells. "As soon as possible"
beca i nil "showers" may soon "clear up" and the finding
remain in permanent doubt.
Vol. I.— 23
and cachexia of Secondary anemia appeal ii) marked
contrast to the one with pernicious anemia who is
plump and well rounded out with fat even to death.
When the blood shows characteristics Buggestive of
pernicious anemia and no primary factor is evident
these features should be carefully considered and a
thorough search made for .in obscure parasitic or
septic agent. It all the clinical features be carefully
Considered it will be rare to find that secondary or
symptomatic anemia presents characteristics identical
with those of pernicious i \ddi onian) anemia.
Exceptions to this statement are the following:
2. Uncinariasis (Hookworm, I ' urimirin il,m,/, ,,,,!,. ,
Ankylostoma duodenale).^M\ that has been said re-
garding pernicious anemia is applicable to the ad-
vanced stage of the anemia associated with this
parasitl — the only difference being the presence of
ova in the feces, .-i low color index, and a tendency
toward an eosinophilic leucocytosis. For further in-
formation on this important subject the reader is
referred to the article with this title in the Reference
Handbook and 1'.. K. Ashford's excellent monograph
published by the I". S. Government.
3. Bothriocephalus lotus. — Except in the early
stage of the anemia, (chlorotic stage) caused by this
worm, the blood is identical with that seen in perni-
cious anemia. The finding of ova in the stools there-
fore constitutes the differential feature.
The blood of children up to six or eight years of age
presents many variations and one must make careful
clinical observation upon a child whose blood shows
oligocythemia, oligochromemia, or a leucocytosis, for
such variations may be compatible with a temporary
reaction to some slight physiological disturbance.
Megalocytes, erythroblasts, and myelocytes may
appear in children with moderate anemia. Well
authenticated cases of pernicious anemia are unknown
in infancy, extremely rare in childhood, and uncommon
before the age of thirty and after the age of fifty.
Prognosis. — Among the 1,200 cases collected from
literature, including his own case reports, Cabot finds
but six recoveries, taking " six years free from trouble"
as the criterion upon which to base an assumption
of cure. While these statements indicate a great
mortality they show also that, as Hunter strongly
maintains, the disease is not invariably fatal. See
section on Relapse and Duration for further con-
sideration of the prognosis.
Treatment. — Although the physician is helpless
before this destructive condition there are one or two
warnings which can with great advantage be given.
During the intervals between paroxysms, even
though the patient feels energetic and is impatient to
be at work, every effort should be made to conserve
the energies. Journeys, sight seeing, long hours at
business, exacting work should at these times be
emphatically forbidden. Travel is not infrequently
prescribed to the business man who is in the stage of
remission of a pernicious anemia, and subsequent
events will lay the physician open to severe and just
criticism for giving such advice. It must be remem-
bered that these people, as though impelled by some
stimulant in the system, are difficult to restrain, not
from hard labor, but from considerable activity.
Hunter's teaching that oral and gastrointestinal
sepsis is largely responsible for the toxemia has sug-
gested intestinal irrigations in an effort to reduce
absorption of any possible toxin from this source.
The condition of the teeth should be repeatedly and
thoroughly looked into. A minimum of protein in
the diet has been recommended, but it is not clear
that this has any importance one way or another.
The only drug employed is arsenic and no one
preparation seems superior to another, and adminis-
tration by mouth seems quite as efficacious as by
hypodermic injection. It is most commonly given
as Fowler's solution or in pill form, the dose of the
353
Anemia, Pernicious
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
former being gradually increased from two to three
minims thrice daily to fifteen or twenty thrice daily.
Physiological effects should be carefully looked for
and the dose reduced accordingly.
Manj T other measures might be mentioned but so
far experience offers nothing in their support.
C. N. B. Camac.
References.
1. "On the Constitutional and Local Effects of Disease of the
renal Capsules," by Thomas Addison, 1855.
_'. "Correspondenzblatt f. Schweizer Aerzte, Biermer, 1872.
3. Lack of space admits of no more references being given. In
Vol. v. of Allbutt and Rolieston's System of Medicine (1009) will
be found a full bibliography. Addison's (1855) and Riermer's
(1872) Monographs, to which reference is given above, mark the
beginning of a clinical recognition of this important disease.
Anemia, Secondary. — Anemia might literally be
assumed to refer to diminution of the amount of blood,
but actual^ it is made to refer to diminution or
deterioration in the erythrocytes, or hemoglobin, or
both.
The greater the accuracy of medical diagnosis, the
fewer will be the conditions to be labelled Anemia."
As "inflammation," ''fever," "indigestion," have
gradually marched out of the column of diseases into
the field of symptoms, so must also anemia. And as
chlorosis has lost many of its class to tuberculosis,
and pernicious anemia to malignant disease and to
the animal parasites, even more must secondary
anemia divide itself up and become a symptom only,
and that of the most varied disorders.
But, for the present, there must continue, for
descriptive purposes at least, the symptom group,
which may be called anemia. This group-name will
include visible pallor, alterations in the physical and
chemical characters of the blood; circulatory dis-
turbances, such as palpitation of the heart and
dyspnea, and a tendency to edema; various muscular
and nervous disturbances, or as has been stated, any
alteration in the respiratory function of the blood.
The particular phase of the symptom group which
is most in evidence will vary with the cause of the
anemia, and here one must be cautious in drawing
conclusions, as in many instances, not the anemia
itself, but the primary cause of the anemia, may be
responsible for the symptoms. For example in the
anemia of tuberculosis the pallor is a marked feature,
while the diminished quantity of blood renders the
blood count often but little removed from the
normal. Again, in beriberi edema may be as
prominent a feature as pallor, while in malignant
disease the pallor as such gives way to the well-
known cachectic hue.
The blood characteristics of secondary anemia are
a diminution of red cells and hemoglobin, but with low
color index, but though this is typical, there are also
secondary anemias such as that due to Ankylosto-
mum and Bothriocephalus, where the blood picture
runs closely parallel with the primary Addisonian, or
pernicious form.
The pathological anatomy of secondary anemia is,
of course, the anatomy of the process which has
given rise to the anemia, but there are certain con-
ditions more or less directly referable to the anemia
itself, such as pallor of the organs and fatty de-
generation, particularly noticeable in the heart and
in the liver, in the capillary blood-vessels; and
changes in the bone-marrow, which may, however,
vary according to the excitant of the anemia.
Broadly speaking, the secondary anemias may be
divided into the Acute and Chronic.
Acute Anemia. — The one great cause of this
condition is hemorrhage, either externally, or into
one of the body cavities. This may be due to
trauma or surgical operation; uterine hemorrhage
occurring either during an abortion, or after delivery,
354
pulmonary or gastric or intestinal solutions of con-
tinuity may give rise to external bleeding, while a
rupture of the liver, spleen, or kidney may be a
cause of internal bleeding.
Symptoms. — Anemia from any of the above causes
shows itself by certain well defined signs:
(a) Pallor.
(b) Actual shrinking of the body; this is brought
about by the flow of the body fluids toward the blood-
vessels to make up for blood lost. The shrinking
shows itself in the drawn face, sunken eyes, s
cadaveric expression.
(c) Nervous Symptoms. These are dependent
upon cerebral anemia, and manifest themselves
through the reaction of the medullary centers; of
these, the respiratory center gives the earliest and t In-
most obvious warning, such as sighing, disturbed
respiratory rhythm, rapid respiration, or in a later
stage actual air hunger.
(d) Psychical manifestations, as restlessness, mild
forms of delirium, failure to appreciate one's
surroundings.
(f) Amblyopias which may terminate in optic
atrophy are also to be found.
(f) 'the Blood Picture. Crile's observations upon
the donors in transfusions showed a fall in both
hemoglobin and red cells, beginning immediately
after the bleeding or up to several hours after. The
white cells in nearly all cases showed a sudden sharp
rise in number, and this rise was maintained above
the previous level for four or five days. In a small
series of experiments made to compare the blood pic-
ture of hemorrhage and shock, Crile found that the
diminution of red cells and hemoglobindid not occur in
shock, and the rise of white cells was not observed.
(g) Cardiovascular Symptoms. A rapid pulse,
becoming more rapid with increasing hemorrhage, is
an almost invariable sign in acute anemia. The
blood pressure falls and the heart sounds become
weak, due not only to the diminished total volume of
blood, but to the diminished flow through the coro-
nary vessels and consequent impairment of the
heart muscle.
The diagnosis between shock and acute anemia
from hemorrhage is naturally difficult in the ab-
sence of external bleeding, or of evidence of free
blood in a body cavity, since most of the symptoms
of the two are identical. However, a preliminary
stage of restlessness, an increasing pulse rate and the
early appearance of diminished hemoglobin and red
cells with increase of leucocytes, speaks strongly for
anemia from hemorrhage.
Subacute Anemia. — As opposed to the sudden
onset of the anemic syndrome, we have to deal with
one having a rapid onset in which the condition may
develop in days or hours instead of minutes. Such
a condition has been reported in acute septicemias.
Chronic Anemia. — Among the chronic anemias,
though their cause is legion, the following groups
may be cited:
1. Anemia from continued losses of blood, e.g.
hemorrhoids.
2. Anemia from infectious diseases, e.g. tuberculo-
sis, rheumatism, typhoid fever, syphilis, sepsis.
3. Anemia from parasites, malaria, uncinariasis,
bothriocephaliasis.
4. Anemia from malignant disease.
5. Anemia from intoxications by lead, arsenic,
cocaine, morphine, carbon monoxide, carbon dioxide,
and in nephritis and pregnancy.
1. Continued Small Hemorrhages. — This cause may
give rise to a most profound degree of anemia which
may, in some instances, show a blood picture very
similar to that of pernicious anemia. The common
causes are uterine hemorrhage in fibroids and chronic
metritis and carcinoma, hemorrhoids, purpura, and
hemophilia.
i;i i EREN< i: II WiU'.ooK OF THE Ml DICAL S< []
VncMii.i. Secondary
These are cases which show an extreme degri f
pallor, and also acquire t lie drawn, haggard look oi
chronic ill health; as a rule there is also associated a
iderable degree of loss <>f weight, but it is rare
them to manifest any appearand lexia.
Tlic patient may be quite unconscious of the cause of
his steady decline in health, since many of the ca
rhage are painless, ii is not uncommon for
such a patient to be dosed over long periods with
inm and tonics, while the actual can-.' is unsuspected.
In this form ol anemia there is usually a considerable
diminution, even to 1,500, r 2,000,000 ii
number of red blood cells with a color index still more
diminished, and as a nil'', a slight or moderate leuco-
cytosis. An extreme grade of poikilocytosis may be
present ami normoblasts may be found in i
at sometimes. Megaloblasts may also be found, but
iiim-h less commonly, and never in a majority of the
nucleated red cells (( 'abot).
cases may be difficult to distinguish by. the
blood picture alone from primary anemia.
2, Infectious Diseases.— Tuberculosis, perhaps, of
all diseases shows the greatest discrepancy be-
tween the apparent anemia, as judged by pallor,
and the diminution of the blood content as shown
by examination.
Red Cells. — In patients undergoing treatment
counts of Li. 00(1.(1(10 or over are not uncommon, and
the number rarely falls below 3,000,000. A slight
diminution from the normal number is the usual
condition found. After hemoptysis there isasudden
slight reduction of hemoglobin. Commonly, even
with marked pallor and loss of weight, the hemo-
globin estimation gives a high figure, but the typical
finding is one of less than normal and a color index
which is reduced. It is claimed that in tuberculosis
the red cells resist hemolysis to a greater extent than
normal cells.
The most satisfactory explanation of the relatively
high red cell and hemoglobin estimation is that there
is an actual diminution in the total blood mass, due
to loss of body fluid by the skin, and through bronchial
lion. In the treated cases also, hyperalimenta-
tion, together with sun and fresh air, stimulate blood
production.
Leucocytes. — In many cases these are diminished
and in non-progressive cases a count in the neighbor-
hood of 5,000 is the rule. In cavity formation a
cytosis is the rule and advancement of the
disease is usually marked by an increase in the number
of white cells, this increase being chiefly in the poly-
morphonuclears. A lymphocytic increase has been
shown to correspond with periods of improvement.
Arneth has pointed out that the number of nuclei
in a polymorphonuclear cell has a bearing upon
prognosis. The greater the number of leucocytes
with one or two nuclei, the graver the outlook, while
an increase in cells having three to five nuclei is an
indication of favorable import. Minor and Ringer
confirm this work.
The pallor of tuberculosis is notorious and, set off
against the red lips and flushed cheeks, tells its own
story; often, however, one sees the bluish-white, or
skim-milk complexion, with a pale palate and con-
junctiva?, while in the later cases a cachectic appearance
not unlike malignant disease may make its appearance,
especially in the poor and ill-cared for.
Si pticemia. — Here is found a quality of anemia
which in acuteness nearest approaches that due to
hemorrhage. The red cells may diminish at the rate
of 1,000,000 a week, and extremely low counts have
been recorded. Hayem's case of puerperal sepsis
showed only 1,450.(100 with twenty per cent, of
hemoglobin. The hemolysis is so marked and so
rapid in severe cases, that the hemoglobinemia causes
staining of the organs, and to this is due the sallow
icteroid tint of acute sepsis.
Leucocytosis. — Polymorphonuclear leucocytosis is
the rule, except in some fulmii es where
there may be actual leucopenia. With leucocyti
or in the al leucocytosis, the presence of red-
!i granules in i he polj nucleai ile leuco-
cytes when I real i 'd by iodine, either in vapor or solu-
tion, is said to be distinctive of a septic or toxic
Methe elobinemia has been recorded following
sept icemia t rom Ba< llv
The anemia of rheumatic fever lias many of the
characters of that found in sepsis and shows itself
early in the disease by a diminution of red cells,
with a greater diminution of hemoglobin, but rarely
to the same degree as in Sepsis. Li i- is
usually present.
:!. Parasites. — CJm which has of late yi
been recognized as a cause of the endemic anemia
in many districts, may give rise to an acute illness or
may run over years. Besides the blood changes
there are symptoms referred to the digestive tract.
Abdominal pain relieved by f 1, perverted appetite,
dyspepsia, constipation followed by irregular diar-
rhea, and with blood frequently found in the mo-
tions. Adults, the subjects of chronic infection,
may show the vocal, bodily, and sexual characters of
infantilism.
The blood picture shows a red blood corpuscle
count which may range from 800,000 to 1,200,000 with
a low color index. The cells may be altered in size,
shape, and coloring. Normoblasts are frequent and
megaloblasts are often found but not as a majority
of the nucleated cells.
Eosinophilia is characteristic and is most marked
before the anemia is pronounced. A rise in the eo-
sinophilia is of favorable import. The number of
these cells has been found as high as sixty-six per
cent, with an average of eighteen per cent.
The diagnosis is suggested from the symptoms in an
infected locality, especially when there is a history of
boils or a papular skin eruption. The finding of ova
in the stools is diagnostic.
Thymol in fifteen to thirty grain doses repeated
for three or four times at short intervals (one to one
and one-half hours) followed by a purge, is the treat
nient of choice; but toxic symptoms from the drug
such as vertigo, delirium and brown colored urine,
must be kept in mind. After one week the stools
should be examined and if ova are still found the
treatment should be repeated.
Malaria. — The chief characteristic is the rapidit}'
of its onset; a drop of from five to ten per cent, in red
cells may occur with each paroxysm. Grawitz
records a fall of 400,000 in six days. The hemoglobin
content falls in proportion. Manson sugge.-ts that
the rapidity of the fall in the number of red cells is
due to the liberation of lytic substances into the
plasma which continue the corpuscular destruction.
Mary Rowley Lawson suggests that the cause of
the rapid blood destruction is the migration of
parasites from corpuscle to corpuscle, destroying
one after the other. The blood volume in malaria
is also diminished. After recovery from the infection
in the tertian and quartan forms, the blood recovery
is fairly rapid, but in estivoautumnal fevers the
anemia is liable to continue.
In some pernicious forms the blood destruction
may be extraordinarily severe, the red count falling
as low as 500,000, with the absence of any nucleated
red cells, indicating an absence of marrow reaction.
In other cases a blood picture closely resembling
that of primary anemia may be seen.
.Malarial cachexia follows usually a chronic estivo-
autumnal infection. Here the red cells may drop to
less than half the normal, while the hemoglobin shows
a corresponding diminution. The mononuclear
leucocytes are increased in number, while pallor with
sallowness, dyspnea, edema, and weakness are
usually prominent. A much enlarged spleen is
355
Anemia, Secondary
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
characteristic of the condition. Plasmodia may be
with difficulty discovered in the blood.
4. Malignant disease is cue of the most constant
causes of severe grades of secondary anemia. It is
rare to find a malignant growth at all advanced
which has not given rise to some blood deterioration.
The typical finding is a greater or lesser decrease in
the number of red cells, with a greater diminution
of hemoglobin, and a moderate degree of leucocytosis.
In cancer of the stomach of typical form, the
average red blood corpuscle count will be about three
to four millions, though in rare instances the count has
gone above five millions, and less rarely as low as one
and a half million. Poikilocytosis and polychromato-
philia are not uncommon. Basophilic granules
and iodophilia have also been noted. Jez reports the
finding of nucleated red cells — normoblasts — with
frequency, and even in cases where the red count
was 4,000,000.
The hemoglobin value is practically always dimin-
ished, and in 150 cases collected by Osier and McCrae
averaged fifty per cent. The hemoglobin content
falls before the red cells and the color index ranges
usually between 0.4 and O.S.
The white cells are nearly always at or above the
normal, rarely below; a white cell count of 10,000
will be an average for any large number of cases. A
differential count shows a polynuclear estimation of
seventy-five per cent. A digestive leucocytosis is
a^ a rule absent. The resistance of the red cells is
increased.
Besides these typical cases of gastric cancer,
Marcorelles points out a group of cases in which the
anemia is the outstanding feature. Here we find,
(a) Clinical signs of cancer of the stomach, with
intense anemia {forme avec anemie). (b) Very
intense anemia without obvious signs of cancer
(forme animique). (c) The form with metastases
in the bone marrow.
The appearance of the first two groups is one of
excessive pallor without the characteristic yellowish
tint of the ordinary case of cancer. The patient
appears exsanguinated, and though usually ema-
ciated, sometimes shows retention of adipose; edema
is common and asthenia is profound, palpitation
and ringing in the ears are frequent. The digestive
disturbances are those found in other grave anemias.
The red cells range from three-quarters of a million
to three millions. The hemoglobin index, though
usually below 0.5, may rise to 1 or over. Poikilocyto-
sis is the rule and nucleated red cells are numerous.
The leucocytes usually range above the normal and
the formula is various, a polymorphonuclear increase
being the rule, but a mononuclear increase is not
uncommon. Eosinophils are increased and myelo-
cytes are sometimes found in considerable numbers.
It will be seen that in almost every particular the
blood picture here may simulate that in primary
pernicious anemia.
Cases with Involvement of Bone Marrow. — Clin-
ically, these are accompanied by tenderness over the
bones, by splenic enlargement and by hemorrhage in
retina, gums, and skin. The blood picture differs
from that of the previous form in the more frequent
elevation of the hemoglobin index and in the greater
number of nucleated cells, particularly megaloblasts.
5. Chemical Poisons. — The type of this group is
saturnism, which gives rise to most intense forms of
blood deterioration. The pallor is usually marked
and is frequently the most noticeable feature. It is
quite frequently associated with a tinge of sallowness.
The blood picture shows a lessened number, often a;
low as 3,000,000, of red cells, a hemoglobin percentage
relatively lower, and a leucocyte count not differing
much from the normal in number or in variety.
Two features of the red cells are almost constant,
basophilic granulation and polychromatophilia. Baso-
philia is more common than in any other disease in a
case where the anemia is not extreme. A lead line
will usually give the clue to the cause of the anemia
if looked for, but many cases occur where the infection
is accidental rather than industrial, and for this reason
the cause of the anemia may remain unsuspected.
The anemia of nephritis may, in the present state
of knowledge, be also classed among the toxic
anemias, admitting, however, that it would probably
be more correct to attribute the anemia and the
nephritis to a common cause, rather than the anemia
to the nephritis.
Though practically all forms of nephritis show a
certain grade of anemia, it is most marked in that
group classed as " chronic parenchymatous," where
pallor and edema are the classical symptoms — "large
white legs, large white kidneys."
The blood picture is a diminished red count and a
greater diminution of hemoglobin with often a
lowered specific gravity due to the hydremia. The
freezing point, though usually low, may rise to normal
from the same cause.
The anemias of infancy are even yet an ill-
assorted lot, the condition known as von Jaksch's
disease being the central figure. The clinical features
of anemia, splenic enlargement, glandular enlarge-
ment, and enlargement of the liver, may exist with
marked diversity of the blood picture, and, on the
other hand, there are seen in rickets, syphilis, and
tuberculosis, cases with similar clinical characters.
The blood picture in infancy is extremely unstable,
variations in the characters and proportions of the
cellular elements occurring with the greatest readiness.
For this reason, in infancy any diagnosis founded
upon the blood examination alone is open to almost
certain error.
Setting aside forms of anemia common to adults,
there remain the anemias due to malnutrition, faulty
feeding, bad hygiene, enteric diseases, marasmus, etc.
The Anemias of Old Age. — "A moist eye, a dry
hand, a yellow cheek, a white beard," are commonly
the things which "accompany old age," and many
troubles incidental to senility are also causes of
anemia. Hypertrophy of the prostate, with its
accompanying cystitis in men and a senile endometri-
tis in women; arteriosclerosis and contracted kidney;
infections of the mouth, as pyorrhea; neoplasms in
various situations; and by no means least, the senile
forms of tuberculosis, may all be reasons for the
anemia of the aged. AYhether infections of the
intestinal tract shall be proved to be as Metchnikoff
considers them, the foundation of old age, as well as
of some of its anemias, remains to be seen.
Diagnosis. — In acute anemias, the distinction be-
tween shock and hemorrhage has been already
mentioned. It is of service to remember that in rare
instances an acute anemia may occur from the action
of an actively hemolytic agent as in some acute
infections, and in poisoning by ricin, potassium
chlorate, or nitrobenzol.
Chronic Anemias. — The diagnosis here is from
chlorosis and from primary pernicious anemia. This
must be made by exclusion on the one hand, and
recognition on the other. In young women tubercu-
losis, Graves' disease, nephritis, lead poisoning, and
gastric ulcer must be eliminated before chlorosis is
diagnosed.
A conscientious use of the thermometer, and if
necessary, of tuberculin, will often clear up doubt in
the case of tuberculosis, and in the other cases the
recollection of the causes suggests the avenue by which
the distinction may be made.
Pernicious anemia, as a rule, offers a definite blood
picture, but it must be remembered that there is no
single pathognomonic sign. Under forty, a diagnosis
of pernicious anemia should be viewed with suspicion.
At the age when this disease is in question, ma-
356
RKFKUKNCE HANDBOOK OF THE MEDICAL SCIENCES
AnestheBla and Analgesia
lignancy insome portion of the digestive tract must
be always before the mind. Repeated hemorrhages,
unknown to the patient, and animal parasites arc
other causes of anemia in which pernicious anemia
may be simulated. The examination of the rectum
and of the stools may give the clue to the cause.
To summarize— the diagnosis of the cause ol a
ndary anemia i- made with certainty only after
mtine examination of the whole body, and only
when no cause for blood deterioration can be made out
is a primary anemia to I"' considered. If then a
sponding blood picture be found, that opinion
infirmed.
Aplastic anemia is a disease of young person-.
chiefly women. The color index is low and lympho-
cytes form the great proportion of the white cells.
Milar leucocytes are few and nucleated red cells
practically absent. The disease runs a progres-
sively downward course.
After the elimination of the so-called primary
anemia-, the further apportioning of the direct cause
of the anemia is done by the associated symptoms.
Treatment. — In the face of so varied an etiology,
it would appear useless to suggest any one form of
treatment.
The diagnosis is everything. This may indicate a
transfusion for acute hemorrhage, an excision of
hemorrhoids for recurring hemorrhage, a change of
diet for scurvy, an antituberculous regime, or
antisyphilitic medication; a change of occupation
for plumbism, or a change of climate for nephritis;
a laparotomy for cancer, or an anthelmintic for
parasites.
In addition to these obvious procedures, the direct
i upon blood production of sunlight and in-
creased elevations should not be overlooked. The
diminished respiratory function of the blood in
anemia calls for free flowing fresh air, and the per-
verted metabolism for extra assimilable nutrition.
Of drugs, we may say there are but two — iron, which has
not the specific action it shows in chlorosis, but which
i- generally useful, and arsenic which clinically, at any
rale, does improve the blood production.
Were the writer to be limited to three preparations
of iron, these would be Blaud's pill, the tincture of
chloride of iron in an acid mixture as dilute phos-
phoric acid, and syrup of the iodide of iron.
Ma-sage and certain hydrotherapeutic douches
may be of definite value; and last, but not least, rest
in bed, which, after the correction of the primary
cause, may alone work wonders. A. H. Gordon.
Anemia, Splenic. — See Splenic Anemia.
Anencephalus. — See Teratclogy.
Anesthesia and Analgesia. — Definition of Terms. —
Anesthesia, accurately speaking, denotes the loss of
e of touch. The term is often used to indicate
the loss of all forms of sensibility, as pain, tempera-
ture, muscular location, etc. In this article, when
the word is used without qualification, it shall mean
the loss of tactile sense. Tactile sensibility is sub-
served by structures that take cognizance of change
of contact, and are stimulated by motion of an ex-
ternal object in contact with the surface.
Analgesia is a term employed to denote the loss
of sensibility to painful impressions.
Thermoanesthesia is a loss of temperature sense.
Present day clinical neurology has been compelled
in large part to abandon these general terms since the
more extended observations of Head and those fol-
lowing him have shown that the sensations, hereto-
fore thought of as simple, are in reality very complex,
and that it is far better to express one's clinical
findings in terms of the test used, than by the em-
ployment of general terms. Thus one discriminates
between touch sensibility to cotton wool, and pri -
sure sensibility to the finger touch. Lo ia)
ol one does not imply loss of the other. A patient
may lose the ability to distinguish between extremes
of neat and cold and yet retain the ability to dis-
criminate between very minute variations in warmth
or coolness.
Mi iioiii- 01 Testing Sensibility. — The determi-
nation of the varying degrees of anesthesia and anal-
gesia is made difficult by the fact that the physii
must depend upon the statement of the patient for
his information. The intelligence, attention, and
sincere cooperation of the patient are necessary to
secure reliable responses. Furthermore, individuals
vary, within the limits of what is normal, quite
appreciably in their sensibility to external irritation.
finally, in patients suffering from lesions which cause
either a slighter, or perhaps a greater degree <>f hiss
of consciousness, sensibility is more or less diminished
up lo entire loss of sensation, even though the lesion
may cause no anesthesia directly.
In testing sensibility, the patient should be blind-
folded or in some other way prevented from seeing
what is being done, in order that simulation or self-
deception may be avoided. It is remarkable how
vividly one can feel the prick of a pin or touch of
a feather through the medium of sight. When the
lesion is unilateral, a comparison of the two sides is
very desirable. Various instruments of precision
have been devised by neurologists for testing sensi-
bility (see Esthesiometer). Some are indispen-
sable, others of value only in carrying out systematic
and controlled observations. A systematic sensory
examination is recognized to be of extreme impor-
tance, and of recent years has become successively
more extended and precise. The following scheme
or schedule laid down by Head and Holmes con-
tains the usual present day necessities for a complete
sensory examination.
A. Spontaneous Sensations: Pain, numbness,
tingling, position of the limb, idea of the limb, hallu-
cinations or illusions.
B. Loss of Sensation:
1. Touch:
a. Light touch, cotton wool on hairless and
hair clad parts; threshold with von Trey's
hairs.
b. Pressure touch, threshold with pressure es-
thesiometer.
2. Localization:
Naming the part touched;
Henri's or Head's method, target, etc.
3. Roughness, threshold with Graham-Brown's
esthesiometer:
Sandpaper tests, discrimination of relative
roughness.
4. Tickling and scraping:
Tickling on soles and palms;
Cotton wool rubbed over hair-clad parts;
Light scraping with finger nails.
5. Vibration, tuning fork:
Loss or diminution of sensibility,
Alteration in the character of the sensation
evoked.
6. Compass points:
Points simultaneously applied.
Points successively employed.
7. Pain:
a. Superficial pain: pinprick; threshold with
algesimeter; reaction to measured pain-
ful stimuli.
b. Pressure pain: threshold with the algo-
meter; reaction to painful pressure.
8. Temperature:
Thresholds for heat and cold:
Effect of adaptation on threshold;
357
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REFERF.XCF, HANDBOOK OF THE MEDICAL SCIENCES
Discrimination of different degress of heat and
cold;
Affective reactions (a) to extreme degrees,
(6) to warmth.
9. Position:
By imitating with the sound limb the
position of the affected limb;
By pointing with the sound limb:
Measurement of defect by Horsley's method.
10. Passive Movement:
Appreciation of movement;
Recognition of the directions of movement:
Measurement of the angle of the smallest
movement which can be appreciated;
Falling away of the unsupported limb
when the eyes are closed.
11. Active Movement:
Imitation of movement by the sound limb;
Ability to touch a known spot;
Measurement of the defect by Horsley's
method.
12. Weight:
a. With hand supported,
Recognition of differences in weights applied
successively to one hand;
Appreciation of increase or decrease of
weight;
Comparison of two weights placed one in
each hand.
6. With hand unsupported,
Comparison of two weights placed one in
each hand;
Recognition of differences in weights applied
successively to one hand.
13. Size:
I Hfference— threshold.
Distinction of the head from the point of
the pin.
14. Shape (two dimensional).
15. Form (three dimensional): Recognition of
common objects by their form.
16. Textures:
17. Dominoes: Ability to count points by touch.
18. Consistence:
19. Testicular sensibility:
o. Light pressure;
6. Painful pressure.
20. Sensibility of glans penis to measured prick.
Such a detailed examination is demanded by the
present day knowledge of the sensory nervous sys-
tem. This knowledge is the accumulation from a
number of research workers. The most important
researches have come notably from English physiolo-
gists and clinicians. A brief summary of this work
as outlined by Head and Holmes in a recent (1912)
monographic presentation will be found useful.
They write that it is a matter of universal belief
that man has evolved from the lower animals, and
yet when we deal with sensation and sensory processes,
we speak as if he were created with peripheral end
organs capable of reacting to one of the sensory
qualities of human experience. The impulses start-
ins: in these end-organs are supposed to pass unal-
tered to the brain, there to set up that peculiar and
unknown change which underlies a specific sensation.
Spots were found on the skin sensitive to touch, to
pain, to heat, or to cold only. With the discovery
of these highly developed end organs, the doctrine
of specific nerve energy seemed to be proved in the
strictest manner. All other forms of sensory appre-
ciation were supposed to be produced by the psychical
transformation of these primitive sensory elements,
in association with an ill-defined faculty called the
"muscle .sense." Recognition of the locality of a
stimulus, and the posture of the limbs were attrib-
ute 1 to judgment and association.
But alongside the systematic investigation of von
358
1 rev, and others, of the capabilities of these specific
areas in the skin the clinicians were discovering the
importance of "muscular sensibility." Sherrington's
demonstration of afferent fibers in muscles and ten-
dons placed the existence of the "muscle sense''
beyond a doubt, and the use he made of these afferent
impulses from deep structures, in his theory of the
proprioceptive system, necessitated a complete explo-
ration of the nature of deep sensibility.
■■ By their experiment directed to this end, Rivers
and Head showed that beneath the skin, indi
of all "touch" and "pain spots," lies an afferent
system capable of a wide range of functions. Pres-
sure, that in ordinary life would be called a touch,
can be appreciated and localized with considerable
accuracy. Increase of pressure, especially on bones
and tendons, will cause pain. Moreover, it is from
the impulses of this deep afferent system that we
gain our knowledge of the posture of the limbs and
the power of recognizing passive movements.
Evidently, therefore, the peripheral mechanism
of sensation is less simple than was at first supposed.
For there are two sets of end organs, that can respond
to tactile stimuli, and two independent mechanisms
for the initiation of pain. Further analysis showed
that the peripheral apparatus in the skin, by which
we become conscious of the nature of external stimuli,
is highly complex. No one sensory quality is sub-
served by a single set of end organs, but every specific
sensation is the result of the combined activity of
more than one group. This is exactly the result
that might have been expected, when we bear in
mind that the structure of man is the product of a
long evolution.
But it is equally obvious, from an evolutionary
standpoint, that these diverse impulses could not pass
uncombined to the highest physiological level. Within
the spinal cord, the opportunist grouping of the
periphery gives place to an arrangement according to
quality (Head and Thompson). All impulses capable
of generating pain become grouped together in the
same path, and can be disturbed simultaneously by
an appropriate lesion of the spinal cord.
The most remarkable condition revealed by an
intramedullary lesion is the complete separation of
the impulses underlying the appreciation of posture,
the discrimination of two points, and their corre-
lated faculties from those of other sensory groups.
All painful and thermal impulses coming from the
periphery undergo regrouping after entering the
spinal cord, and, whether they arise in the skin or in
deeper structures, become arranged according to
functional similarity. Then, after a longer or shorter
course, they pass away to the opposite side of the
spinal cord.
This process of filtration leaves all the impulses
associated with postural and spacial recognition to
continue their course unaltered in the posterior
columns; they are the survivors of peripheral groups
broken up by the passing away of certain compo-
nents into secondary afferent systems. At any point
in the spinal cord these columns transmit not only
impulses from the periphery which are on their way,
after a shorter or longer passage, to regrouping and
transformation, but at the same time they form the
path for impulses, arising both in the cutaneous and
deep afferent systems, which undergo no regrouping
until they reach tlie nuclei of the medulla oblongata.
Thus, a lesion confined to one-half of the spinal
cord, even at its highest segment, may interfere with
the passage of sensory impulses, some of which are
traveling in secondary paths, while others are still
within the primary level of the nervous system. All
impulses concerned with painful and thermal sensa-
tions from distant parts, disturbed by such a lesion,
will be traveling in secondary paths and will have
come from the opposite half of the body: for. after
regrouping, they have passed across the spinal cord.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Anesthesia and Analgesia
But those impulses underlying the appreciation of
posture, the compass test, size, shape, form, weight,
consistence, vibration, will be affected on the same
half cf the body as the Lesion. They still remain in
paths of the peripheral level and have undergone
n.i regrouping.
In such a case the parts on the side opposed to the
lesion may l"' insensitive to pain, heal and cold; but
all the postural and spacial aspects of sensation will
ba perfectly maintained. Yet, all power of recog
owing position, of estimating size, shape, form and
weight, or of discriminating the two compass points,
will lie lost in the limbs which lie on the side of the
in, although tactile sensibility and localization
the spot stimulated maj be perfectly preserved.
This remarkable arrangement enables one to
analyze the nature of the peripheral impulses upon
which depend our power of postural and spacial
recognition. Obviously, even at the periphery, they
must be independent of touch and pressure. The
r to distinguish two points applied simultane-
ously and to recognize such size and shape, requires
as a preliminary the existence of sensations of touch;
the patient may be deprived of all such powers
of spacial recognition without any discoverable loss
of tactile sensibility. In the same way, our power
to appreciate the position of a limb, or to estimate
the weight of an object, is based upon impulses which,
even at the periphery, exist apart from those of touch
and pressure called into simultaneous being by the
same external stimulus.
This long delay of the postural and spacial ele-
ments in reaching secondary paths enables them to
give off afferent impulses into the spinal and cere-
bellar coordinating mechanisms, which lie in the
same half of the spinal cord. The impulses which
pass away in this direction are never destined to
r consciousness directly. They influence co-
ordination, unconscious posture and muscular tone,
and, although arising from the same afferent end
organs, they never become the basis of a sensation.
finally, the last survivors of these impulses from
the periphery become regrouped in the nuclei of the
posterior columns and cross to the opposite half of
the medulla oblongata in paths of the secondary
level. So they pass to the optic thalamus and
thence to the cortex, to underlie those sensations
upon which are based the recognition of posture and
spacial discrimination.
Groups op Sensory Disturbances. — In clinical
neurology and psychiatry it is important to realize
then that it is possible closely to localize and delimit
sensory disturbances into the following groups:
1. Sensory disturbances of the peripheral neurons:
Neuralgia, neuritis, etc.
2. Sensory disturbances within the cord.
3. Sensory disturbances of the brain stem.
I. Sensory disturbances of the optic thalamus.
5. Sensory disturbances of the cortex: (a) Due
to altered fiber tracts (so-called organic); (6) Due
to altered ideation (psychical alterations as seen in
psychoneuroses and psychoses).
1. Sensory Disturbance in the Peripheral Neurones.
— No attempt will be made here to give the specific
anatomical disturbances such as underlie the various
neuralgias and neuritides. The laying down of
general principles which enable one to determine
that the lesion is one of the peripheral neurone is
alone attempted. Thus the various sensory dis-
turbances occurring in diseases of the cranial nerves,
the branches of the cervical, or brachial plexus, the
thoracic nerves or the lumbar and sacral plexuses,
will be found under their appropriate headings:
trigeminal neuritis, brachial neuritis, median nerve,
intercostal neuralgia, sciatica, etc., etc.
Attention will be directed here solely to certain
general facts which the work of Head, Rivers and
Sherren have bought out relative to the peripheral
sensory system. They first show thai the ordinary
method of testing for sensibility, i.e. by touching with
the linger is worthless. It fails to show, in per-
ipheral lesions, such as sections of the median oi ol
the ulnar nerve, that grave def cl oi en ibility may
i" present, for the pressure touch of the fingers is
after all a type of test for deep sensibility, and that
i he tibers for deep sensibility pass nil in t he tendons,
muscles or deep motor nerves. Thus in a wound,
say of the wrist, severing median or ulnar or both,
pre ure touch would not be involved at all, unless
the tendons were also divided, but that tests by
cotton wool and by pin prick would show marked
epicritic and protopathic loss respectively are ac-
curately locahzable. Their researches sh.ev that.
e types of sensibility, subserved by distinct se ts
of libers, must be distinguished in the eutan.
system. These are the protopathic, the epicritic and
deep sensibility fibers. Protopathic sensibility is the
more elementary and original type of sensibility, It,
is that which serves as a general protection of the
animal body from harm. It distinguishes pain, as
from pin prick, it distinguishes between extreme ot
heat and cold, but not between warm and cool.
Epicritic sensibility on the other hand is a specialized
discriminative type of sensibility. It distinguishes
light touch as by cotton wool, determines minute
variations in temperature, localizes compass points
which are close together. Deep sensibility finally
is concerned with postural sense, and deep pressure
sense tested by an algesimeter (Carttell) the epi-
critic and protopathic sensibilities travel in the
cutaneous system, that of deep sensibility in the ten-
dons and muscles and motor nerves. Attention has
been called to the fact that in severe nerve injuries
deep sensibility is lost only when tendon or muscle
or motor nerve is implicated. Again, as in median or
ulnar nerve injury it is observed that if the periphery
is involved the area of insensibility to cotton wool is
usually larger than that of pin prick. Immediately
following the injury they may be coterminous but
soon the condition of wider extension of epicritic
touch loss becomes apparent. When the lesions
reach the main branches of the plexuses however it
is noted that the epicritic and protopathic loss is
about equal and enduringly so until recovery takes
place, whereas, and this is an interesting point
brought out by Head, when the injury involves the
sensory roots, there is a peculiar reversal of the
reaction and here the loss to pin prick is wider and
more extensive than the loss to cotton wool.
In recovery the practical point to bear in mind is
that if the area to cotton wool loss rapidly recedes, i.e.
within five or six weeks, it is probable that the nerve
affected has been partially cut across only. Cotton
wool loss usually persists about 100 days in a totally
divided nerve before recovery commences to set in.
If after that time the area to cotton wool loss does
not recede, operation is indicated. Testing then by
cotton wool, by pin prick and for deep sensibility are
absolute necessities in determining lesions of the per-
ipheral nervous system. For research purposes the
use of compasses, of von Frey's hairs, of measured
thermal and pressure stimuli, are necessary. In
practical work they are valuable but under certain
circumstances may be dispensed with.
2. Disturbances of Sensibility in Spinal Cord Affec-
tions. — Similarly no detailed description of the
diseases of the spinal cord will be attempted. It is
well-known that one disease process will give rise to a
number of clinical pictures. Thus a plaque of mul-
tiple sclerosis may give rise to the picture of a tales,
amyotrophic lateral sclerosis, a poliomyelitis, a
spastic paraplegia, or a complete transverse myelitis.
This section will deal only with those diagnostic
criteria which from the analysis of the sensory symp-
toms alone indicate that the sensory paths are inter-
rupted in their spinal course.
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Anesthesia and Analgesia
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
In the previous section it has been shown that the
epicritic, protopathic and deep sensibility fibers are
capable of being stimulated separably and that these
three systems remain distinctly isolated as systems.
Not so in the spinal cord. Here an entirely new dis-
tribution takes place and we find that functional
pathways make way for quality paths: Heat as heat,
cold as cold, pain, pass up separately, and there is
no longer any distinction between epicritic and pro-
topathic heat, epicritic or protopathic pressure,
etc . such as is found in the cutaneous system in the
arms or legs.
In the spinal cord one finds the pain and thermal
fibers usually crossing the cord — traveling up in the
spino-thelamic paths in the anterolateral portion of
the cord. Deep sensibility fibers, subserving postural
sense, pass up in the posterior columns of the same
side, while pressure touch usually passes up both sides
of the cord. The work of Head and Thompson has
given the main clue to the study of the different
forms of sensibility in their pathological alterations
in lesions of the spinal cord.
3. Disturbances of Sensibility in Lesio?is of the
Brain Stem. — Disease of the brain stem offers special
problems of diagnosis of extreme difficulty, so far as
the analysis of the sensory disturbances is concerned.
So long as the sensory paths were in their spinal
route they were capable of a certain amount of isola-
tion either as they entered the cord and made their
first synapses, or as they continued up the cord in
primary or secondary paths. But as these paths
converge to enter the brain stem they become closer
anatomically, disease processes are apt to overrun
many paths, and thus the analysis becomes increas-
ingly difficult up to the entering of these paths into
the optic thalamus.
Head and Holmes hold that the impulses under-
lying sensations of pain, heat, and cold seem alone
to run unaltered, either directly or by intercalated
fibers associated with the ganglion cells of the forma-
tio reticularis, between the upper end of the spinal
cord and the optic thalamus. Here are received
the regrouped secondary impulses from the face
which cross and join the specific paths for pain, for
heat or for cold. These paths are so situated that
they can be interrupted without disturbance of any
other form of sensation on the body, and the anal-
gesia and thermoanesthesia so produced resemble in
quality the loss of sensation to pain, heat and cold
caused by a lesion in the spinal cord.
Thus when a lesion of the bulb interferes with
sensation of pain, not only may the skin be insensitive
to prick, but the readings of the pressure algometer
may be raised on the analgesic side. In the same
way the affected area of the body may be insensitive
to all degrees of heat, and to all stimuli capable of
evoking normally a sensation of cold. Here, how-
ever, in the bulb, in distinction to lesions of the cord,
the grosser form of pain and discomfort may traverse
other paths if the usual ones are closed — whereas in
the cord all painful impulses are blocked by an
equivocal lesion.
In the bulb moreover all three forms of sensibility
may be affected together or any one may escape or
be alone involved.
These impulses of pain, heat and cold all run up in
the neighborhood of the fifth nerve nucleus, and in
cases of occlusion of the posterior cerebellar artery
the paths are usually implicated. This same accident
may occasion a dissociation of the impulses underlying
the appreciation of posture and passive movement
from those concerned with spatial discrimination.
A summary of the findings which may occur in the
lesions which cut off the sensory pathways between
the nuclei of the posterior columns and the optic
thalamus has been stated by Head and Holmes as
follows:
1. The impulses for pain, heat and cold continue
360
to run up in separate secondary paths on the opposite
side of the nervous system to that by which they
entered. They receive accessions from the regrouped
afferent impulses from the nerves of the head and
upper part of the neck.
Although these paths are frequently affected
together, they are independent of one another, and
any of the three qualities of sensation may be disso-
ciated from the others by disease.
2. Lesions of the spinal cord tend to diminish
simultaneously all forms of painful sensibility, but
with disease of the brain stem the gross forms of pain
and discomfort may pass to consciousness, although
the skin is analgesic. This applies not only to painful
pressure but to the discomfort produced by excessive
heat.
3. The impulses concerned with postural recogni-
tion part company with those for spacial discrimina-
tion at the posterior column nuclei. Up to this
point, they have traveled together in the same
column of the spinal cord, but as soon as they reach
their first synaptic junction they separate. Above
the point where they enter secondary paths, the
power of recognizing posture and passive movements
can be affected independently of the discrimination
of two points and the appreciation of size, shape and
form in three dimensions.
4. It would seem as if those elements which under-
lie the power of localizing the spot touched or pricked
become separated off from their associated tactile
impulses before they have actually come to an end
in the optic thalamus. The long connection of local-
ization with the integrity of tactile sensibility is here
broken for the first time.
All these changes are preparatory to the great
regrouping which takes place in the optic thalamus.
4. The Thalamic Syndrome and Se?isory Changes
in Disorders of the Thalamus. — Practically the entire
mass of sensory fibers carrying impulses of all kinds —
the tests for most of which have already been outlined
— have synaptic junctions within the optic thalamus.
No note has been made here of the numerous fibers
coming from the chemical receptors of the respiratory,
gastrointestinal, or genitourinary tract, nor those
from the organs of internal secretion, nor even of the
sympathetic — all of these make up an enormous
terra incognita for the future explorer.
Lesions in and about the thalamus cause sensory
symptoms, as well as motor ones, of a very char-
acteristic nature — so much so that one can speak of
a special thalamic syndrome. Such a syndrome was
first described by Dejerine and his pupils, particu-
larly by Roussy, who devoted a monograph to the
subject.
Here one observes the following notable features:
1. A persistent loss of superficial sensation of one-
half of the body and face. This loss to touch, pain,
and to temperature, is more or less definite, subject
to considerable variation and to partial recovery,
but the loss of deep sensibility, deep pressure, pos-
tural sense, etc., is much more pronounced, and is
more apt to persist. This latter is usually more
marked distally and in many instances diminishes
as one approaches the trunk.
2. There is slight hemiataxia and more or less com-
plete astereognosis.
3. There are in the complete syndrome acute pains
on the affected side which are very persistent, coming
on in paroxysms. They are frequently extremely
severe and rarely respond to the ordinary analgesics.
These pains may involve a single member, may he
limited to the side of the face, simulating a trigeminal
neuralgia, or they may involve one whole side of the
body.
4. There is usually a more or less distinct though
slight hemiplegia, which in the unmixed syndromes
rapidly clears up. Contractures rarely develop in
the pure syndrome. In the mixed syndrome — with
REFERENCE HANDBOOK OF THE MEDICAL SCIEN( I -
Anesthesia and Analgesia
extension of the lesion to the external capsule — con-
tracl ures may be pres ;n1 .
5, Choreic, athetoid, or paralysis agitans-like
movements may be present on the affected side.
rhese are the symptoms which permit one to diag-
nose a lesion of the optic thalamus and its surrounding
pruts, but in addition to these Head ami Holmes have
pointed out an extremely suggestive series of affect-
ive reactions which arc due to lesions in the optic
thalamus. They have opened up an attack upon
the analysis of the sensory content of emotional
reactions. They show that in thalamic lesions there
ia a tendency to react excessively to unpleasant
luli. The prick of a pin, painful pressure, exces-
sive heat or cold, all produce more distress than on
the normal half of the body. Thus, in one of Head
and Holmes' patients, if a, pin is dragged lightly
- the face or trunk from the sound to the
affected side, there is felt an excessive discomfort
passes the middle line. She not only complained
that it hurt her, but the face was contorted with
pain, and all this notwithstanding the fact that she
was less able to distinguish head from point, yet
the prick hurt her more. This very anomalous state
of affairs is a purely thalamic reaction.
This excessive reactivity is seen not only to pin
prick, hut also to deep pressure, to extremes of heat
and cold, to visceral stimulation, to scraping, rough-
ness, vibration, tickling, to pleasureable stimuli,
and to ideational emotional states. Not all patients
show all of these reactions, but in practically ninety per
cent, of the thalamic cases examined by Head and
Holmes excessive affective response to one or more
measured stimuli were found. For head and cold, and
other forms of sensibility as well as for pain the exces-
response may be present, and yet the patients are
unable to detect — i.e. are anesthetic to — trie stimulus
itself. So far as the ideational affective reaction
is concerned these patients express themselves as
follows: On hearing affecting music "a horrid feel-
ing came on in the affected side, and the leg screwed
up and started to shake." The singing of a comic
song left one patient absolutely cold, but a tragic
2, produced a very distinct unpleasant effect.
One patient said "my right hand seems to crave
sympathy, my right side seems more artistic." In
practically all of the cases the increased affective
reaction was accompanied by actual sensory loss.
\ more detailed study- of the loss of sensibility in
thalamic disorders made by Head and Holmes re-
vealed the following: Xo sensory^ functions are so
frequently affected as the appreciation of posture
and the recognition of passive movement. The
amount of this loss varies greatly from a scarcely
mensurable defect to complete want of recognition
of the posture of the limbs of the abnormal naif of
tic body.
Tactile sensibility is frequently diminished; but,
excepting in a few cases where all appreciation of
contact was destroyed, a threshold could be obtained.
It was always possible to show that increasing the
Strength of the stimulus improved the proportion of
right answers unless the observations were confused
by the disagreeable tingling or other accessory
sensations.
Localization of the spot touched was defective in
half the cases where sensation was sufficiently pre-
served to carry out accurate tests. This inability
to recognize the site of simulation was equally great,
whether the patient was pricked or touched. In
cases where localization was gravely affected, the
disagreeable sensation, so easily evoked, tended to
spread widely on the abnormal half of the body.
A prick on the hand may cause an extremely painful
ation in the cheek or side, and sometimes the
patient simplv recognized the stimulus as a change
within himself, and did not refer the discomfort from
which he suffered to the action of any external agent.
Sensibility to heat and cold may show all degl
of change from total loss to a slight increase of the
neutral zone. Beat and cold are not dissociated;
and if one form of sensation is lost, the other will be
ely disturbed. The apparent exceptio
from a misinterpretation of the sensatio ed by
high or low temperatures on the affected half of the
body.
\oi infrequent l\ I lie compa tesl cannot be carried
out because of the gro sation and inability
to recognize contact; but whenever this method can
be applied a threshold can be worked out, and wii
ing the distance between the points increases the
accuracy of the answers.
The power of estimating the relation between
two weights is frequently disturbed on the abnormal
half of the body. If the appreciation of posture and
movement is affected, the patient can no longer
recognize the identity or the differi vo weights
placed in the unsupported hands. Hut so long as
tactile sensibility is not diminished, he can still
estimate the relation between weights applied one
after tl ther to the same spot, and can recognize
the increase or diminution in weight of in object
already resting on tin- hand.
The appreciation of relative size is often disturbed
in tin but with care it is usually easy to dem-
onstrate a difference-threshold. Shape and form in
three dimensions are frequently not recognizable on
the affected hand. But. if tactile sensibility is not
grossly affected, the patient usually retains an idea
that the object possesses a form, and may obtain a
considerable percentage of right answers.
Vibration of the tuning fork is recognized by all
but three of our patients. In almost every case,
however, the length of time during which it was
appreciated was shorter, and sometimes the rate of
vibration was thought to be slower on the affected
half of the body.
Roughness, as tested with Graham Brown's esthe-
siometer. was always recognized, except in three
cases where the loss of all forms of sensation was
unusually severe. Usually the threshold was the
same on the two sides, but it was occasionally raised
on the affected hand,
5. Sensory Disturbances due to Cerebral Lesions. —
The sensory paths from the thalamus to the cortex
undergo a new distribution, thus making at least
five distinct regroupings of the sensory phenomena
in the entire course of the sensory neuron. The
analysis of the phenomenon introduces more com-
plex factors, and the necessity for abandoning
all generalizations, even those more refined, that
anesthesia, analgesia, as, for instance, light touch,
cutaneous sensations, etc., become more apparent.
Newer valid terms may be coined, but one is here
forced to state the results in terms of the tests
emploved.
1. Using graduated tactile stimuli such as von
Frey's hairs, and the pressure esthesiometer, Head
and Holmes have found as follows:
A cortical lesion may reduce the accuracy of
response from the affected part to graduated tactile
stimuli.
The form assumed by this defective sensibility
differs from that produced by lesions at other levels
of the nervous system. Here the affected part may
respond to the same graduated hair as the normal
hand; but this response is irregular and uncertain.
Increasing the stimulus may lead to no corresponding
improvement, and even the strongest tactile hair may
occasionally evoke less certain answers than a hair
of much smaller bending strain. Moreover, a touch
with the unweighted esthesiometer may be as effec-
tive at one moment as the same instrument weighted
with 30 grm. at another. In such cases no tactile
threshold can be any longer obtained.
2. This irregularity of response is associated with
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persistence of the tactile sensation and a tendency
to hallucinations of touch.
Where the sensory defect is not sufficiently gross
to abolish the threshold, persistence, irregularity of
response and a tendency to hallucinate may still
disturb the records.
3. In all cases where tactile sensibility is affected,
whether a threshold can be obtained or not, fatigue
is induced with unusual facility. Although the
patient may cease to respond to tactile stimuli over
the affeeted part in consequence of fatigue, his an-
swers may remain as good as before from the normal
parts. The fatigue is local and not general.
4. With stationery cortical lesions, uncomplicated
by states of shock or by "diaschisis," sensibility to
touches with cotton wool is never lost over hair-clad
parts. Over hairless parts, stimulation with cotton
wool may produce a sensation which seems "less
plain" to the patient, and his answers may show the
same inconstancy so evident when he is tested with
graduated tactile stimuli.
For measured painful stimuli they found that a
pure cortical lesion leads to no change in the threshold
to measureable painful or uncomfortable stimuli.
Nor does the patient express greater dislike to these
stimuli on one side than on the other. A prick
may be said to be "plainer" or "sharper" on the
normal than on the affected side; but this is due to a
defective appreciation of the pointed nature of the
stimulus and bears no direct relation to the pain-
fulness of the sensation evoked.
The temperature tests they found as follows:
1. The neutral zone, within which the stimulus was
said to be neither hot nor cold, was considerably en-
larged in comparison with that observed on similar
normal parts of the same patient.
2. The patient complained that although he
recognized correctly the nature of the stimulus, it
seemed "less plain" than over normal parts. His
answers were less constant and less certain; a tem-
perature recognized without difficulty at one time
seemed doubtful at another.
3. The power of discriminating the relative cool-
ness of two stimuli, or the relative warmth of two
hot tubes may be diminished. Thus 20° C. may be
said to be the same as ice, although both are uniformly
called cold, and 40° C. may seem as warm as, or even
warmer than 48° C. The faculty of appreciating
the relation to one another of two temperatures on
the same side of the scale is disturbed.
For recognition of posture and for passive move-
ments they found that:
1. Cortical lesions most frequently disturb the
recognition of posture and of passive movements.
Whenever sensation is in any way affected in conse-
quence of a cortical lesion these two functions suffer.
2. In all their cases the distubrance in the faculty
of recognizing posture and passive movements was
greater toward the peripheral parts of the affected limb.
3. When a patient with unilateral disturbance of
these faculties attempts to point to some part of his
body, defective knowledge of its position causes
greater error than want of recognition of posture
and movement in the hand with which he points.
4. When testing the patient's power of appreciat-
ing passive movement, the answers are frequently
uncertain and hallucinations of movement may occur.
And yet the patient may be remarkably consistent
and accurate when normal parts are tested.
5. Localization tests showed:
(a) The power of localizing the stimulated spot is
not infrequently preserved, although sensation may
!»■ otherwise disturbed as a consequence of cortical
lesions.
(b) This faculty is independent of the power of
recognizing the position of the affected limb; appre-
ciation of posture may be lost, although localization
is not in any way diminished.
362
(c) If the power of localization is lost, the patient
will be unable to recognize not only the position of a
spot touched but also the position of a prick.
(d) When localization is defective in consequence
of cerebral lesions, the patient docs not habitually
localize in any particular direction, but ceases to be
certain where he has been touched or pricked.
6. The compass test revealed that:
(a) A cortical lesion may destroy the power of
discriminating two compass points, both when applied
simultaneously and collectively.
If this is the case, no threshold can be obtained for
either form of the test; increasing the distance be-
tween the points does not constantly improve the
accuracy of the answers.
(b) This disturbance is not caused by changes in
tactile appreciation; for it can be demonstrated
equally well with two painful as with two tactile
stimuli.
(c) The condition of tactile sensibility and the
accuracy of the simultaneous compass-test are cloi elj
associated; a disturbance of the tactile threshold is
usually accompanied by a raised threshold for the
appreciation of two points applied simultaneously.
(d) Should the power be preserved of recognizing
two points when the compasses are applied consecu-
tively, localization will be found to be intact. The
patient's appreciation of the two points when they
are separated by an interval of time is due to the
recognition of the separate locality of the two spots
touched.
7. Appreciation of weights showed that:
(a) The power of estimating the relative of two
objects of the same size and shape is readily disturbed
by cortical lesions.
(6) Though the patient may retain sensations
of contact when the weight is placed in his hand, all
power of recognizing the relative heaviness of the
object has disappeared.
(c) This faculty is equally disturbed in most cases
whether the weights are placed on the supported
or the unsupported hand.
From these and related studies, it would appear
that sensory impulses pass from the thalamus to the
cortex is five groups:
1. Those concerned with the recognition of posture
and passive movement. If these impulses are
affected the power of discriminating weights on the
unsupported hand may be also diminished.
2. Certain tactile elements; integrity of this group
is necessary for the discrimination of weights placed
on the fully supported hand.
3. Those impulses which underlie the appreciation
of two points applied simultaneously (the compass
test); on this group also depends the recognition of
size and shape.
4. Those which underlie the power of localizing
the situation of a stimulated spot. Recognition of
the double nature of two points applied consecutively
also depends on this group of impulses.
5. All thermal impulses are grouped together to
underlie a scale of sensations with neat at the one
end and cold at the other. At the level with which
we are now dealing these impulses have already ex-
cited the affective center and are passing away to the
cortex.
Head and Holmes believe that the functional
integrity of the cortex enables attention to be con-
centrated upon those changes which are produ 1
by the arrival of afferent impulses. When this is
disturbed, some impulses evoke a sensation, but others
from lack of attention, do not affect consciousness.
Attention no longer moves freely over the sensory
field to be focussed successively on fresh groups of
sensory impressions. Sensations, once evoked, are
not cut short by the moving away of the focus of
attention as when cortical activity is perfect. Hence
arise persistent sensations and hallucinations which
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Anesthesia, General Surgical
are so prominent a feature after lesions of the
cortex.
They believe that the cerebral cortex is tin- organ
1 ,y which we are able to foi i ition upon
changes evoked by sensory impulses. A pure cortical
lesion, which is not advancing or causing periodic
discharges, will change the sensibility of the affected
- in such a way that t he patient 's answers appear
to be untrustworthy. Such diminished power
makes the estimation of a threshold in many cases
impossible. Uncertainty of response destroys all
power of comparing one set of impressions with
another and so prevents discrimination.
;.: addition to its function as an organ of local
attention the sensory cortex is also the storehouse of
past impressions. These may rise into consciousness
as images, but more often, as in the case of spacial
impressions, remain outside central consciousness.
Here they form organized models of ourselves which
may be termed "schemata." Such schemata modify
the impressions produced by incoming sensory im-
pulses in such a way that the final sensations of
position, or of locality, rise into consciousness cha
with a relation to something that has happ
before. Destruction of such "schemata" by a lesion
of the cortex renders impossible all recognition of
posture or of the locality of a stimulated spot in the
affected part of the body.
In daily life all stimuli excite more or less both
thalamic and cortical centers, for most unselected
itions contain both affective and discriminative
elements. But, among the tests employed in sen-
sory analysis, some appeal almost entirely to the one
or the other center. The test for recognition of
posture, as carried out by Head and Holmes, is
purely discriminative; while the pain produced by
dug the testicle, or to a less degree by the
pressure algometer, appeals almost exclusively to
the more affective center.
- nsory impulses arriving at the optic thalamus
are regrouped in such a way that they can act upon
both its essential center and the sensor}- cortex. The
itial organ of the thalamus is excited to affective
activity by certain impulses, and refuses to react to
those which underlie the purely discriminative aspects
of sensation. These pass on to influence the cor-
tical centers where they are readily accepted. In a
similar way. the primary centers of the cortex cannot
receive those components which underlie feeling
tone: in this direction they are completely blocked.
It has long been recognized that sensations are
endowed with feeling tone to different degrees. In
those which underlie postural appreciation this
quality is entirely absent, while visceral sensations
are, in some instances, little more than a change
in a general feeling tone, one set of impulses appeals
almost exclusively to the cortical center, the other
to that of the optic thalamus. All thermal stimuli,
however, make a double appeal. Every sensation
of heat or cold is either comfortable or uncomfortable;
the only entirely indifferent temperature is one that
is neither hot nor cold.
In the same way. some unselected tactile stimuli
appeal both to the sensory cortex and to the optic
thalamus. For not only is a touch always related to,
and distinguished from, something that has gone
before it, but we have shown that contact, especially
of an object moving over hair-clad parts, is capable
of exciting thalamic activity. Vibrations of the
tuning fork also make a double appeal, for when the
cortical paths are cut the amplitude of the vibration
must be greater in order that it may be appreci-
ated; on the other hand, the vibratory effect may be
stronger on the abnormal side in those thalamic
cases where the affective response is excessive.
But these two centers of consciousness are not co-
equal and independent. Under normal conditions
the activity of the thalamic center, though of a dif-
ferent nature, is dominated by that of the cortex.
When we examine ttion normally prod
by a prick, we rei ■ , lops
slowly and lasts a considerable time after the stimu-
lus has ceased. Moreover, the same intensity of
stimulation will produce a different effect 01
same spot on different occa ions. A long, latent
and want of uniformity, are char-
acteristic of all painful Si This is seen in an
exaggi rat d form in cases "her.- the thalamic center
has been freed from control. The to prick
is slow, but persists long after the stimulus has ceased.
Moreover, the reaction when it occurs, tends to be
explosive; it is as if a spark had fired a magazine
and the consequences were not commensurate with
the cause.
On the contrary, the sensations normally prodt
by moderate tactile stimuli are characterized by a
short latent period, and disappear almost immediately
on the cessation of the stimulus! A lesion of tic
sory cortex disturbs both these characteristics.
Tactile sensations become uncertain and incalcu'able,
and no threshold can be obtained; persistence and
hallucinations mar the uniformity of the records.
Now we have shown that the sensory cortex is the
organ by which attention can be concentrated on
any part of the body that is stimulated. The focus
of attention is arrested by the changes produced by
cortical activity at any one spot. These are sotted
out and brought into relation with other sensory
processes, past or present. Then the focus of atten-
tion sweeps on, attracted b} 7 some other object.
All stimuli which appeal to the thalamic center
have a high threshold. They must reach a high
intensity before they can enter consciousness, but
once they have risen above the threshold they tend
to produce a change of excessive amount and" dura-
tion, and this it is the business of the cortical mechan-
ism to control. The low intensity of the stimuli
that can arouse the sensory cortex, and its quick
reaction period, enable it to control the activity of
the cumbersome mechanism of the thalamic center.
The view of the sensory mechanism put forward in
their paper explains many of the facts already recog-
nized by both psychologists and clinicians. It
enables us to understand how integrations can occur
at all afferent levels of the nervous system, and makes
development possible even in the individual. The
aim of human evolution is the domination of feel-
ing and instinct by discriminative mental activities.
This struggle on the highest plane of mental life is
begun as the lowest afferent level, and the issue
becomes more clearly defined the nearer sensory
impulses approach the field of consciousness.
Smith Ely Jelliff!:.
Anesthesia, General Surgical. — Anesthesia (apaur-
thpla) may be defined as loss of feeling or sensation,
and general surgical anesthesia, with which this arti-
cle deals, as loss of feeling or sensation in the entire
organism during any surgical procedure, caused by
introduction into the blood of an anesthetizing agent.
It is impossible to say at what time in human his-
tory attempts were first made to relieve pain and suf-
fering. Certain it is, however, that the Assyrians
and the Egyptians were familiar with substances cap-
able of producing soporific and anodyne effects.
Homer, Herodotus, Dioscorides, Pliny, and many
other ancient writers frequently referred to such sub-
stances. Shakespeare also frequently mentioned an-
esthetizing draughts, but the production of surgical
anesthesia, as we now understand it, is a matter of
quite modern development.
During the early part of the nineteenth century
considerable attention was given to the anesthetic
properties of nitrous oxide and ether by different
observers, but no satisfactory and practical applica-
363
Anesthesia, General Surgical
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
tion was made in the induction of general surgical an-
esthesia till December, 1S44, when Horace Wells, a
dentist of Hartford, Connecticut, demonstrated the
anesthetic properties of nitrous oxide by having one
of his own teeth extracted while he was insensible
through the inhalation of this gas. Further experi-
ence with the use of this anesthetic convinced Wells
that painless tooth extraction was both possible and
practical, but after an unfortunate failure in a dem-
onstration at the Harvard Medical School this use
of nitrous oxide was generally, but undeservedly,
discredited for several vears.
On September 30, 1846, \V. G. Morton, a dentist of
Boston, employed ether vapor in anesthetizing a
patient for tooth extraction, and thereafter admin-
istered it for surgical operations with complete suc-
cess. The use of this agent rapidly spread and it was
soon quite extensively employed in America, Great
Britain, and on the Continent.
On November 10, 1847, Sir James Simpson an-
nounced the discovery of the anesthetic properties of
chloroform and, on account of Simpson's influence
and of the more rapid action and less irritating and
disagreeable vapor of the drug, chloroform began rap-
idly to supplant ether in general surgery. However,
in a few weeks after its first use a fatality was reported,
and from time to time similar casualties occurred,
until finally it became quite apparent that whatever
advantages the new agent seemed to possess its anes-
thetic use was not without considerable danger to life.
In 1847 Heyfelder first administered ethyl chlor-
ide for a surgical operation, and successfully demon-
strated its anesthetic properties; but it did not pax
into general use until about fifty years later. It will
thus be seen that surgical anesthesia and the anes-
thetic properties of nitrous oxide, ether, chloroform,
and ethyl chloride all were discovered within a short
period of three years; and in the three-quarters of
a century that has since elapsed, although replete
with research, experimentation, and synthetic produc-
tion, no widely used inhalation anesthetic has been
discovered or evolved, so that the four agents above
mentioned, used either singly, in sequence, or in com-
bination, hold practically undisputed sway in this
great and important field of modern medicine.
The Physiology of General Anesthesia. — Gen-
eral anesthetics affect all the various systems of the
organism in a more or less characteristic manner.
There is a distinct difference, however, in the effect
produced by each of the general anesthetics in the
same organism, no matter by what means or manner
the anesthetic may be introduced. Furthermore, the
same subject displays different phenomena under the
influence of the same anesthetic with only a difference
in the method of administration. Finally, subjecl .
seemingly essentially similar, display markedly differ-
ent phenomena under the same anesthetic and iden-
tical system of administration. It will be readily in-
ferred from a consideration of these facts that the
selection of the anesthetic and the practical applica-
tion of a method of administration that will secure
the desirable phenomena and avoid the undesirable,
in any individual subject, are matters that present
no small amount of difficulty.
Nitrous Oxide. — As nitrous oxide when inhaled pure
readily combines with hemoglobin, producing a dark
colored blood on account of the cells being deprived of
oxyhemoglobin, it rapidly causes cyanosis as well as
loss of consciousness and sensation. Inasmuch as
the cyanosis and anesthesia are intimately associated
when only nitrous oxide is inhaled, it was formerly
thought that the anesthesia was due to the cyanosis
or asphyxiation. However, Edmund Andrews of
Chicago, in 1868, conclusively proved, by the sim-
ultaneous administration of pure oxygen, that
nitrous oxide possessed distinct anesthetic properties
separate and apart from its asphyxial phenomena,
36 1
and that anesthesia might be secured with it when
mixed with sufficient oxygen to maintain a normal
color.
The initial sensations of nitrous oxide are of an
agreeable and stimulating character, as is the case
with the other general anesthetics, and, with oxygen
excluded, anesthesia and cyanosis rapidly follow, to-
gether with jactitation, stertor, respiratory depres-
sion, muscular spasm, and finally respirator}' failure
all usually in the order mentioned.
Under nitrous oxide anesthesia the amount of car-
bonic acid in the blood is less than during anesthesia
produced by the other general anesthetics, but accord-
ing to investigations thus far reported it produces
no permanent effect upon the cells or other constitu-
ents of the blood. Arterial tension, however, is
slightly raised by the action of this anesthetic. As
nitrous oxide is unirritating it causes no pathological
change in the cells of the tract of its administration
and elimination, or degenerating effect upon the cells
of the liver, kidneys, or brain. Its toxicity, therefore,
is very low indeed.
Ether.— One of the leading characteristics of ether is
that it is a very energetic stimulant to the respira-
tory, circulatory, nervous, and glandular systems.
Its vapor is irritating to the respiratory passages,
often causing the secretion of considerable mucus and
saliva. As is the case with nitrous oxide, its effects
are greatly increased by the limitation of oxygen. In
ether toxemia respiratory failure precedes that of the
circulation. The effect upon blood pressure is prob-
ably nil, as some observers claim that it increases
it, while others claim it produces a slight fall in
arterial tension.
The blood changes under ether anesthesia are quite
important and far reaching, affecting detrimentally,
both the quantity and quality of the blood constitu-
ents. The volume index shows an immediate loss
which is not regained till after the seventh day. The
color index shows an almost constant drop beginning
during or immediately after anesthesia and continu-
ing till the fifth or sixth day. The most important
blood effect, however, is upon the leucocytes, for while
it produces a leucocytosis it decreases the functional
activity of the phagocytes, and in this manner very
materially lowers the patient's resisting power against
infection.
In addition to its degenerative effect upon the
cells of the blood ether likewise causes a pathological
change in the cells of the brain, liver, and kidneys.
and decreases the secretion of urine as to both its
watery and nitrogenous elements. The pathological
change in the brain cells induced by ether is undoubt-
edly one of the leading factors in the depression and
shock that follow every ether anesthesia of any con-
siderable duration or depth.
Chloroform. — In common with the other general
anesthetics chloroform at first stimulates respiration,
but as narcosis becomes established the breathing is
quiet and shallow, and under full effect respiratory
paralysis follows. It is a mistake to believe that chlo-
roform always produces fatality by primary cardiac
failure, for in true chloroform toxemia the heart may
continue to beat after respiration has ceased, although
one of the leading causes of such respiratory failure is
a circulatory effect, viz., a fall in arterial tension.
Chloroform produces a dilatation of the whole car-
diovascular system. Circulatory paralysis, or sud-
den heart failure, however, is due to the use of a loo
concentrated vapor, for if precaution is taken to avoid
this the heart continues to beat after respiration
ceases. What really constitutes a too concentrated
vapor, or overdosage, is a matter that varies consider-
ably, but depends more upon the depth of res-
piration than upon any other factor other than the
percentage of vapor. Most of the fatalities with chlo-
roform have occurred during the induction of anes-
thesia, and often by the patient simply making a
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Anesthesia! Genera] Surgical
deep inspiration of a vapor, which, with an ordinary
inspiration, would doI have been too concentrated,
and, therefore, would not have been an overdosage,
Chloroform product's more destructive changes in
the cells of (he blood and liver, and less in the e
oreting cells of the kidneys, than does ether. The
degenerative visceral effects of chloroform are very
pronounced, especially upon the liver, and when taken
in connection with the immediate fatalities the com-
plete mortality is very high indeed.
Ethyl Chloride. — In physiological action ethyl chlo-
ride more nearly resembles nitrous oxide than any
other general anesthetic. It first stimulates respira-
tion and rapidly causes loss of consciousness, muscular
spasm, stertor, and cardiac paralysis. It affects the
cardiovascular system in very much the same manner
as chloroform, by causing a fall in blood pressure, and
death occurs either directly or indirectly through its
effect upon the circulatory system. Its effects upon
the blood, brain, and viscera have not as yet
investigated.
SELECTION OF THE ANESTHETIC AND METHOD OF
Administration. — The anesthetist of the present
day has at his disposal the four primary inhalation
anesthetics, a number of mixtures and combinations
of these agents, a number of sequences, and a large
variety of methods of administration, and each has
its special advantages.
In the selection of the anesthetic, as well as in the
determination of the method of administration, the
primary consideration should be the safety of the
Satient, but unfortunately this is not always the case.
[ere convenience or a slight difference in cost should
not for a single moment be weighed against the
patient's safety while on the operating table or
welfare during the period that should be one of
convalescence. Selecting a particular anesthetic
and method of administration on the basis that it is
safe in the hands of the unskilled, as is so often the
case, is unscientific and belongs to a bygone age
The surgeon never recommends a particular method of
operation because, perchance, it is safe in the hands
of the unskilled! Why then, the question may well
be asked, is the literature of to-day so replete with
the advocacy by surgeons themselves of a particular
method of administering ether because it is safe in
the hands of the unskilled? Such practice is a
stigma upon the whole profession. If any other
method or any other anesthetic is safer and better
for the patient, the necessary skill for its proper
administration will be forthcoming just as soon as
the surgeon makes a real demand for it. It is not a
valid or scientific criticism or objection against any
anesthetic or method that its use requires skill.
It is a very difficult, if not impossible, matter
to determine the real mortality of the different anes-
thetics. The personal factor of the anesthetist is
more important than the anesthetic or method, so
even if individual statistics were accurate, which is
usually not the case, they would be very misleading.
Besides, as a rule, statistics cover only the immediate
mortality, while the remote effect and its accom-
panying mortality, which with some of the anes-
thetics is high, is disregarded.
Practically all authorities agree that nitrous oxide
is the safest anesthetic known for the induction of
anesthesia, and the mortality for this particular form
of administration is very low indeed, being given by
\Yood at 1 in 1,000,000. For prolonged administra-
tion oxygen must be combined with nitrous oxide,
and while this combination is safer than nitrons
oxide alone, the mortality during prolonged use is
much higher than in brief administrations, though
it is very generally considered to be less than that of
ether. Certain it is that when the innocuous effect
of nitrous oxide-oxygen is considered, the entire
absence of any irritation of the respiratory and genito-
urinary tracts and of degeneration of the cells of
tli. 1 blood, brain, liver, and kidneys, together with its
shock-preventing and immunity-preserving quali-
ties, show that its real or total mortality is decidedly
less than (hat of el her.
It is quite certain that ether ranks second a to
safety. Its mortality is usually given a- I in 16,000.
Such statistics, however, cover only the immediate
mortality, and, when in connection with this the
remote mortality is considered, tin' real or total
mortality is much higher than the figure just given.
The mortality of chloroform is usually given as
1 in 4,000, leit tic real or total mortality, a- i- the
case with ether, is much higher than the stati tics
thai cover only the immediate mortality indicate.
The mortality of ethyl chloride is generally placed
between that of ether and chloroform, or about I in
in. null. As ethyl chloride is used chiefly to induce
anesthesia, and it is for this form of administration
upon which this rate of mortality is based, it is evident
that for such use it is many times more dangerous
than nitrous oxide.
As the majority of deaths that are given in statis-
tics occur in the induction stage, it is quite evident
that the patient's safety demands that nitrous oxide
be used as the preliminary anesthetic; also that
for this purpose ethyl chloride is much safer than
chloroform.
Difficulties and Dangers of General Anes-
thesia. — The immediate danger to the life of the
patient inhaling an anesthetic is connected with the
respiratory and circulatory systems. Either system
may be the one primarily affected, but the other
one soon becomes involved, so that it is usually a
complex state when the patient's condition is serious.
Respiratory failure may be classified under two
general heads: (1) Obstructive, (2) central.
The obstruction to respiration may arise: In the
mouth by the lips being drawn together during
inspiration; in the nose by polypi, spurs, malforma-
tion, tumors, etc., and if the mouth and lips are
tightly closed there may be complete obstruction
to the respiratory movement. At the beginning of
the administration the obstruction may be only
partial, but on account of the attending congestion
and swelling of the mucous membrane, it may later
on become complete.
The tongue, increased in size on account of conges-
tion, may cause obstruction simply on account of its
abnormal size, or, as is more often the case, it falls
backward, thereby causing more or less complete
obstruction. Morbid growths of the tongue, palate,
tonsils, pharynx, and epiglottis and foreign bodies
also offer more or less obstruction to the respiratory
movement. Excessive secretion of mucus may
produce considerable obstruction. Spasm of muscles
about the neck, jaw, and of the glottis may produce
complete and sudden arrest of respiration. Keflex
stimulation by operative procedure, distention of the
abdomen producing upward pressure on the dia-
phragm, or position of the patient on the operating
table producing the same effect, and distention of
the pleural cavities with fluid alter or obstruct normal
respiration.
Respiratory failure from central cause may be due
to an overdose of the anesthetic, loss of blood, or
shock. This form of failure usually develops insidi-
ously, and is more difficult to treat.
The most common form of sudden and temporary
respiratory arrest occurs with the act of vomiting,
and this in itself is not serious. However, if the vom-
it ns is not immediately and completely wiped away,
it may, during inspiration, be aspirated into the
trachea and thus cause complete respiratory obstruc-
tion, or, by the conveyance of infection, be the direct
cause of a subsequent pneumonia.
In the treatment of respiratory obstruction, arrest,
365
Anesthesia, General Surgical
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
or failure the cardinal principle, of course, is to re-
move the cause, and this usually is not a difficult
matter if the cause is only recognized. The anesthe-
tist must be ever alert to detect the indications of the
various cause,-, of respiratory embarrassment.
In the induction stage, or during incomplete
anesthesia, too great concentration of the vapor is the
most frequent cause of holding the breath and of
spasm of various muscles concerned in respiration. If
the spasm is not severe, the temporary withdrawal
of the anesthetic is usually sufficient; but if this does
nut relieve the condition the jaws should be widely
Fig. 203.— Hard Rubber Oral Screw.
opened with a wedge, a gag inserted, the tongue
grasped with a pair of forceps, and traction used, at
the same time intermittent compression being made
upon the chest, or actual artificial respiration being
resorted to; unless the spasm is unusually severe these
means will quickly restore nor-
mal breathing. Tracheotomy
will always afford the desired
relief, unless its use is too long
deferred, and if the spasm is
very severe, and jaws closed
and rigid, it is practically the
only available effective treat-
ment.
If the tongue falls back
against the posterior wall of
the pharynx, the patient's head
should be turned to one side and
the angle of the jaw pressed for-
ward. In case it is necessary to
keep the jaw thus pressed for-
ward, or whenever such a position does not completely
relieve this source of obstruction, a Coburn "breathing
tube" (Fig. 204) should be quickly placed in position.
This tube is specially moulded with a curve adapting
it to be slipped over the base of the tongue, and car-
dioxide in the blood. Accordingly whenever respira-
tion needs stimulation no more effective or practical
respiratory stimulant can be used than carbon dioxide.
This may be administered from two sources, allowing
the patient to rebreathe his own exhalations, or add-
ing pure carbon dioxide direct; am! with the carbon
dioxide utilized from either source pure oxygen should
be added. A very practical method, other than the
rebreathtng, is to administer from a cylinder a mix-
ture of ten per cent, carbon dioxide and ninety per
cent, oxygen. Hypodermics of atropine and a heart
stimulant, preferably adrenalin, with either caff, ine
camphor, or alcohol, may also be used. If these
means fail pharyngeal or intratracheal insufflation
of air or oxygen is the last resort. If there is a sudden
respiratory arrest, artificial respiration by Silvester'a
method must be maintained until the patient inspires
sufficient carbon dioxide to stimulate the respiratory
center, but if the patient does not respond to tins
treatment properly the insufflation should not be too
long delayed, or else circulatory failure may supervene
as well.
It is important always to bear in mind that mere
movement of the chest does not necessarily indicate
actual respiration, and in all doubtful cases the
anesthetist must immediately make absolutely sure
whether there is a true respiration or not. In some
1' ig. 204. — Coburn 's Breathing Tube.
ries a metal fitting at its outer end which fits between
the teeth, holding it in position and preventing it from
being closed during incomplete relaxation of the
jaws. The curve facilitates its introduction and
keeps it patulous. The tube is ample in size for
full and free respiratory movement, and presents
no interference with the application of any face
mask.
When respiratory failure is due to central cause the
treatment is radically different. Henderson, with his
revolutionizing theory of carbon dioxide, has shown
that the great controller of respiration is the carbon
366
Fig. 205. — Pozzi's Tongue Forceps.
methods of administration this matter is difficult to
ascertain. The Coburn apparatus has an automatic
indicator which always shows whether the patient is
actually breathing, no matter what anesthetic is used
or what method is employed.
Circulatory failure may be either gradual or
sudden. In gradual failure of circulation there is
usually ample warning. The patient becomes pale,
eyelids separate, pupils dilate, lips and finger-tips
become slightly cyanotic, pulse is fast and feeble, nose
is "pinched," cold sweat comes out on the forehead,
and the pulse finally becomes imperceptible at the
wrist or about the head.
Whenever there is marked weakening of the pulse
appropriate treatment is imperative. Before insti-
tuting treatment, however, the anesthetist should
quickly make sure of the exact condition of the pa-
tient. If the corneal reflex is abolished the anesthetic
should be withheld for a short time at least. If the
anesthesia is light and there is any tendency toward
vomiting the anesthesia should be deepened. An
absolutely free air-way should be immediately secured
ami good oxygenation maintained. A change in anes-
thetic or method may be desirable. The patient's
head should be kept low. Hypodermics of ergotol
(large amounts) and of camphor or caffeine may be
administered. A very effective treatment is a saline
infusion of 1,000 c.c. to which has been added about
forty minims of adrenalin solution, even though there
has been no considerable loss of blood. The admin-
isl ration of carbon dioxide and oxygen stimulates res-
piration and vascular tonus and thereby indirectly
greatly improves the circulation and is the most
effective single treatment for this condition, unless
the anesthetic itself is exerting a direct inhibitory
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES Amnesia, General Surgical
action upon the heart, when, of course, a change in the
anesthetic is imperal ive.
In sudden circulatory failure the anesthetic
be discontinued and the patient immediately inverted
nearly as possible, and carbon dioxide-ox
administered, using :ui ili nit rou oxide. < >r in other
words ether prod id four times as much shock as
nitrous oxide a very important scientific matter, as
, hock is a feature of every surgical operation.
Practically all critical observers agree thai in
infection the toxemia is decidedly more pronounced
after ether or chloroform anesthesia than after that
of nitrons oxide. Graham Shows that chloroform
and ether markedly impair phagocytosis, and thereby
demonstrates the scientific basis of the previously
observed clinical facl .
Pneumonia and bronchitis are sequels of general
anesthesia, most frequently Observed after ether and
least frequently after nitrous oxide. The explana-
tion of this difference is to be found in the irritant
qualities of ether vapor, and in the fact that the
resulting anesthesia markedly lowers the patient's
resistance against infection.
lEMflfJNSCC.N V
Fig. 208. — Mussey's Mouth Gag.
The irritant action of ether upon the kidneys and
genitourinary tract and the degenerating effect of
chloroform upon the liver contraindicate these agents
whenever these organs are involved. It has recently
been shown that ether also produces a degenerating
effect upon the liver, and that chloroform likewise
affects the kidneys.
In diabetes nitrous oxide is always strongly indi-
cated as the anesthetic, as coma much more frequently
follows the administration of ether and chloroform
in this condition.
Role of Carbon Dioxide.- — Dr. Yandell Hender-
son, of the Yale Medical School, in his remarkable
Fig. 209. — Cusco's Tongue Forceps.
work on carbon dioxide, has startled the entire
scientific world with his demonstrations of the vast
role that carbon dioxide, heretofore considered practi-
cally an insignificant waste-product, plays as a regu-
lator of so many of the vital functions of the human
body. His work is reported mainly in a series of
papers published in the American Journal of Physi-
ology, and I can here make only a brief summary
367
Anesthesia, General Surgical
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
ami quotation of the more important features that
pertain to anesthesia.
Respiration. — The great regulator of respiration is
nut an automaticity of the respiratory center similar
to that of the heart, or afferent nerve influences, or
need of oxygen, but the amount of CO, in the blood.
The respiratory center requires a continuously acting
stimulant to force it into constant activity. The
afferent impulses, under ordinary conditions, affect
only the rate or depth of respiration and not the
amount of pulmonary ventilation. Whenever pul-
monary ventilation is increased, the amount of CO,
in the arterial blood is thereby decreased, i.e. acapnia
results. "Perhaps there is no idea more firmly fixed
in the medical mind, or which it will be harder to
root out, than that the respiratory center is sensitive
to alterations in its oxygen supply. Yet during the
past few years it lias been ((inclusively demonstrated
that within wide limits the respiratory center is
indifferent both to excess and to lack of oxygen.
It should be added, however, that this statement
needs modification, so as to admit that conditions
which result from anoxhemia do irritate the center.
These conditions, however, are produced slowly and
in the tissues, not primarily in the center. Even
to a total lack of oxygen the respiratory center
makes no immediate response, although it may be
killed thereby.
" The crucial experiment in this field is that of
voluntary forced breathing. The experiment is so
simple and easily performed, at any time, by any
one, that it ought to become universally familiar.
It is only necessary to breathe as rapidly and as
deeply as you can (for several minutes)
Thereby you will induce in yourself a moderate degree
of acapnia. When you cease the voluntary effort
you may find that your hands are temporarily
paralyzed. Your legs and arms may be asleep.
You may shiver as in a chill. You will feel strangely
lightheaded If your efforts have been
sufficiently energetic and a considerable degree of
acapnia has been induced, when you stop forcing
yourself to breathe you will stop breathing alto-
gether. In this respect the respiratory center is
automatic. If you nave previously reduced your
store of CO„ sufficiently, you will remain breathless
and without any desire to breathe, until you turn blue
in the face," thereby demonstrating that it is not the
lack of oxygen but the amount of CO, in the blood
that is the essential factor in respiratory control.
Circulation. — The carbon dioxide content of the
blood exerts far-reaching effects upon the circula-
tion by its control over venous pressure. A decrease
from normal of the CO, in the blood causes loss of
venous tonus, and thereby lowers venous pressure —
an essential phenomenon in shock. "Both Crile and
llnmberg and Passler concluded (correctly, I believe)
that in shock the circulation fails in the same manner
as after hemorrhage, and that the heart fails because
too little blood is supplied to it through the veins.
Both found that intravenous infusion restored for a
time normal arterial pressure and heart action.
Unfortunately both labelled this true picture with
the misleading formula — the only formula for it
offered by current physiology — vasomotor failure.
Present knowledge regarding the vasomotor nervous
system indicates that its control is exercised — mainly
at least — upon the finer branches of the arterial
system Now the failure of vascular
tonus in traumatic and toxemic shock is almost
wholly in the venous system. Both Crile and Rom-
berg and Passler saw and emphasized this fact. It
seems not to have occurred to them that they were
dealing with the failure of a mechanism as yet un-
recognized in physiology. In this; they were in it
alone. For half a century physiologists have been
so dazzled by Claude Bernard's discovery of the vaso-
motor nervous system that they have neglected to
368
emphasize the fact that the circulation must involve
a third factor in addition to the heart and the per-
ipheral resistance of the arterial system. Otherwise
it would be as unstable as a stool balanced only on
two legs. It must include a mechanism, or mechan-
isms, regulating the volume of the blood, and deter-
mining the venous supply to the right heart. It is
1 1 1 i — ; venopressor mechanism, I believe, and neither
the heart nor vasomotor nervous system, which is
the essential element in the failure of the circulation
in shock.
" It is so easy to record arterial pressure and so
difficult to measure the minute volume of the arterial
blood stream that one is inclined to forget that the
pressure in the arteries is really a phenomenon of only
secondary importance The primary func-
tion of the circulation is the volume of blood pumped
onward by the heart in unit time The
heart can discharge during systole only so much
blood as distends its chambers during diastole. The
diastolic filling of the right heart depends upon the
volume of the stream flowing to it through the veins
and upon the distending pressure which this stream
affords. Venous pressure, is, so to speak, the fulcrum
of the circulation.
" The respiratory center, by regulating the CO,
content of the arterial blood within narrow limits of
variation, exerts an indirect but powerful control
of the venopressor mechanism. Any considerable
accumulation of CO, above normal augments the
venous pressure. Excessive pulmonary ventilation
tends to lower it. Acute acapnia diminishes the
volume of the blood as effectually as does an extensive
hemorrhage."
Henderson was able to produce all grades of severity
of shock in animals by excessive artificial respiration,
the increased pulmonary ventilation causing acapnia.
" Voluntary forced breathing in man, so far as
the experiment can be carried, induces symptoms
similar to those of shock. Death from failure of
respiration would probably result from vigorous
voluntary hyperpnea for fifteen to twenty minutes.
Pain, ether excitement, sorrow, fear, and other con-
ditions inducing shock, involve excessive respiration.
" Excessive artificial respiration, applied to dogs
for twenty-five to thirty minutes, is followed by
apnea so prolonged that the heart fails, after seven
to eight minutes, for lack of oxygen. The inactivity
of the respiratory center is solely due to the depletion
of the body's store of C0 2 Administra-
tion of CO, gas during apnea induces an immediate
return to natural breathing. Administration of
oxygen by the Volhord method affords ideal condi-
tions for recovery from acapnia, and prevention of
asphyxial acidosis."
The dangers of anesthesia that are concerned in
the acapnial theory are thus summarized by
I tenderson:
" 1 . Anesthetics tend to prevent shock because they
diminish pain-hyperpnea, and thus obviate the de-
velopment of acapnia.
"2. Respiratory excitement during the initial
stages of anesthesia diminishes the C0 2 content of
the blood, and thus tends to induce a subsequent
failure of respiration.
" 3. Morphine raises the threshold for CO, more
than it does the afferent threshold of the respiratory
center. Chloroform elevates the latter threshold more
than the former. Ether in quantities short of pro-
found anesthesia exerts a respiratory stimulant in-
fluence which lowers the threshold for C0 2 , and thus
tends to induce acapnia.
"4. Apnea in anesthesia depends, in the same
manner as in normal life, upon the relation of the
level of the threshold of the respiratory center
for CO, to the quantity of CO, in the blood and tis-
sues. Whenever the former is above the latter,
spontaneous breathing ceases.
IiEKKUKXCK HANDBOOK OK THE MEDICAL SCIENCES
Anesthesia) General Surgical
"5, Under anesthesia the threshold for Co.. may
be elevated fifty per cent, above normal, or depressed
fifty per cent, below normal. Such a depression
of the threshold causes vigorous hyperpnea. If
Inns,' continued, it results in intense acapnia.
■•~ii. Chloroform apnea may be regarded as
merely a form of apnea vera.
"7.' Experiments show thai ether-hyperpnea is quite
fective as pain-hyperpnea as u means of inducing
a suoscqui nt fatal apn> a r, ra.
Kg, in normal subjects under chloroform respi-
ration always fails before the heart. Subjects which
passed through a period of sickness and suffering,
or tin ir experimental equivalent, are hyper-susceptibli
to the toxic influences of chloroform.* In uchca es the
circulation failsfirst, or simultaneously with respiration.
i. Hypercapnia during anesthesia may be the
factor which determines the development of chlor-
oform necrosis.
"10. Skilful anesthesia consists in maintaining
the threshold of the respiratory center for CO s al a
\ normal level, and in avoiding the developmenl
either of acapnia or of hypercapnia."
The Signs and Stages of Anesthesia. — For
enience of description the phenomena of anes-
thesia are usually divided into four stages:
1. The first stage extends from the beginning of
the administration to complete loss of conscious-
ness. The phenomena observed in this stage arc
dependent largely upon the manner of administration
and the character of respiration. If the anesthetic
is cautiously and skilfully administered, and the
patient breathes fully and regularly, the induction is
doI disagreeable, but if the anesthetist is unskil-
ful the first stage is distinctly unpleasant, especially
if the patient is nervous or becomes excited, and
ether or chloroform is the anesthetic. With such
quickly acting anesthetics as nitrous oxide and
ethyl chloride this stage is very short and the pa-
tient usually experiences no unpleasant sensations.
During this period the room should be kept as quiet
as possible, conversation being especially prohibited.
During this stage there is increased cardiac action
with a rise in blood pressure, and respiration is in-
ised in frequency and depth unless modified by
emotional disturbances or irritant action of the
anesthetic vapor; the pupils are dilated.
2. The second stage extends from the loss of
consciousness to the loss of the corneal reflex, and
is otherwise known as the stage of "struggling,"
for during this period many patients, especially
those addicted to alcohol or to smoking, struggle
more or less violently. While assistants should
be at hand to prevent self-injury if the patient strug-
gles, yet the patient should never be forcibly re-
strained as that increases the tendency to struggle.
The limbs are often rigidly extended, respiration
is temporarily suspended "through contraction of
t ho muscles controlling respiratory movement, and
the jaws are at the same time firmly clenched. The
respirations become deeper and more frequent unless
impeded by muscular spasm, deglutition, etc. Heart
action is still further increased, much depending,
however, upon respiration. It is in this stage, espe-
cially if there be struggling and holding of the breath,
that chloroform becomes so dangerous, for when there
has been no breathing for several seconds and a deep
inspiration is taken, as is often the case, sufficient
chloroform for a fatal overdose may be inhaled and ab-
sorbed even though the strength of vapor would have
been tolerable under normal respiration. With ether
the patient's skin will be flushed, and the secretion
of mucus and saliva increased. The pupils are
smaller than in the first stage.
3. The third stage, otherwise known as the stage
of surgical anesthesia, begins with the loss of the
* The italics are mine.
Vol. I.— 24
corneal reflex. The muscular rigidity of the second
stage disappears in the third stage, but more quickly
under chloroform than under ether or nitrous oxide.
Under ether the patient is more florid, if there is
ufficienl oxygenation, the secretion of mucus and
saliva is still further increa ed, and the circulation
still further stimulated. If chloroform is being ad-
ministered it is of the Him" I importance thai there
should be good oxygenation of the blood, so evidences
of pallor or of cyanosis, especially about the lips
and cars, should be closely watched, as even mild
asphyxia greatly increa e the depre ing effect of
this anesthetic. Accordingly it is of the utmost im-
portance that the air-way be open and respiration
free and not obstructed in any way whatever when-
ever chloroform is being administered. The color of
the face, more especially of the lips and ears, is a
reliable index of oxygenation.
The character of the respiration is perhaps the
most important single guide in the maintenance
of the proper degree or depth of anesthesia. The
rhythm in this stage is regular under all anesthet-
ics, increased in frequency and depth under nitrous
oxide and ether, and somewhat decreased in these
respects under chloroform. At the time of mak-
ing the initial incision the anesthetist should notice
if this procedure alters the respiratory movement
in any way, and if it does, the anesthesia should be
immediately deepened. A careful watch should be
at all times kept of the respiration, as slight changes
in it will forewarn the experienced administrator
of impending danger. The anesthetisl musl not only
know that air is passing into and out of the lungs,
mere movements of the muscles of respiration not
being sufficient, but he must also know about what
the volume is. If the breathing in this stage becomes
quiet and shallow it is because the anesthesia is
cither too light or too deep. If the former, the lid and
corneal reflexes will be present and more of the
anesthetic should be administered; if the latter, the
pupil will be widely dilated and the lid and corneal
reflexes abolished, and the administration should be
held in abeyance temporarily.
The pulse in the third stage also settles down to a
regular rhythm and volume, increased in both re-
spects under nitrous oxide and ether, and slightly
decreased under chloroform. The pulse should be
taken at frequent intervals, as sudden changes may
take place at any time in both heart action and blood
pressure. As the operation proceeds the tendency
is for the pulse to increase slightly in frequency and
decrease in volume, but any considerable change in
these respects demands attention, as shock may be
developing.
The pupil is of value in determining the depth
of anesthesia ordinarily only when there has been
no preliminary hypodermic medication that affects
its size. As the tendency to the use of such medi-
cation is increasing, and rightly so, less and less
attention is being given to the size of the pupil;
although it is a very delicate indicator when no such
medication has been used, yet it is not at all essential.
In the surgical stage the average size of the pupil
under ether is about 4 mm. in diameter, and about
2.5 mm. under chloroform. A contracted pupil
indicates a light anesthesia, while a dilated pupil
indicates cither a light or a deep anesthesia. When
it is dilated under a light anesthesia, the lid and cor-
neal reflexes are present and the dilatation is due to
reflex stimulation by the operative procedure, and
of course indicates that more of the anesthetic should
be given if a deeper anesthesia is desirable. If the
pupil is dilated and the corneal or lid reflex is absent
the anesthesia is deep, and the further adminis-
tration of the anesthetic must be carefully watched,
for the danger line has been reached. Even with
these conditions present it is sometimes necessary in
the administration of ether to increase further the
369
Anesthesia, General Surgical
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
depth of anesthesia by adding more of the anesthetic
in order to obtain complete relaxation, but in such
instances the anesthetist must be thoroughly alert
and watch the pulse, respiration, and color most
assiduously. When the upper lid is raised quickly
the pupil responds to the stimulation of light by
contracting during a light or moderate depth of
sthesia, but in deep anesthesia it remains dilated.
Muscular movements in the surgical stage are
usually in complete abeyance, but it is not necessary
or even desirable that this depth of anesthesia should
always be maintained. It is well to bear in mind
that coughing, vomiting, etc.. with, of course, special
exceptions, occur during light anesthesia, and that
anesthesia should be maintained at such a depth
that these phenomena are suppressed whenever
their occurrence would interfere with the work of
the surgeon. The invariable rule should be that the
patient receive as little of the anesthetic as is neces-
sary to procure the depth of anesthesia desired for
the particular procedure. For some operations the
anesthesia may be very light, while for certain others
it must be profound. In a general way it may be
said that abdominal operations and those upon
the genitourinary organs require a deep anesthesia.
but even this is subject to exceptions. Some pan
particularly alcoholics, require a large amount of the
anesthetic to produce the desired state of anesthesia,
while others, particularly the debilitated and elderly
subjects, and more especially women than men,
require only a small amount to produce the same
effect.
The aim should be not only to administer the min-
imum amount of the anesthetic, but also that the
rate of administration be continuous and as even as
practical, so as to maintain a smooth anesthesia.
i. The fourth or toxic stage is not separated from
the third or surgical stage by a clear line of demar-
cation. However, the general condition of a patient
suffering from an overdose of the anesthetic is so
different from that of one properly anesthetized that
even the onset of the fourth stage is readily recog-
nized by the experienced observer. The respiration
is shallow, usually increased in frequency under
ether, and decreased under chloroform. The pulse
is very feeble and rapid, though it may be slow under
chloroform. The eyelids separate. The face is
"deathly pale" under chloroform, and cyanotic
under ether. The nose is cold and cold sweat appears
upon the forehead. There is a peculiar expression
of the face. The pupils are widely dilated and fixed,
and the lid and corneal reflexes are entirely absent.
In case ether is the anesthetic the patient is not
in so much imminent danger, as when chloroform
is used to a toxic degree, for in the former instance
the patient usually recovers if the condition is recog-
nized, the administration stopped, and appropriate
treatment instituted. With chloroform, however,
this stage is much more serious, as irreparable dam-
age may have been done before the serious condition
of the patient is recognized.
The IxDrcnox of Anesthesia. Preparation
of the Patient. — In all but emergency cases the patient
should undergo a preparation before being anes-
thetized. Whenever possible the diet should be
supervised and regulated, the bowels kept open,
and tobacco and alcohol avoided for twenty-four to
forty-eight hours immediately preceding a major
surgical anesthesia; for a minor anesthesia a less
rigid regime should be followed, as far as circum-
ill allow. Whenever possible the patient
should undergo a rigid physical examination prefer-
ably a day or more prior to the anesthetization,
special attention being given to the condition of the
heart, lungs, kidneys, blood, and to the state of the
bowels. Oftentimes an appropriate course of med-
ical treatment will improve the patient's condition
and fortify it against the shock and depression of the
anesthetic and operative procedure. The attending
physician will often furnish valuable information
o the patient's peculiarities and idiosyncrasies.
The ingestion of food and fluids should be regulated
so that the stomach is empty at the time of anes-
thetization. The bowels should be emptied, but not
by drastic means, shortly before the administration,
unless there is some special contraindication, while
the bladder should be emptied immediately prior to
the anesthetization. Children especially are liable
to micturition under nitrous oxide unless the bladder
is thus emptied.
The mouth should be examined in all cases to in-
sure the removal of all artificial teeth that are not
firmly fixed. Notice should also be made of loose
teeth which ruay become dislodged by spasm of the
muscles of the jaw, or during the introduction of a
mouth wedge or gag.
All examinations of the patient just prior to the
administration of the anesthetic should be very brief
and tactful, as the patient, at this particular time,
is highly susceptible to nervous impressions, and
consequently much more damage than benefit rnav
follow an extended examination at this time.
Apparatus, Appliances, and Remedies. — The anes-
thetist should, if practical, have his apparatv.-
perfect working order before the entrance of the
patient, or if the anesthesia is to be induced or main-
tained in the patient's room the apparatus should be
inspected and placed in order beforehand.
The anesthetist should always have conveniently
at hand, in addition to the apparatus or applia'
for administering the anesthetic, the necessary instru-
ments and remedies for the prompt
treatment of any accident or compli-
cation that may arise at any time
during the administration. This in-
cludes a mouth wedge, a gag. tongue
forceps, mouth prop, a hypodermic
syringe, and solutions of adrenalin,
or its equivalent, atropine, digitalin,
morphine, caffeine, camphor in oil,
ergotol, whiskey, a "'breathing tube," oxygen and
carbon dioxide in cylinders, and means for perform-
ing tracheotomy and pharyngeal or intratracheal
insufflation.
In using a tongue forceps of the pressure-contact
form care must be exercised not to make too much
pressure or allow it to be applied too long, as it may
cause serious injury to the tongue, consequently
a puncturing tongue forceps (Fig. 205) is very useful.
Mouth props are used in practically all dental cases.
and in all other surgical cases where it is desirable to
keep the mouth open for a considerable period of
time, or where the gag interferes with the applica-
tion of the face mask, especially when nitrous oxide
is being used.
The '"'breathing tube" is very useful whenever
there is respiratory obstruction at the base of the
tongue as often occurs under nitrous oxide and less
frequently under ether. In suspension of respiration
it is also highly useful, as this part of the respir-
atory tract can thereby be kept open and a mask
applied tightly to the face, and oxygen, or preferably
oxygen and carbon dioxide, forced into the lungs,
while artificial respiration is simultaneously main-
tained.
The use of the hypodermic solutions alone should
never be depended upon in any serious case, and in
emergencies they are of little or no value, but when
possible they should be conveniently at hand so as
not to delay their prompt administration, when
wanted. The hypodermic injection during the
administration should be given b}- an assistant, and
not by the anesthetist.
The apparatus for the administration of anesthetics
should be simple in design, construction, and opera-
Fta _10. — Clover's
Mouth Prop.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Anesthesia, General Surgical
ii,,n, ->i as to be easily manipulated under the varying
conditions in which it has to be used. No matter
how apparently efficient ii may be, a large, cumber-
some, and i iplicated apparatus is open to criticism.
Ml apparatus and appliances should be kepi thor-
oughly cleansed and sterilized, and no apparatus
deserves a second consideration thai cannol be easily
and thoroughly sterilized. Since the recent intro-
duction of rebreathing in the administration of nitrous
oxide most of the designers and manufacturers of
uratus for such use have lost sight of the fact that
rebreathing should cause a change in construc-
tion, so that all parts contaminated by the rebreathing
be sterilized. Regardless of this fact hundreds
of apparatuses for administering nitrous oxide
by rebreathing through an integral part of a large
and cumbersome stand, not capable of practical
sterilization, are being used in this country. Such
practice is to be strongly condemned. It is little
short of criminal to compel a patient to breathe
hark and forth through an apparatus contaminated
by the expirations of a previous patient suffering
from tuberculosis or other infection. Complete
sterilization is indispensible in the rebreathing
method.
Morphine before Anesthesia. — The use of mor-
phine hypodermically as preliminary medication to
general anesthetic has been growing in favor, and
is now recognized as a good procedure. It has long
been noticed that pal ients who suffer from fright and
fear preceding the anesthesia or during its induction,
suffer greatly from shock, and that out of all pro-
portion to the extent of the operative procedure.
That, such fright and fear produce distinct patho-
logical lesions of the brain cells has been clearly and
lusively demonstrated by C'rile. A hypodermic
injection of morphine one-half to one hour preceding
the anesthesia quiets the patient's nerves, induces a
tranquil state of the higher centers of the brain,
dispels fear, and creates a pleasant state of mind,
thereby preventing or minimizing the shock that
usually follows the preanesthetic state. Besides,
after this preliminary medication the induction of
anesthesia is smoother, quieter, and more rapid,
relaxation is more complete, and a lesser amount of
the anesthetic is required throughout the entire
administration. While this medication alters the
size of the pupil, yet there are so many other and
more reliable signs in determining the depth of
anesthesia that this objection to the use of mor-
phine may be disregarded, for its benefits far out-
weigh its disadvantages. In prolonged anesthesia
under nitrous oxide the use of morphine, combined
with either atropine or hyoscine (scopolamine), is
practically imperative, as morphine aids materially
in securing muscular relaxation, and prevents the
inhibitory action of nitrous oxide upon the heart.
Moreover, morphine alone should never be used in
nitrous oxide anesthesia on account of its depressing
effect upon respiration.
Administration and Subsequent Treatment. — It is
preferable to anesthetize some patients in their own
room, others in the regular anesthetizing room, while
with nitrous oxide it is often advisable to anesthetize
on the table in the operating room, with the patient
previously prepared and in proper position. Wher-
ever the patient is anesthetized, and whatever anes-
thetic is used, the aim should always be to subject the
patient to the shortest possible influence of the
anesthetic, consequently the administration should
never be begun until all the other preparations con-
nected with the operative procedure are either com-
pleted or will certainly be completed at such a time
as not to delay the continuous and expedituous work
of the surgeon just as soon as the patient is brought
into the proper degree of anesthesia. Any consider-
able handling and moving of a patient in the state of
surgical anesthesia is to be condemned. Except in
the case of nitrous oxide or ethyl chloride the induc-
tion should alwaj - be made w ith the patient lying on
his back with the head in the body plam and prefer-
ably turned a little to one side, the head thereafter
being kept iii thai plane if pos ible. With few excep-
tions it is dangerous to ke.-p the head of a fully
anesthetized patient above the body level.
During the administration of an anesthetic it
is quite important that the clothing about the
patient's chest and neck should be light and loo i ly
lilting, the room warm, and the patient's limbs
especially protected with blankets. The anesthe-
tist should see that the patient's chest is not encum-
bered with heavy instruments, and that none of the
assistants should lean i hereon. Also t hat the patient's
entire body be kept properly covered, and as warm
and dry as is compatible w ith the operative procedure
at hand, and thai this same care in this respect be
exercised until the patient is afterward placed
in bed, for undoubtedly much of the unnecessary
exposure which one sees in many Operating rooms ami
in the handling and transference of anesthetized pa-
tients through cold and draughty halls, is a very great
factor in the subsequent complications and sequela
that occur, and for which the anesthetist or the
anesthetic is often held responsible.
After the operation is finished and the dressings
are applied, the patient's wet clothing should bore-
placed by dry, and the patient carefully lifted onto
the stretcher or carried to his bed, care being used
not to elevate the head. The bed should have been
previously warmed by hot-water bottles or by ironing
the sheets. The room should be of a temperature of
about 06° F., and well ventilated, but with abso-
lutely no draughts, and the patient should be kept
warm by proper clothing and artificial heat when
indicated. The anesthetist should see that the pulse,
respiration, and color are satisfactory, and that
the reflexes are returning, and when these con-
ditions are met his responsibility in the case ordi-
narily ceases. The patient's head should be only
moderately elevated, unless there are special indica-
tions for deviating from this rule. When the cir-
culation is poor the foot of the bed should be elevated.
The patient should be kept quiet and moved as
little as possible, as otherwise vomiting and syncope
are more likely to occur. The room should be
darkened, and kept quiet and the patient should
be encouraged to sleep. All anesthetized patients
should be carelully watched until complete conscious-
ness returns.
The time when water and food may be allowed
varies w-ith different anesthetics and with the gas-
tric condition of the patient. In general it may be
said that they may properly be allowed much sooner
after nitrous oxide than after chloroform or ether.
If postanesthetic vomiting occurs there should be
abstinence from food and water for several hours,
excepting that small amounts of very hot water at
frequent intervals may be administered to allay
nausea and vomiting. A rectal injection of 1,000 to
1,500 c.c of saline solution at the completion of the
operation has a tendency to relieve thirst and improve
the circulation, and is a good routine procedure after
major operations.
The Practical Administration op Anesthet-
ics. — Nitrous oxide, N,(), is a colorless and prac-
tically tasteless gas, and is known either under its
chemical name or as "gas," or "laughing gas," on
account of its specially pleasant effect upon the emo-
tions. Under a low "temperature and high pressure
it becomes a liquid, and the nitrous oxide of commerce
is in this form, stored in steel cylinders, varying
in capacity from twenty-five gallons to several thou-
sand gallons. As heat expands liquid nitrous oxide
the cylinders containing it should not be exposed to
any high temperatures, as an explosion may result,
371
Anesthesia, General Surgical
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
although interstate commerce cylinders must be
provided with an appropriate safety device which per-
mits the gas to escape, before the pressure becomes
dangerously high. The gas weighs one ounce to each
four gallons, and by knowing the net weight of the
cylinder, which is always marked thereon, the amount
of gas in each cylinder can be determined quite
accurately. This is a very important matter when
nitrous oxide is to be used in major anesthesia outside
of hospitals where there is no reserve supply at hand.
Institutions using large amounts of nitrous oxide
find it practical to manufacture their own gas in a
private plant, usually located in the basement,
store it in gaseous
form in a large tank,
and pipe it to the
operating rooms, ils
cost being thereby
greatly reduced.
Nitrous oxide is
administered i n
several ways, and
as the technique of
each is slightly dif-
ferent the several
methods will be de-
scribed in more or
less detail. These
different methods of
administering ni-
trous oxide are: (1 )
Nitrous oxide
alone; (2) nitrous
oxide with air; (3)
nitrous oxide with
oxygen; (4) nitrous
oxide-oxygen, with
ether as an adju-
vant; (5) nitrous
oxide as a prelimi-
nary to ether; (C)
nitrous oxide-oxy-
gen by the intra-
tracheal method,
and For brief adminis-
trations nitrous
oxide is remarkably
free from danger, being for this purpose much
the safest anesthetic known. It also possesses the
great advantages of being practically tasteless and
odorless, rapid in action, and quickly eliminated,
the patient losing and regaining consciousness in
very short periods of time with comparative freedom
from unpleasant after-effects. While for this form
of use it is not essential that there be t lie usual pre-
liminary preparation of the patient it is desirable
that the stomach be at least comparatively empty,
and in children and nervous folk the bladder should
be empty. Usually t he patient is able to arise and
walk in a very few minutes after such adminisl rat ions.
For the prolonged administration of nitrous oxide
there should he the same preliminary preparations
of the patient as with the other anesthetics, and
while consciousness returns very quickly after this
anesthetic is withdrawn yet the patient should not
be permitted to make any undue exertion for the first
hour after a major anesthesia.
The Apparatus. — The apparatus for administering
nitrous oxide is of necessity more complicated than
that for the other anesthetics. However, experience
has shown that the large, heavy, and cumbersome
apparatus is not only not necessary, but a distinct
disadvantage, for in the light of present day science
the principles underlying the administration of the
different anesthetics are so similar that one apparatus
may advantageously be used for all anesthetics and
for all methods except those highly specialized.
The Coburn apparatus, devised by the author,
Fig. 211.
—Hewitt's Nitrous < >\i.k'
Oxygen Inhaler.
and herewith illustrated, is based primarily upon
the principle of simplicity. While for administering
nitrous oxide a special stand is not necessary for
holding the cylinder or cylinders, such a stand is
however, highly desirable, convenient, and useful'
The stand should furnish means for holding at least
two cylinders, so that when one cylinder is exhausted
a fresh supply is at hand and ready for instant use
without delay. The stand should also provide means
for holding two cylinders of oxygen. Instead of one
of the other cylinders mentioned a cj'linder of CO,
gas or of a mixture of CO., gas and oxygen may be
attached. Certainly such C3 r linders should always
be in the operating room at least, ready for immediate
use at any time.
The hospital stand (Fig. 212) carries four cylinders,
and is constructed so that means may be added for
holding two additional cylinders. It matters not in
what order or position the different cylinders are
attached .-is they all. both singly and conjointly,
communicate with the tubing that leads to the rubber
bag. The stand is strong, and will support the
medium sized cylinders. It is mounted upon wheels
Fig. 212. — Coburn Apparatus Complete, with Hospital Stand,
for Adniinistei itijr ami Warming Nitrous < >xide-oxygen aud Ether
by the Rebreathing Method.
and may readily be moved about the operating room
or from one room to another with the cylinders
attached. In the center it carries two shelves on
which may be kept all the paraphernalia of the anes-
thetist and the inhaler when not in use. It serves,
therefore, as a combined anesthetist and cylinder
stand.
The portable stand (Fig. 213) is of light construction
and so arranged that it may be very easily and quickly
assembled or taken apart and folded into a small
space, thus rendering it readily portable. It is
mounted on castors and supports four cylinders,
372
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Aiirsthc^i.i, General Surgical
which either singly or in combination communicate
with the rubber tubing that leads to the rubber stop-
cock attached to the rebreathing bag
Fig. 213.-
Apparatua w
nil Folding, Portable Stand.
The neck of the bag is attached to a metal fitting
which carries a shut-off and air-vent operated
together; when the ether attachment is not used this
fitting is attached directly to the inhaler. The
inhaler carries an inner tube in which are
located two light and delicately acting valves,
so arranged that one prevents breathing back
into the bag when the exhalations are to escape,
while the other prevents air being inspired
through the expiratory orifice during inspira-
tion. When there is to be rebreathing the
valves are both thrown out of action and the
expiratory orifice is closed by turning the little
knob (rebreathing control) through an angle of
90°. To the inhaler is attached a face mask
(made either of transparent celluloid or of
metal) which carries an inflatable rubber hood.
The ether attachment consists of a chamber
for holding the gauze and a cup for holding the
ether, the bag carrier fitting into one end of the
chamber and the inhaler into the other. The
opening at the end of the chamber into which
the bag carrier slips is quite large, and through
this opening the necessary gauze is easily and
quickly placed within the chamber. As the
chamber is ample in size it is never packed, but
just loosely filled with coarse gauze. The cup
is attached to the chamber and may always be
maintained in an upright position by turning
the chamber on its connection with the inhaler.
At the top of the cup is a needle-point valve
for controlling the flow of the ether upon the gauze
in t he chamber. As the ether drops from the cup
upon this gauze it can be plainly seen, and the rate
of administration can thus be accurately regulated at
all times.
The rubber bag and the ether attachment extend
either back over the patient's head or down over the
chest.
A small and light electric heater (] ig, 215), which
may lie connected to any lamp socket, either diri I
or alternating current, i- attached to the chamber
by spring clamps whenever it is desired to warm
the vapor. A small rheostat i- provided to control
the radiation. This heater may l>e attached or
detached at any time without interrupting the
administration of the anesthetic, and it thoroughly
warms all the vapor to body temperature at the
time it is inhale, I,
Systems of Administering Nitrous Oxide.— 'There
are two systems of administering nitrous oxide: (1)
Without rebreathing; (2) with rebreathing.
1. In the first system the exhalations all pass
out into the air, and the patient continuously in-
spires fresh nitrous oxide either with or without
other additions (air, oxygen, or ether); this is its
nei-i e .p. nsive I or ui of admin ist rat ton, as the patient's
respiratory movement, under nitrous oxide averages
"Joll gallons per hour.
_'. In tin- system of rebreathing there are two
fundamentally different principles:
(a) When the supply of nitrous oxide is a con-
tinuous flow only a part of each expiration passes
back into the bag and is reinhaled, the other part
escapes from the inhaler into the air. .Most of
the apparatuses for this form of administration re-
quire the patient to rebreathe through a long tube.
This tube presents a two-fold disadvantage: (1) it
requires energy to breathe back and forth for a length
of time through a long tube; at the same time _')
it causes an unnecessarily high retention of carbon
dioxide, inasmuch as one expiration does not reach
the bag before the next inspiration takes place, and
this inspiration, therefore, consists almost entirely
of a mixture of the previous expiration and the con-
tent s of the face mask and tube only; consequently
the patient continually inspires a higher percentage of
carbon dioxide than would be the ease were the bag
placed close to the patient's face. This method of con-
tinuous supply and rebreathing through a long tube
requires about 125 gallons of nitrous oxide per hour.
(6) When the supply of nitrous oxide is inter-
mittent, the patient breathes back and forth into
"EE-DLE y*l.VE
f ■ ■ n r
Respcath^
Inhaler
\
RcarTEATHtNa
CONTROL
\
Fig. 214. — Coburn Apparatus for Administering Ether and Ethyl Chloride
by the Rebreathing method, Stand Disconnected.
the bag from one to eight minutes, by which time
the bag is emptied, usually by the exhalations escap-
ing from the inhaler instead of passing back into the
bag. The bag is then refilled and the patient again
rebreathes the bag of gas the desired length of time.
373
Anesthesia, General Surgical
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
The method of intermittent supply and rebreathing
requires an average of about thirty gallons of nitrous
oxide per hour, and is therefore much the most econom-
ical method of administration. Besides it is the more
scientific, as the stimulant action of carbon dioxide on
respiration is needed to counter-balance the depressing
respiratory action of nitrous oxide, as well as to pre-
vent shock. And in the method of intermittent supply
of nitrous oxide the amount of rebreathing, and conse-
quently the carbon dioxide retention as well, is under
much better and more positive control.
Fig. 215. — Coburn Apparatus for Administering and Warming all
Liquid Anesthetics by the Open Drop Method.
Rebreathing nitrous oxide undoubtedly renders
its administration, whether short or prolonged, much
safer, and at the same time the resulting anesthesia
is deeper, smoother, and better in every particular.
Pure Nitrous Oxide and Nitrous Oxide with
Air. — In addition to the apparatus and gas the
anesthetist should also be provided with at least a
mouth wedge, props, tongue forceps, a gag, and, if
possible, the other accessories previously mentioned.
In dental work the mouth prop should be placed in
position before the administration begins. All such
props should have a ligature attached so that they
may not be swallowed should they become displaced.
For short anesthesias — the only form of administra-
tion for which nitrous oxide alone, or combined with
air is adapted — the patient may be placed in any posi-
tion required by the operator, except in grave car-
diac cases, but usually a semirecumbent posture gives
sufficient elevation of the head. It is important
that the respiratory movements and the air-passages
be unobstructed at all times.
The rubber cushion should be well inflated, the
bag nearly filled with gas, with the air-vent open
and shut-off closed. With the expiratory orifice
open the inhaler is next placed over the patient's
face, care being exercised to see that the mask and
inflated cushion form an air-tight fitting with the
patient's face. The patient is allowed to make a
few respirations in order to get accustomed to the
apparatus and to learn that it need cause no appre-
hension. Air is being inspired through the air-vent,
and the expirations escape at the expiratory orifice.
After thus breathing a few times, the air-vent is
closed. The patient now inspires nitrous oxide from
the bag and all the exhalations escape at the expi-
ratory orifice. After making four or five such exhala-
tions, so that the air in the apparatus and respira-
tory tract may be replaced with nitrous oxide, the
expiratory orifice is closed, and the patient now re-
breathes nitrous oxide back and forth from and into
the rubber bag. During all this procedure the room
should be kept quiet.
The induction of anesthesia with nitrous oxide is
usually so rapid that it is impossible to divide it into
all the different stages. The first effect usually dis-
cernible is a change in the patient's color; at first
it is a little dusky, grows darker, and finally becomes
markedly cyanotic, the breathing becomes loud and
stertorous, and jactitations or irregular muscular
contractions rapidly follow, unless the administra-
tion is stopped or air (or its equivalent) admitted.
The administration should not be pushed to the point
of causing jactitation, so whenever there is marked
cyanosis or stertor the anesthetic should be discon-
tinued, or the air-vent opened for one or two inha-
lations of air (the shut-off operated simultaneously
automatically prevents the waste of the nitrous oxide).
The administration may be continued by allowing
the patient to inspire a breath of air about e
five respirations. A bag full of nitrous oxide may
thus be rebreathed for from three to five minutes.
The time required to produce anesthesia varies
from a few seconds to a few minutes, the average
being a little less than one minute.
The administration of nitrous oxide pure and com-
bined with air should be confined to dental and
other very brief operations when a complete anes-
thesia is not required.
In some cases, especially for dental work, it is
desirable to administer nitrous oxide so that at the
same time the oral cavity may be open and unob-
structed for operations therein. For this purpose
a nasal inhaler is used and the gas is forced into the
nasal passages under pressure. It is absolutely
essential that such an inhaler make an air-tight fitting
over the patient's nose, and that a net be placed over
the rubber bag to prevent its excessive expansion
under the pressure necessary to force nitrous oxide
through the patient's nasal passages. If a Macintosh
bag is used the net is not needed.
The patient is anesthetized in the same manner
as with the face inhaler except there is no rebreathing
and the mouth is kept covered with a small sheet of
rubber. "When the patient is anesthetized the ex-
piratory orifice is closed, and nitrous oxide is forced
through the nasal passages, while the mouth is open
during the performance of the operation. Although
the patient necessarily inspires considerable air
through the mouth, it is advisable to administer
simultaneously a small amount of oxygen when in-
dicated by the patient's color.
The state of analgesia in which there is loss of setts
sation of pain but not loss of consciousness, and which
is now very much used in dentistry, is secured by
administering a somewhat smaller amount of the
anesthetic than is necessary for anesthesia. In this
form of administration for dental purposes the nasal
inhaler is used, and as the mouth is open, more or
less air is inspired through it, consequently very little
additional oxygen is required in prolonged adminis-
trations. Analgesia might be termed "anesthetic
intoxication."
Nitrous Oxide with Oxygen. — The administration
is begun the same as that of nitrous oxide pure, but
at soon as the patient shows the first tinge of cyano-
sis, pure oxygen, in a small amount, is added from a
cylinder to the rebreathing bag. The anesthetist soon
learns to gauge the amount of oxygen needed, being
cautious not to add too much, as more can be added
at any time if the color indicates that the oxygena-
tion is deficient. It is entirely unnecessary to know
the percentage of oxygen used; sufficient oxygen
should be added to maintain a normal oxygenation,
374
RKFEHEXCE HANDBOOK OF THE MEDICAL SCIENCES
Anesthesia, General Surgical
and as the patient's color is the most, delicate indi-
ator no other guide is needed.
After the patient has rebreathed a bag of gas from
two to eighl minutes the expiratory orifice is opened,
and the bag is automatically emptied by the exhala-
tions passing out into the air. Just before the bag is
mletely empty the expiratory orifice is closed,
the bag is nearly refilled with nitrous oxide, and the
indicated amount of oxygen added, or, if the patient
lightly cyanotic, the oxygen maybe added Brst.
thus rebreathing a bag of gas and oxygen for a few
s, emptying and refilling in turn, as outlined,
this form of anesthesia may be maintained as long as
desired. Care and skill, however, must be exercised to
maintain, as nearly as possible, a normal color of I he pa-
1 s cutaneous circulation, for a continued cyanosis
throws considerable extra strain upon the heart.
On the other hand, too much oxygen should not be
i, as it lightens the anesthesia. It requires a
little aptitude and experience to administer this
anesthetic throughout a prolonged operation and
io pilot the patient successfully through the narrow
mnel that lies between a too light and a too deep
anesthesia. The best guide in maintaining the
proper depth of anesthesia is the respiration and the
respiratory sounds.
The amount of rebreathing is to be governed by
depth of anesthesia and the effects of the retained
carbon dioxide. As a considerable amount of
the nitrous oxide is absorbed by the blood the
anesthesia may become too light on account of the
diminished strength of the gas in the bag, so that it
is not advisable to rebreathe the maximum period.
The effects of the retained carbon dioxide upon
respiration are very noticeable. As has been shown
by Henderson, the respiratory center is controlled
by the amount of carbon dioxide in the blood. When
the carbon dioxide is increased (the threshold of the
respiratory center remaining the same) pulmonary
ventilation is increased, i.e. respiration is stimulated
in frequency, or depth, or both. When the carbon
dioxide in the blood is low, respiration is depressed
and the venous system loses its tonicity. When the
veins dilate less blood reaches the heart, and there-
fore less blood is pumped on through the circulatory
system, consequently shock supervenes.
As nitrous oxide primarily stimulates, and finally
depresses respiration, there is a special indication for
its administration by rebreathing, so as to secure the
direct stimulant action of carbon dioxide upon the
respiratory center. Besides, the increased rate and
depth of respiration permit of the absorption of a
larger amount of nitrous oxide, and rebreathing
therefore deepens the anesthesia.
Under ordinary conditions an eight-liter bag of
gas can be rebreathed for an average of about three
minutes. A condition of excessive carbon dioxide
retention is shown chiefly by deep and labored res-
piration. Increased blood pressure and decreased
frequency of cardiac action also indicate too high a
retention of carbon dioxide.
Pulmonary ventilation, however, is not the only
source of excessive loss of carbon dioxide, for, being
a diffusible gas, it readily transpires through the thin
capillary walls whenever there is a considerable
exposure of these vessels. In abdominal operations,
with the viscera exposed, there is such a pronounced
loss of carbon dioxide from this source that a patient
will tolerate to good advantage double the amount
of rebreathing that the same patient will tolerate
in the same anesthesia when the abdomen is closed,
or in an operation where there is little exposure of the
capillaries. Accordingly, in abdominal operations,
and kindred conditions, a patient can advantageously
rebreathe an eight-liter bag of gas from four to eight
minutes.
As nitrous oxide causes more or less swelling of the
tongue, there is considerable trouble in this anes-
thesia from the tongue obstructing respiration. Aa
one hand is required to hold the mask tightly against
the patient's face, and the other is occupied with
supplying the requisite ease . etc., there is little
opportunity for holding the .jaw forward. To meet
this situation I devised the breathing tube'' iiig.
204) previously described. It can be inserted
the mask reapplied so quickly, that the patient
makes no n very during its introduction, from
even this evanescent, anesthetic.
The advantages of nitrous oxide-oxygen anes-
thesia are: It is pleasant for the patient, causes
little or no depression (or shock), and is followed by
little or no depression or vomiting; it causes no
irritation of the respiratory or genitourinary tract
and does not impair the- patient's resistance against
infect ion.
[ts disadvantages are: The anesthesia and relaxa-
tion are not always complete; it requires a special
apparatus and rather burdensome supplies for its
administration, and the cost, of the nitrous oxide is
more than that of the other anesthetics (about SI. 00
per hour with the method just described, or sixty-five
cents with hospital discounts).
Nitrous Oxide-oxygen with Bther as an Adjuvant. —
This administration is conducted the same as that
of nitrous oxide-oxygen (just described) except that
when the anesthesia is too light or the relaxation
incomplete a small amount of ether vapor is added
to the nitrous oxide by slightly turning the needle-
point valve on top of the anesthetic cup, and the
ether drops slowly upon the gauze in the chamber,
and is immediately vaporized. And with the
respirations deep and rapid under the stimulating
influence of the carbon dioxide in the rebreathing
method it only requires a small amount of the addi-
tional ether vapor to obtain a deep anesthesia with
relaxation in all cases. In order that the ether may
drop regularly it is necessary that the bag never be
distended, for otherwise the pressure prevents the
ether from dropping upon the gauze. It is also
necessary that the cap does not completely close the
opening on the top of the cup, for without a little
air-supply a vacuum is created in the cup, and this
prevents the ether from dropping into the chamber.
Inasmuch as the ether may be added continuously,
or pure ether administered by either the open or
closed methods until the desired depth of anesthesia
and degree of relaxation are secured, this method of
administration is dependable and is adapted equally
well for major as for minor surgery.
The aim in this form of administration should be
to use the minimum amount of ether, and have the
major part of the anesthesia produced by nitrous
oxide, so as to avoid, as far as possible, the depress-
ing, nauseating, irritating, degenerating, shock-
producing, and immunity-destroying effects of the
former anesthetic. And the fact, which is not usually
recognized, is to be strongly emphasized that the
ether thus used does not produce the same propor-
tion of its toxic effects that this amount bears to the
amount necessary to maintain anesthesia with straight
ether. It is the last third, and not the first two-
thirds, of straight ether that produces almost all of
its toxic effects. In other words, after a certain
effect is produced by the administration of straight
ether the additional amount necessary produces
toxic effect out of all proportion that this additional
amount bears to the total amount used, and it is this
fact that explains the comparative absence of the
toxic effects of the ether used as an adjuvant to the
nitrous oxide, as outlined.
When hyoscine (scopolamine) has been combined
in the preliminary hypodermic injection with mor-
phine, considerably less ether will be needed as an
adjuvant, and in a smaller percentage of cases, than
when atropine has been combined with the morphine.
Whenever hyoscine is used it is necessary to keep the
375
Anesthesia, General Surgical
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
blood extra well oxygenated, especially until the
stimulant action of carbon dioxide upon respiration
is secured.
Nitrous Oxide as a Preliminary to Ether. — This
administration is begun the same as that of nitrous
oxide alone (q.r.). The average patient, after re-
breathing the nitrous oxide for twenty to forty
seconds, shows the signs of anesthesia, and at this
time, but not until there are signs of anesthesia
observable, the valve on top of the cup is slightly
turned, and ether
thus slowly
dropped upon the
gauze. The ether
should be gradu-
ally increased but
not more rapidly
than the patient's
tolerance of the
irritating vapor
will permit with-
out disturbance.
Marked cyanosis
should be pre-
vented by opening
the air-vent and
allowing the pa-
tient to inspire one
or two breaths of
air every five or six
inspirations, or by
leaving tlie air-
vent slightly open
during the re-
mainder of the in-
duction period.
(A much better
method is to add
pure oxygen direct
to the rebreathing
bag and thereby
prevent all cyano-
sis.) It is impor-
tant that, the drop-
ping of the ether should not be begun until the patient
is unconscious from the nitrous oxide, and that it
should be added very slowly at first, for if the vapor
is too strong the patient will either hold his breath or
cough. But if no coughing occurs and the patient
breathes deeply and regularly the ether may be in-
creased quite rapidly. Smokers are quite liable to
cough with even a mild vapor, so with this class it is
necessary to proceed with the ether administration
very slowly. Alcoholics are very susceptible to the
oxygen deprivation of nitrous oxide and so require a
large amount of air (or of pure oxygen).
Only a few patients will require more than one
bagful of nitrous oxide. The rebreathing bag should
be used until the patient is relaxed, when it may be
removed, and the administration of ether continued
by the open method, if desired.
" Nitrous oxide should not be administered imme-
diately before the administration of chloroform, but
if chloroform is to be the anesthetic, and there is no
respiratory irritation, the induction may be made
with nitrous oxide-ether as above outlined and the
change made to chloroform just as soon as the pa-
tient is anesthetized witli the ether sequence.
Ethyl Chloride. — While ethyl chloride was em-
ployed about sixty years ago to produce general anes-
thesia it was not until within the last decade that its
use has met with any general public favor. Many of
the fatalities following its use have been attributed to
impurities which, to-day, are not found in the product
intended for inhalation use. It is supplied in con-
tainers of 60 to 100 c.e. capacity and in glass ampoules
of 3 and 5 c.c. The latter are to be broken and used
at once, while the former has a valve which controls its
Fig. 216.— Hewitt's (
with Clover's Etl
as-ether Inhaler
er Chamber.
administration, which is usually in the form of a spray.
Ethyl chloride for inhalation differs from that intended
for local anesthesia as marketed by some manufac-
turers, so one should always be sure that the prepara-
tion for general anesthesia is used. Pure ethyl chlo-
ride is the only form that is adapted for inhalation.
Ethyl chloride may be administered by either the
open or closed systems, and, as is the case with ether,
the skilled and qualified anesthetist usually prefers
the closed method. Like nitrous oxide it is rapid in
action, and the anesthesia
is likewise evanescent. If
the administration is for a
dental operation a prop
should always be previ-
ously inserted, and the
patient may be in a semi-
recumbent position.
In the open method any
suitable mask such as the
Schimmelbusch or Yank-
auer's may be covered with
ten or twelve layers of
gauze and used. The Co-
burn apparatus, with the
bag removed, offers dis-
tinct advantages in this
Fig. 217. — Schimnielbusch's
Folding Mask.
form of administration, inasmuch as the gauze in it is
several inches distant from the patient's face, and conse-
quently the vapor is always well diluted with air before
being inhaled. And, besides, the exhalations do
not pass over the gauze and needlessly waste about half
of the anesthetic. Whatever apparatus or mask is used
the ethyl chloride is slowly sprayed upon the gauze,
but if the usual open mask is used care must be
exercised not to spray the anesthetic suddenly, or in a
large amount, or with much force. Respiration is
stimulated in frequency and increased in volume, and
the patient's color should be quite florid. Anesthesia
is induced so quickly that the different stages are
u -i tally not distinguishable, as it ordinarily requires
only about a minute for the induction period, and a
few c.c. of the anesthetic. If a prolonged anesthesia
is desired, the anesthetic is sprayed in small quanti-
ties at frequent intervals upon the gauze, extremely
diligent care being exercised in watching the eye
reflexes, the pulse, blood pressure, and, of course,
the breathing, for signs of overdosage.
As ethyl chloride produces a fall in blood-pressure
it is not well adapted for prolonged administration,
and its after-effects are more unpleasant than those
of nitrous oxide.
In the closed method of administering ethyl
chloride a special apparatus is necessary and for
this purpose numerous ones have been devised. The
kauer's Mask.
Coburn apparatus, with the bag attached, is well
adapted for this purpose. The bag is partly filled
with the patient's expirations and the anesthetic
sprayed in small quantities at frequent intervals
into the bag through a slight opening of the air vent.
It only requires about forty or fifty seconds of time
and from 3 to 5 c.c. of ethyl chloride to induce anes-
thesia by this method. The anesthesia is recognized by
376
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Anesthesia, General Burglcal
its usual signs but more especially by the snoring char-
acter of respiration. Many anesthetists -pray from
;; to 5 c.c. of ethyl chloride into the bag at once, but
I believe it to be dangerous practice to introduce
such large amounts at one time. Prolonged anes-
thesia is maintained by spraying the anesthetic
into the bag al frequent intervals, extreme care be-
ing taken to watch for the signs of overdosage.
When ethyl chloride i- used as a preliminary to
ether tin- Coburn apparatus can be very advanta-
f;-lv used in either the open or closed methods.
administration is begun a mtlined, es
that the cup should be previously filled with ether
.lust as soon as the palie.it exhibits signs of at
thesis the valve on the cup is slightly turned, and thi
ether is slowly dropped upon the gauze, the rate oi
the ether administration being cautiously and gradu-
ally increased by turning the needle-point valve.
In the open method it i> advisable to spray a little
ptlivl chloride upon the gauze after the admini
tion of ether is begun so as to prevent any recovery,
but in the closed method this will rarely be necessary.
Ethyl chloride possesses no particular advantages
over nitrous oxide except that of convenience; it is
inctly more dangi rous and its use is followed by
more disagreeable after-effects, .such as headache.
vomiting, dizziness, etc In general, it may be said
that ethyl chloride is better adapted for administra-
tion to i hildren than to adults.
Ethyl bromide is administered in practically the
manner and amounts as ethyl chloride except
that it is dropped upon the gauze or poured into the
bag or inhaler instead of being sprayed. In the
trn apparatus -4 to S c.e. are poured into the cup
and it is then dropped upon the gauze by turning
the needle valve. If there is to be an ether sequence,
just as soon as the patient is anesthetized ether is
poured into the cup and the administration of this
anesthetic begun, so there is no recovery from the
preliminary agent.
Ethyl bromide seems to possess no special advan-
over ethyl chloride, and is much more liable to
decomposition.
Ether. — Ether is administered by one of four
general systems: (1) The open; (2) the closed; (3)
rectal etherization; (4) intravenous etherization;
and various modifications of these systems, including
the intratracheal method, in conjunction with pure
oxygen, warmed vapor, etc.
Hewitt makes a different classification, including
the semi-open system, which he defines as '•limiting
to some extent the access of atmospheric air without
in any way retaining the expiratory products for
rebreathing." This definition, however, describes
an impossible condition, for the air supply cannot
possibly be limited unless the expiration is rebreathed.
Limiting the air supply, in the administration of
ether, does not decrease the respiratory volume,
hence, in a general way, there must always be re-
breathing in the proportion that the air supply is
restricted (excepting, of course, where there is an
artificial supply of some gas, such as nitrous oxide or
oxygen, that is simultaneously respired, and whose
volume is equal to that of the restricted air). The
semi-open system, or as it is sometimes called, the
semi-closed system, then, is simply a modification
of the closed system.
The intratracheal method, on the other hand,
appears to be simply a modification of the open
system, inasmuch as there is no rebreathing and the
air supply is abundant.
The induction of anesthesia with ether requires
several minutes, and is more or less disagreeable to
the patient, inasmuch as the odor of the vapor is
unpleasant and produces more or less of a choking
sensation. Besides, there is a very general fear and
dread of undergoing the ordeal of a general anesthesia,
hence at the time of administration the patient's
nerves are in a state of exa ed excitation which
causes a prolongation of the induction period and
ised resistance ami struggling. Tin- fright
fear, and the struggling, especially with ether by the
method, all tend to produce rapid breathing,
which in turn causes shock. The acapnia thus
produced by etherization may In i to
primary heart failure, even in normal subjects,
according to Henderson. 1" Cril ha down
thai tear and fright produce distinct pathological
lesii >ns of t he brain cells. Mi.', two tnvi
have demonstrated the scientific basis fur the a
lute need of a rapid and pleasant induction of ane —
the ia and the elimination "i preanesthetic fear.
Anesthesia cannot be in. lined rapidly, as that term
is here intended, with straight ether, and such an
induction is usually distinctly unpleasant, hi
there is a scientific, as well as esthetic basis, for the
plea-ant induction of anesthesia with rapidly act-
ing anesthetizing a^'-uts such a- nitro ■ ■ and
ethyl chloride, followed by an ether sequence when-
ever the latter anesthetic is t.i be administered, the
methods having already been described. The pre-
anestl c is best prevented by the administra-
tion of morphine, as outlined by (.file. Besides,
when morphine is used less of the inhalation anes-
thetic is required, and morphine in proper dosage is
less toxic than ether.
Ether vapor is highly inflammable and therefore it
should never be administered near an open flame. In
the use of the Paquelin cautery this physical property
must always be borne in mind by the anesthetist, as
well as by the surgeon.
The open system of administering ether requires
only a very simple inhaler, preferably a Yankauer's
mask, but any chloroform mask will answer very well.
In the selection of face masks preference should be
given to those that fit the contour of the face so that
ail the air that the patient breathes is inspired
through the gauze. Accordingly, the masks that
have a pliable rim that can be formed to fit the con-
tour of individual faces are useful. The mask should
be made of metal and simple in design and construc-
tion so as to be easily sterilized by boiling. Such a
mask should be covered with ten or twelve layer- of
gauze.
The perfection of the open system is attained in
the open drop method, and it is this method that
will be outlined. If the anesthesia is to be induced
with ether the gauze-covered mask is placed gently
over the patient's face in proper position and the
patient permitted to breathe for a few seconds through
the mask and learn that it offers no obstruction to
respiration. The highly esthetic anesthetist next
adds a few drops of some pleasant perfume. The
administration of the ether is begun by dropping
the ether very slowly a single drop at a time upon the
gauze, and very gradually increasing the rate of
administration as the patient becomes accustomed
to the vapor. The frequency of the drops and the rate
of increase will depend largely upon the regularity
of respiration and laryngeal irritation. If the patient
holds his breath or coughs, the vapor is too strong
and the ether must be dropped more slowly. Mus-
cular subjects, and more especially alcoholics, will
sometimes struggle violently, but forcible restraint
should be used only when necessary. The mistake
is much more frequently made of administering the
ether too rapidly during the induction rather than
too deliberately. It is not the amount of ether that
is dropped upon the mask that produces or maintains
anesthesia, but the amount that the patient inhales
and absorbs, consequently the rhythm and depth of
respiration are important guides in determining the
rate of administration in the induction as well as in
the maintenance of anesthesia. The idea cannot
be too strongly emphasized that in the open drop
method the ether should be dropped regularly and
377
Anesthesia, General Surgical
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Fig. 219. — Allis' Ether Inhaler.
continuously, and not poured upon the gauze in
quantities at intervals, as is so often done.
Muscular subjects, and more especially alcoholics,
are often quite difficult to relax under ether by this
method, so that it becomes necessary to use some
rebreathing. This may be secured by covering the
gauze with a small sheet of rubber in the center of
which is a hole about five-eighths of an inch in diameter
and through this hole the ether is still dropped upon
the gauze. If an impervious covering is not available
several more sheets of gauze or a towel may be placed
on the mask so as to limit the air supply and thereby
cause rebreathing. After the patient is relaxed only
the original gauze need
cover the mask. Surgical
anesthesia is recognized by
the absence of the lid re-
flex, moderate dilatation
of the pupil, and muscular
relaxation.
Whether surgical anes-
thesia is induced with
straight ether, or by a
preliminary anesthetic
with an ether sequence,
the anesthesia is further
maintained by a regular
and constant dropping of
l he ether upon the gauze.
< hi account of the diffi-
culty of continuously hold-
ing the ether can in the
hand and continuing a reg-
ular and constant drop-
ping of the anesthetic, especially throughout a pro-
longed operation, the Coburn apparatus is very useful
for this form of administration, inasmuch as the ether
is added by a mechanical drop method, and therefore
the drops are mechanically regular and constant.
Since the air supply in this apparatus, when the bag
is removed, is free and no rebreathing takes place it
completely fulfils the requirements of the open drop
method. Besides, in this apparatus the expirations
do not pass over the gauze and thus waste the
anesthetic and thereby saturate the operating room
with ether vapor.
As ether stimulates respiration, its administration
by the open method causes more or less acapnia, and
consequently more or less shock supervenes. Periods
of apnea from a few to many seconds in duration are
frequently seen during this form of administration,
and these are undoubtedly due to the acapnia which
the open method of administration tends to produce.
It has long been recognized by skilled anesthetists
that less shock follows the administration of ether
by the closed method than by the open method, and
the work of Henderson gives scientific vertification of
this clinical observation.
The acapnia of the open method may be overcome
by the simultaneous administration of carbon dioxide
gas, either pure or mixed with oxygen, for when there
is a pronounced indication for carbon dioxide admin-
istration oxygen is usually indicated also. A mixture
of ten per cent, carbon dioxide and ninety per
cent, oxygen is a very good proportion to use and
either such a mixture, or the carbon dioxide and
oxygen in separate tanks, should be convenient at
hand in every well-appointed operating room, for
use not only in emergencies, but also when shock is
either probable or developing. The old adage that
"an ounce <>f prevention is worth a pound of cure"
is strikingly verified in all general anesthesia work,
and as this science is developed it becomes more and
more apparent that the anesthetist must be a person
keen in perception, discriminating in judgment, and
most attentive to detail. For years there has been
such ceaseless agitation regarding the desirability of
administering ether drop by drop in the open method
that sight has been lost of the other and even more
important duties of the anesthetist. Almost any one
can be taught to drop ether; it is easy to take the
pulse, and to count the respiration, and it requires
little instruction to record the blood pressure accu-
rately. But these are not all that must be observed,
for as Henderson well shows it is the volume of the
blood actually pumped onward, that, in the proper
protection of the patient's vital interests, surpasses
all else in importance, for in the development of shock
the arterial blood pressure is high and the pulse and
respiration are good.
The evaporation of ether upon the gauze in the
open method produces quite a cold vapor, on account
of the large quantity of ether used. In a series of
observations I found that in a moderate anesthesia
the temperature of the inspired vapor was 45° F., in a
deep anesthesia 3.5° F., and in a profound anesthesia
32° F., the operating room temperature being 75° F.;
and in these temperature observations I have been
corroborated by Joss, who conducted a perfectly
independent investigation of this phase of the
matter.
Vapors, as a rule, are more irritating cold than
warm, and this is especially true of ether, conse-
quently it has long been held that the cold vapor of
ether was, per se, a factor in the production of post-
operative lung complications. This general belief is
probably correct, although it is conceded that in pass-
ing through the upper respiratory tract it is probably
warmed to body temperature by the time it reaches
the lungs. It is also certain that the heat necessary
to warm this cold vapor to body temperature is ab-
stracted directly from the patient's vitality. In
prolonged anesthesia with ether by the open method,
the energy thus abstracted from the patient is not
infinitesimal in amount by any manner of means, and
in a number of such cases, it must be borne in mind,
there is urgent need for the utmost possible conserva-
tion of vitality, so the needless loss from this source
should not be longer disregarded.
Davis says: "The effect of warming ether vapor
before inhalation is very marked. In twenty-six
patients anesthetized by this method the loss of
temperature averaged 0.29° F., against a loss of 1.02°
F. in 140 cases under similar operating-room condi-
tions by the open drop method." This shows a
difference of 0.73° F. in loss of body temperature in
favor of the warm ether vapor over that of the
cold.
This double loss of heat, however, is not the only
detrimental effect of cold ether vapor, for as Joss
well says, the cooler air chills the air passages, undoubt-
edly lowering their resisting powers and checking the
movements of the cilia of the epithelium lining them.
The ciliary movement is affected by variation of tem-
perature and is entirely arrested at the freezing-point.
Infectious material is thus liable to find its way more
readily into the finer air passages as salivation becomes
increased under the influence of the anesthetic.
In order to avoid the effects of the cold vapor,
when either is administered by the open method,
I devised the electric heater previously described,
and when this is attached to the chamber it warms
the vapor to body temperature at the time it is in-
haled. And as I have elsewhere stated that "while
it would require very extended clinical experience to
establish any reliable statistics on the difference in
postoperative complications it can be said with a
certainty that when the warm vapor is used the
respirations are quieter and smoother, and the secre-
tion of mucus less — facts strongly indicative of less
trauma to the respiratory passages. And this is all
the more significant when it is recalled that pneumo-
cocci and other pathogenic organisms are practically
ever present in the respiratory tract, and that ether,
through its action on the phagocytes, materially
weakens the patient's natural defenses against in-
378
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES Am . Mll ,. ,.,„,,,, nurKical
feotion in general, as well as thai against pneumo-
cocci in part icular."
/ ■/.,. [dm n ration of Ether by the Closed S
H is doubtful who firs) discovered theadvantai
Limiting the air supply in the administrat ion of ether.
Clover, in 1876, described "An Apparatus for Ad-
ministering Nitrous Oxide Gas and Ether Singly or
Combined. And a few months later he described
y s "Portable Regulating Ether Inhaler." In L877
Ormsby brought his inhaler to the attention of the
profession. While neither of these inhalers is in use
iv extent in the United States modifications of
the two types of inhalers are used, so a brief descrip-
of them and more particularly of their differences,
will here be given.
the Clover and the Ormsby inhaler have a
fare mask and a rubber rebreathing bag, and be-
tween the lias; and mask is the ether supply for vapori-
zation. The original Clover inhaler has no special
provisions for air supply while such provision is
B/..2&
FlG. 220. — Clover's Self-regulating Kther Inhaler and Case.
made in the Ormsby inhaler. The difference in
supplying the ether vapor is quite radical, and it is
to this difference that special attention will here be
given. In the Clover inhaler a part of the patient's
inspirations and expirations pass back and forth
over liquid ether, thus producing a vapor practically
uniform in strength, while in the Ormsby inhaler the
ether is poured on a sponge in quantities at intervals.
producing at one time a strong vapor and at another
time a weak vapor. Practically all of the inhalers in
the United States that are specially designed for the
administration of ether by the closed method embody
the Ormsby method of supplying the ether after the
patient has been anesthetized.
To the author it seems a significant fact that in
England, where the Clover principle of supplying a
uniform vapor predominates, the closed method is in
very extensive use, while in the United States, where,
after the patient is anesthetized, the Ormsby prin-
ciple of supplying a vapor varying greatly in strength
at different intervals, has been practically the only
closed method used, the closed method is not so
popular. Besides, it is this feature of the intermittent
and irregular supply of ether by the closed method
that has been assailed by so many writers on the
subject, including the Anesthesia Commission of the
American Medical Association. The concentrated
vapor that occurs at intervals produces pronounced
and unnecessary irritation of the respiratory passages
as evidenced by the increased secretion of mucus and
injury to the epithelial cells. Inasmuch as less ether
is required by the closed method than by the open
method, there should be less irritation, and this is
the ease when the vapor of the closed method is
constant and regular. Besides, the vapor is warmer,
since the warmth of the expirations elevates its
temperature.
The other chief objection to the closed method is
the retention of carbon dioxide, but, as Henderson
has so clearly and conclusively shown, the
carbon dioxide, properly regulated, is a distinct
benefit and not a detriment.
An inexpi n tve inhaler is always available, a- i
can be made from a paper-COne and a folded tov.el or
gauze, ami while this is crude it is quite efficient.
[n inducing anesthesia with such an inhaler, three or
four drams of ether are pom,-. I upon the absorbent
material, which should be of coarse composition, and
the cone slowly placed In position over the patient's
face, allowing the patient's respirator} pa ages to get
accustomed to and anesthetized bj the vapor before
placing the cone tightly over the face. Holding the
breath, coughing, or laryngeal or other spasm indicates
that the- vapor is too strong, o the inhaler should be
removed, the patient allowed a little air, and the
inhaler then held SO that a more attenuated vapor is
inspired until the anesthesia deepen-, when a stronger
will be tolerated. More ether is added in small
quantities as indicated.
In inducing anesthesia with ether by the clo
method with the author's apparatus, the bag is first.
partly distended with the patient's expirations, and
then the administration of ether is begun very slowly
by slightly turning the valve on the cup, and as tin;
ei her drops upon the gauze it can be plainly seen and
the rate of administration can be very accurately
gauged. As the patient's air-passages become accus-
1 to the vapor the drops are to be increased in
frequency. Holding the breath, coughing, or spasm
of any of the respiratory muscles indicates that the
vapor is too strong, and the valve should be turned
back a little so the drops will be slower; then, as the
patient's breathing becomes regular, the rate of the
drop is gradually increased by slightly turning the
needle-point valve. When signs of cyanosis appear
the air vent should be slightly opened, so that a
little air is inspired with each inspiration, or a little
pure oxygen may be added to the rebreathing bag.
If the latter method is used for furnishing the requisite
oxygen there is a retention of a larger amount of
earl 'on dioxide, and respiration is quickened and
deepened, which causes the absorption of a larger
amount of the anesthetic, and therefore the patient is
brought into the state of surgical anesthesia quicker;
at the same time, this procedure is safer, inasmuch as
the carbon dioxide by stimulating respiration, tends
to prevent spasm of the respiratory muscles — the
chief source of danger in the induction period.
After the stage of surgical anesthesia has been
reached the rate of administration should be decreased,
but regulated at all times by the patient's condition
and the depth of anesthesia required. It is to be
particularly noticed that from the beginning till the
close of the administration, the ether is added drop
by drop and therefore the vapor is never concentrated,
and after the induction it is practically uniform in
both strength and temperature. Unnecessary irrita-
tion and injury to the respiratory passage^ are con-
sequently prevented.
The prevention of shock, so far as acapnia is con-
cerned, lies in maintaining a normal amount of
carbon dioxide in the blood. Such anesthetics as
ether that stimulate respiration produce acapnia by
overventilation of the lungs, consequently there is
a special indication for the rebreathing of ether so as
to maintain the carbon dioxide at a normal level. In
nearly all of the specially designed apparatuses used
in this country for the administration of ether by the
closed method, the amount of rebreathing is governed
by the air supply or oxygenation. In other words,
the rebreathing cannot be increased beyond the point
where the air supply barely furnishes sufficient
oxygen, for to increase the rebreathing is to decrease
the air supply. Since with ether it is necessary to
have rebreathing to prevent acapnia, for ordinary
conditions there is usually a sufficient amount of
rebreathing when the air supply is restricted as much
379
Anesthesia, General Surgical
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
as proper oxygenation will allow, but, as carbon
dioxide readily transpires through the thin walls of
the capillaries whenever there is a considerable
exposure of these vessels, in abdominal operations
with the viscera much exposed, there is such a marked
and direct loss of carbon dioxide from this source that
the rcbreathing must be markedly increased over
S3078
Fig. 221. — Pynchon Apparatus.
that necessary in ordinary conditions in order still to
maintain the carbon dioxide at a normal level. To
meet this condition, either the air supply should be
further restricted, thereby increasing the rebreathing,
pure oxygen being added to the rebreathing bag, or
with the air supply sufficient for oxygenation carbon
dioxide gas should be added to the bag. Accordingly
in the apparatus which the author uses there is
provision for a cylinder of nitrous oxide for the
induction of anesthesia, and a cylinder each of
oxygen and carbon dioxide for instantaneous use
whenever indicated, either in routine or emergency
work. A mixture of carbon dioxide and oxygen
is also very useful, and can be attached to the
same stand. Each of the four different cylinders
is in direct connection with the rebreathing bag,
and all are easily wheeled about the room and
kept entirely out of the way of the surgeon and
assistant- at all times.
The Insufflation Method. — In some operations,
especially about the face, it is impossible to use a
mask, and then it becomes either desirable or Fig
necessary to force the vapor through a flexible
tube, placed either in the mouth or nares. With
such a method of administration the mouth, nares,
and throatare perfectly accessible throughout a pro-
longed anesthesia, and the anesthetist is at quite a
distance from the patient's face so as to be completely
out of the way of the surgeon and his assistants.
The Pynchon inhaler (Fig. 221) is very simple and
compact and well exemplifies the essentials of this
Fig. 222. — Paine's Nasal Catheter.
form of apparatus. It consists of two large-mouthed
bottles (about eight ounces) connected together with
a screw-cap metal fitting; one bottle contains ether,
and the other acts as a mixing or safety chamber,
and has located within it also a small bottle for
chloroform. Connected with the ether bottle is a
ten ounce Politzer foot-bulb for forcing an air current
380
through the ether, and for carrying the vapor onward
to the patient's respiratory passages. The bag carries
an air-inlet valve, and in the tubing between the bag
and ether bottle is another valve to prevent suction
of ether or vapor back into the bag when the latter
is expanding after being compressed. To the other
or safety bottle, is attached a small rubber tube which
leads to the patient's respiratory passages. This
tubing may be terminated in one of several different
methods, depending chiefly upon the requirementa
of the individual case. The illustration (Fig. 221)
shows it. terminating in two nasal tips which, when of
the proper size, fit tightly into the nares. Instead
of the nasal tips, nasal catheters (Fig. 222) may be
attached to the tubing by means of a Y-fitting, and
often only one such catheter is needed. Instead of
these nasal fittings the tubing may be attached to a
special gag such as a Ferguson, with anesthetic
tubes added, which distributes the vapor well within
the mouth as well as acting as a gag. The tubing
may also be connected with a mouth tube, or the
regular tracheotomy tube, and in certain instances
become most useful in the maintenance of anesthesia.
Many other end attachments for the efferent tubing
will be found serviceable.
Within the safety bottle, which is large enough to
prevent any ether being pumped through the tubing
which leads to the patient's respiratory passages in
case a large volume of air is suddenly forced into the
ether bottle, is placed a small bottle for chloroform.
The chloroform is forced out of this bottle by a small
hand bulb and made to drop into the larger bottle in
the original apparatus. Kilmer's suggestion is good,
that a little gauze be placed just beneath the metal
tube that leads from the chloroform bottle, and as
the hand bulb is compressed the chloroform drops
upon this gauze, and is rapidly vaporized by the air, or
etherized air current that passes into the mixing bottle.
At all other times the ether vapor passes through this
mixing bottle without t he absorption of any chloroform.
223. — Coburn Apparatus for Administering all Liquid Anesthetics
by the Insufflation Method.
The apparatus is light and may be conveniently
hooked or pinned to the anesthetist's coat or gown.
The Coburn apparatus is also well adapted for this
form of administration, the mask, chamber, cup, and
heater being used (Fig. 223). The mask and heater
maintain the cup in an upright position. Into the
opening of the chamber is inserted a stopper to which
is connected the tubing that leads to the
Politzer bag. In the opening within the mask
is inserted another stopper to which tubing is
attached that leads to a small "safety bottle."
and connected with this bottle is also the
tubing that leads to the patient's respira-
tory passages. The administration of ether is con-
trolled by the needle valve, and any desired strength
of vapor or rate of administration may be attained in
this, as in all other methods. Chloroform may be
added to the "safety bottle,"' if the addition of this
anesthetic is desired at any time.
In most of the cases in which this method is well
REFERENCE IIAXDIK >< >K OF THE MEDICAL SCIENCES
Anesthesia, General Surgical
suited there is considerable advantage in using a
I,, bulb to force the air current through the appara-
tus for the compressions of tin' bulb can be timed
with the patient's inspirations and little or ither
wasted or blown into the surgeon's face. When
two bulbs are used the vapor current is continuous,
an.l much of it is wasted by the patient's expirations
ami blown out into the surgeon's face.
Ordinarily the patient i.-- anesthetized in the 1 usual
manner, preferably by gas-ether sequence, and the
anesthesia continued with some special apparatus.
However, the patient may be primarily anesthetized
with an insufflation apparatus by connecting the
of the efferent tubing with a face mask covered
with rubber, and the vapor then pumped into this
mask. If the operation is to be in the throat, after
the patient is anesthetized either the nasal tips or
catheters are fitted into the nares, and the vapor thus
pumped through the nasal passages, or the end of the
afferent lulling is connected to a modified Ferguson
gag or metal mouth tube and the vapor thus forced
into the oral cavity.
This method of procedure is to be much preferred
to that of an intermittent anesthetization for
ations within the mouth or throat, where the
original anesthesia does not last till the completion of
the operation. Henderson lias clearly shown that in-
termittent anesthetization is highly conducive to
shock, and may even cause primary heart failure in
normal subjects; consequently the method of anes-
thetizing deeply with ether in tonsillectomies ami
similar work, then removing the mask and reapplying
it when the patient begins to recover, deeply anes-
thetizing again, and again removing the mask, is to be
severely criticised. Furthermore, in tonsillectomies
chloroform should not be used even in conjunction
with ether vapor, although the apparatus is well
adapted for such a combination, for in this class of
operations chloroform has been found to be extremely
dangerous.
Fig. 22i. — The Jauway Apparatus; front veiw.
The method just described has been called the
"Vapor Method," but this is a misnomer, for all in-
halation anesthetics are administered as a vapor,
ami consequently they are all vapor methods.
Intratracheal Insufflation. — To Meltzer and Auer
the profession is indebted for the developing and
perfecting of the intratracheal insufflation method of
anesthesia. The essentials of this method consist in
the introduction deep into the trachea of a flexible
tube, the diameter of which is considerably less than
that of the lumen of the trachea and the forcing
through this tube of the anesthesic vapor, the excess i if
air and vapor and the products of respiration passing
out through the space between the tube and the walls
of the trachea. The essentials as thus outlined, are
very few, and quite easily attained. Apparatus,
however, for this method of administration is usually
quite elaborate and complicated, not because of
absolute necessity, but rat her to render the method of
administration as nearly automatic as possible, and
to guard against dangers which are more or
1 1 etical.
The .laneway apparatus (figs. 224 and 225) is com-
pact portable, and will be briefly described. It con-
sists of an electrically driven fan for forcing a st<
air stream through I he apparatus and finally into i in-
patient's trachea. A valve deviate- any de ired
portion of this air stream so that il pa se over
liquid ether, thereby furnishing the anesthetic vapor.
The ether vapor and air then pass over water kept
hot by an electric heater; from this warming-moisten-
ing bottle the etherized air passes into a small con-
1 rrr^
1 1 imiL^
Fig. 225. — The Janeway Apparatus; back view.
denser, removing the excess moisture, and then it
passes through a small rubber tube several feet in
length to the catheter introduced into the patient's
trachea. The hot water heats and moistens the
ether vapor and air. Connecting with the tubing
which leads to the trachea is a mercury manometer
which registers the intratubular pressure. The in-
tratracheal pressure is usually one-fourth of the in-
tratubular pressure. It is very important that the
pressure be neither too high nor too low. If the
intratracheal pressure is too high death may easily
be caused by rupture of the lungs and if this pressure
is too low an insufficient amount of air will be supplied
to the lungs and consequently oxygenation will be
low. Usually a pressure of twenty millimeters
fulfils all requirements. Increasing the pressure
decreases the muscular respiratory movement.
Accordingly, if the respiratory movement impedes the
work of the surgeon, the pressure may be increased
up to thirty millimeters, but it is dangerous to in-
crease it much beyond this amount.
On account of the danger connected with an ex-
cessive intratracheal pressure, especially if sudden,
it is advisable to use a "safety valve." This is con-
nected with the etherized air current and the height of
the mercury column is such that the mercury blows
out when the pressure exceeds a certain point. The
safety valve may be set at any desired pressure,
usually forty millimeters, and unless the air current is
absolutely constant and reliable it adds a great ele-
ment of safety to this method of anesthesia.
An interrupter is operated by the electrically
driven motor so as to interrupt the air-ether current
every few seconds. The frequent interruption of the
current entering the lungs is an element of safety in
the method. There is also an air filter near the fan.
Instead of the electrically operated fan a foot
bellows may be used, and even if the former is used
a bellows should alway-s be conveniently at hand
ready for use in case of an accident in the electric
service or mechanism.
3S1
Anesthesia, General Surgical
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
An extremely simple and portable apparatus for
the intratracheal method of administration is the
Coburn apparatus as shown in Fig. 223, with the
following changes: A foot bellows is substituted for
the Politzer bag; a pressure dropping cup is sub-
stituted for the regular cup; and a manometer and a
"safety valve" are connected with the efferent tubing.
.Much of the success and safety of the anesthesia
depend upon the size of the catheter introduced into
the trachea, as well as upon the method of its intro-
duction. If the catheter is too small the return
current is so rapid that too small an amount of the
.•mi -i lutic is absorbed, and therefore the anesthesia is
too light. If the catheter is too large it offers too
much obstruction to the return current, and the
intratracheal pressure becomes too high, approaching
that of the tube registered by the manometer. The
end of the catheter should be introduced to a point
about three centimeters above the bifurcation of the
trachea. If the catheter is introduced too far it pro-
duces overdistention of a lung, and if it is not
introduced far enough not a sufficient amount of the
anesthetic and air reaches the alveoli of the lungs,
and consequently the anesthesia is too light and
oxygenation incomplete. Finally, the catheter is
sometimes passed into the esophagus instead of the
trachea, and the stomach is thereby inflated.
Just prior to use the apparatus should be connected
up and tested in order to insure that it is in good
working order. The size of the catheter should be
selected according to the size of the glottis. The
proper size for adults is usually 22 French,
and in order to facilitate its introduction it should be
a silk woven catheter, the plain rubber being too
pliable. While the catheter must, of course, be
flexible, it must not be too pliable, for in its introduc-
tion the fingers or holder are several centimeters
distant from the glottis, and in passing it through
the glottis down into the trachea, there is sonic
little resistance. If the catheter is too pliable it
will curl upon itself instead of passing on down into
the trachea, and if it is too rigid it will not adapt
its shape to the necessary curves. The silk woven
variety has been found to answer all the various
requirements. The point to which the catheter should
be introduced is, in the adult, about twenty-six
centimeters from the teeth, so an indelible ring should
be marked on the catheter twenty-six centimeters
from the internal end. As the glottis is about thir-
teen centimeters from the teeth it is well to have
another such a ring thirteen centimeters from the
end to be introduced. The catheter should, of course,
be sterile and lubricated.
While not absolutely necessary it is advisable to
have the patient deeply anesthetized, preferably
with ether, just prior to the introduction of the
catheter so the muscles about the head and neck will
be relaxed, and so that the patient's reflexes will not
recover and displace the catheter by coughing before
the intratracheal insufflation of the anesthetic can be
started. After the mask has been removed the patient
is quickly moved on the table so the head and neck are
clear of the edge, and a mouth gag is inserted. An
assistant then places one hand at the back of the
patient's neck and presses upward, and grasps the
forehead with the other hand and presses downward
The tongue is then pulled forward and a Jackson
laryngoscope passed over its base, the epiglottis
is identified and the laryngoscope passed over it also,
and as the larynx is completely exposed, the catheter
is passed between the vocal cords down to the indi-
cated mark. While it requires a little experience to
make the introduction deftly the necessary skill is
usually acquired readily. Special introducers have
been designed lo facilitate the introduction of the
cat liefer, but 1 he I hod and means here outlined are
practical, convenient, and efficient, and are quite
generally employed.
As soon as the catheter .has been introduced the
proper distance a special examination should be
made to determine whether it was actually introduced
into the trachea, as intended, or into the esophagus,
as has frequently been the case. If air passes in and
out of the catheter with the patient's respirations, of
course it has been introduced into the trachea. Tin-
respiratory movements can be heard or felt at the
external end of the catheter. A very positive way
to determine this matter is to place the end of the
catheter near the top surface of some water in a
small vessel, and if the catheter is in the trachea the
expiratory current will make a distinct depres
and disturbance on the surface of the water. ( if
course, if the catheter is found by any of these
means to be in the esophagus, it should be immedi-
ately withdrawn and properly introduced into the
trachea.
After one is assured that the catheter is in proper
position, a metal protector is slipped over the catheter
to prevent its being closed at any time by the patient's
teeth, the gag is removed, the patient is moved down
on the table, and the catheter is connected with the
tubing that leads from the apparatus. When the
etherized air stream is forced into the trachea it is
advisable to take the precaution to anchor the cathe-
ter with a strip of adhesive plaster to prevent its
displacement should the patient cough.
As soon as the air current is started through the
intratracheal catheter the patient should be watched
carefully for the first minute or two for evidence of
faulty' introduction of the catheter, for herein lies
much of the clanger connected with this method of an-
esthesia. If it has been introduced into the esophagus
instead of the trachea the stomach will be rapidly and
dangerously inflated. Should this accident occur the
tubing must be immediately disconnected from the
catheter, the stomach emptied, the catheter with-
drawn and then properly introduced.
If the catheter has been passed too far into the
trachea the end may reach one of the bronchi (usually
the right), and through hyperdistention of the lung
rapidly cause pneumothorax. Should there be evi-
dence of too low an introduction the catheter must
be immediately withdrawn a few centimeters so that
the end rests about three centimeters above the right
bronchus.
By the time the catheter is properly introduced and
connected with the apparatus the patient may begin
to show signs of recovery, so for the first few minutes
it is usually necessary to use quite a strong vapor,
but the strength of the vapor, as in all other methods
of administration, must be regulated according to the
individual requirements and the indications of the
particular case at hand. The strength of the vapor
is easily regulated by turning the valve on the
Janeway apparatus which controls the amount of the
air current that passes over the liquid ether, and this
valve may be set so that it may run for many minutes
without any change or manipulation of any other
part of the apparatus. As the air current passes
over the ether, and not through it, the maxi-
mum amount of ether that may thus be administered
to the patient is limited, but for most patients it is
sufficient to secure complete anesthesia with relaxa-
tion. In the Coburn apparatus the administration
of ether is controlled by the needle valve, just as it is
with all other methods. The amount of ether used
slightly exceeds that of other methods, but the patient
does not absorb as much, as the return current quickly
carries the excess out of the lungs.
Nitrous oxide and oxygen may also be used as the
anesthetic, the general principle involved being the
-: as that for ether, except no fan or bellows is re-
quired, since both gases are under pressure, and when
expanded furnish sufficient power to force the an-
esthetic stream automatically through the tubing and
catheter.
:',s-2
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Anesthesia! General Surgical
The advantages of this method oi anesthesia are
many and distinct, especially in the field for which
it Is particularly well adapted, and its pronounced
benefits are not limited to thoracic surgery for which
ii was originally intended. Willi this method of anes-
thesia the che I cavity may be opened with impunity.
It ^ also highly useful in operations within the mouth
or upon the tongue or upper respiratory tract as 1 1 n-
mums outward flowing stream of air prevents
|, infectious and other material from reaching
lower respiratory tract or interfering in any way
with respiration, it is also useful in operations
; the face, head, and neck when the usual face
mask cannot lie used or when it is desirable to have t he
anesthetist away from the field of operation. Finally,
it is useful in operations where the usual respiratory
movement interferes with the work of the surgeon and
where there is continuous vomiting, as in intestinal
obstruction.
Diffi rential Pressure. — The work of Sauerbruck
and Brauer first made possible and feasible the open-
ing of the chest cavity for surgical purposes, the one
using positive, and the other negative pressure.
Connected with each form of apparatus, however,
were many deficiencies and difficulties. Willy .\le\ er
bined the two methods into one apparatus, over-
most of the difficulties, added original improve-
it 5, and perfected a system of differential pressure
thai completely fulfils all of the requirements for
thoracic surgery. The Meyer differential pressure
apparatus consists of a positive chamber within a
negative chamber, and the necessary means for ven-
tilating and controlling the pressure in both cham-
bers. The positive chamber is of sufficient size so
that the anesthetist may have plenty of room for
himself and supplies. The patient's head is placed
jusl within the positive chamber, and the body lies
on the table in the outer or negative chamber. A
sheet of rubber is drawn snugly around the patient's
neck to make the inner or positive chamber air-tight
when the door leading into the same is closed. The
negative chamber is sufficiently large for the
table, the surgeon, his assistants, and necessary
paraphernalia.
With this apparatus any desired negative or posi-
tive pressure may be secured or any desired combina-
tion of negative and positive pressure, or a change
from either pressure to the other, and artificial
respiration may be had at any time.
The different anesthetics are administered in the
usual manner when using the Meyer differential pres-
sure apparatus.
Nitrous oxide and oxygen may be administered
under sufficient positive pressure for thoracic surgery
without any special apparatus. The supply of gases
must be continuous, the mask very accurately fitted
to the face, and the exhaling valve closed by a coiled
spring set at the desired pressure. The gas bags must
be kept distended sufficiently to open the expiratory
valve slightly during expiration. Otherwise the ad-
ministration is the same as at normal pressure.
The Administration of Anesthetics in Conjunction
with Pure Oxygen. — The intimate physiology of
anesthesia is closely associated with the oxidation of
the brain cells. In the prolonged administration of
nitrous oxide the amount of oxygen required approxi-
mates that required under ordinary circumstances.
and the same may be said regarding all administra-
tions of chloroform. With ether and ethyl chloride,
however, there are some advantages in limiting the
Oxvgen supply in normal or robust subjects. In the
delicate and debilitated subject, on the other hand,
there is an advantage in increasing the normal oxygen
supply.
The administration of pure oxygen in conjunction
with nitrous oxide and ether in the closed method has
already been described. If the condition of the
patient is such that there is need of increasing the
normal supply "i oxygen in the administration of
ethyl chloride (with exceptional cases in thi <'
in, . 1 .... 1 1 i In ane I het ic i ab olutelj cont i aindicated.
I I....' remains ft .1 con ii lera 1 ii in here, t hen. 1 he
administration of chloroform, anesthol, and ether by
the open method, and for this purpose no special
apparatus is required. T) xygen is allowed to
bubble through the water slowly, and the end of the
efferent i u I h • i- pi,-..-,, | beneath the patient's nare ,
the tube extending through or beneath the ma 1.
With the Coburn apparatus the end of the tube is
extended into the chamber, and is held in position by
the gauze. Will, the Pynchon and Junker inhalers
the efferent tube is attached to the apparatus so thai
the oxygen passes through the liquid anesthetic,
\ apprizing it, instead of air.
The advantages of administering oxygen in con-
junction with ether, chloroform, and anesthol
are that, in debilitated subjects, it conserves the
patient's vitality and t he post narcotic ell eels are less
pronounced.
Rectal Etherization. — Very soon after the anesthetic
properties of ether were demonstrated bj pulmonary
administration Etoux, in 1M7, suggested its admin-
istration per rectum. Pirogoff, during the same
year, so administered it upon the human subject, using
liquid ether mixed with water, the chief object in
view being to facilitate the performance of operations
within and about the moiilh, nose, and pharynx.
The method was tried by a few others, and it was
soon learned that t he administration of the vapor
was followed by better results than that of the liquid
ether, either pure or diluted with water. Little
attention, however, was given to this method of
administration for several decades, when Molliere,
in 1884, after quite an extensive trial, reported favor-
ably concerning it. Weir, the same year, reported
t he death of an eight months child from rectal
etherization, the operation being for harelip. Death
occurred from melena within twenty-four hours
after the operation. Bull, the same year, reported
seventeen cases of rectal etherization, but the results
were unsatisfactory, for not only did melena and
diarrhea supervene in some of the cases, but others
had prolonged and profound stupor, and asphyxia!
symptoms. Buxton has used this method and finds
it to answer admirably for operations about the
mouth, nose, postbuccal cavities, and larynx, and for
operations for the relief of empyema. Cunningham
in 1S9S reported forty-one cases, there being no
deaths, diarrhea, or bloody stools. Leggett, in 1907,
had a series of thirty-one cases, with anesthesia
incomplete in three cases, and with bloody stools in
one case, but no deaths.
In this form of administration it is absolutely
essential that the bowels be empty, for the feces will
not only prevent the absorption of the anesthetic but
will also plug the rectal tube.
The Pynchon apparatus previously described
(Fig. 221), is admirably suited for this method of
administration. The Coburn apparatus with the
insufflation attachments (Fig. 223), may likewise be
used if a pressure dropping cup is substituted for the
regular cup. An efficient apparatus is easily im-
provised by using an ordinary graduated flask, having
a rubber cork with two holes. Into one of the holes
insert a rod nearly to the bottom of the flask, and
into the other hole insert a short rod that extends
just through the cork. Connect the long rod to a
Politzer bag and the short rod to a small rubber tube
one meter long. Fill the flask one-third full of ether.
A double current rectal tube is used, the ether vapor
entering through one tube and the excess vapor
and gases escaping through the other tube, the end
of which tubing is immersed in alcohol to the depth
of three or four centimeters. When wanning de-
vices are used they should be placed as close to the
I patient as possible so that the vapor may not be cooled
383
Anesthesia, General Surgical
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
before it reaches the rectum, as warm vapor cools
very rapidly.
After inserting the tube high into the rectum and
connecting it to the efferent tube of the apparatus, the
vapor is slowly pumped into the rectum, the excess
vapor returning through the escape tube, as de-
scribed. It requires longer to anesthetize with this
method than with the pulmonary methods, but the
signs of anesthesia are the same, and similar care must
be exercised at all times to see that the respiratory
movement is free ami unobstructed.
Advantages and Disadvantages of Rectal Etheriza-
tion. — Prior to the perfection of the insufflation
methods, and of nitrous oxide-oxygen anesthe ia,
rectal etherization had some practical advantages,
inasmuch as it prevents, to a very great extent, the
irritant action of pulmonary methods of administra-
tion of ether upon the respiratory tract, displaces the
face mask, and removes the anesthetist away from
the patient's head. However, all the advantages
of rectal etherization can be better secured by the
methods and anesthetic just mentioned without the
slow induction, uncertain anesthesia, rectal irritation
and diarrhea that so often follow the rectal method,
Besides, its death rate has been the highest of any
method described in this resume.
Intravenous Etherization. — The direct introduction
of anesthetics into the vascular system has attracted
considerable attention during the past few years, and
during the past year considerable use, both practical
and experimental, has been made of this method of
administering ether. Five per cent, of ether in
normal saline solution is usually employed. At first
the administration was conducted with an intermit-
tent introduction of the dilute ether into the vein, but
the interruption of the stream had a tendency to
cause the formation of thromboses in and about the
cannula. A continuous, but slower rate of adminis-
tration, however, overcame this objection and at the
same time the resulting anesthesia was more satis-
factory inasmuch as it was smooth and even.
The apparatus used successfully by Rood is simple,
practical, and satisfactory. The ether, diluted with
ninety-five per cent, saline solution, is held in a. reser-
voir placed about eight feet above the floor. Rubber
tubing with a pipette attached leads from the bottom
of the reservoir to a chamber, the pipette being within
the latter. From the bottom of the chamber rubber
tubing leads to a warming bottle and thence to the
cannula into the vein. There is a shut-off below
tin 1 chamber to control the rate of administration and
there should be one above the chamber to control the
rate of flow into it. As the ether solution drops from
the pipette the rate of flow can be plainly seen, and
regulated according to the special requirements.
It is preferable to give the preliminary hypodermic
of morphine and atropine, or morphine and hyoscine
The arm is lightly bandaged to a splint to prevent
flexion at the elbow. Eucaine is then injected locally,
and the vein exposed by a one-third inch incision.
The cannula is properly tied in the vein, and the
wound packed with sterile gauze, strict asepsis
being observed through the procedure. The ether
solution is allowed to flow rapidly until the patient is
anesthetized, which requires about ten minutes of
time and eight ounces of the solution. After anes-
thesia is established the rate of administration is much
slower, about sixteen ounces of the solution per hour
being ordinarily sufficient.
Rood reports one case of three and one-half hours
administration, in which four and one-half ounces of
ether and four and one-half pints of saline solution
were used, and several cases of over two hours dura l ion.
The advantages claimed are: (1) The anesthesia is
delicately controlled; (2) early return of conscious-
ness; (3) postanesthetic vomiting and pulmonary
irritation are rare; (4) saline infusion per se is of
benefit sometimes.
Chloroform. — In the administration of chloroform
it is quite essential that the air supply be unrestricted,
consequently it is always administered by the open
system, but by a variety of methods. The open
drop method is the most popular method in this
country. Any open mask such as Esmarch's or
Schimmelbusch's covered with a single layer of flan-
nel, or a few layers of gauze, is well adapted for the
open administration. On account of the local irritant
properties of chloroform the skin beneath the mask
should be protected with vaseline, cold cream, or
some such preparation.
The chief source of immediate danger in the ad-
ministration of this anesthetic is "overdosage."
It is ordinarily stated that the percentage of the
chloroform vapor is too high, but the percentage of
the vapor that the patient may safely inspire de-
pends upon the rate and depth of respiration, and is
therefore variable. With the ordinary rhythm and
volume of respiratory movement it is generally con-
sidered that a two per cent, vapor is the maximum
amount that the patient may safely inspire, but
there are circumstances, such as deep and rapid
respiration after an apnea from muscular spasm,
holding the breath, and other respiratory impedi-
ments, when this percentage might be excessive.
Accordingly, in the induction of this form of anesthesia
especially the anesthetist, must gauge the strength
of the vapor according to the patient's respiration,
particularly when he is not dealing with known
percentages.
Fig. 226. — Esmarch's Mask and Dropper.
When chloroform is exposed to light it decomposes
and is rendered unfit for use. Therefore, it should
be purchased in small, strongly colored, and well
stoppered bottles. Chloroform vapor when exposed
to an open flame is decomposed into irritating gases,
which apparently affect the other occupants of the
room more than they do the patient. If it is neces-
sary to have an open light in the room it should be
placed as high as possible, as the anesthetic vapor is
heavier than air, and therefore tends to settle down-
ward. The fumes of ammonia are said to combine
with the chlorine and other irritating gases liberated
in this decomposition of chloroform, and render them
innocuous.
In order to reduce the size of the drop a special
dropper such as the Esmarch's or Filling's should be
used, as the rate of administration is much easier
controlled if the drop is small. The Coburn appara-
tus also has such a special dropper for the open
administration of chloroform. The dropping of
the anesthetic should be very slow at first and
gradually increased. Coughing, holding the breath,
:;m
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES Anegtne ,ia, General Surgical
or muscular spasm indicates that the vapor is too
strong, and whenever such symptoms occur the rate
of administration must be decreased, or withheld
altogether temporarily, until normal respiration is
resumed. Excitement, struggling, crying, etc., in
this method of induction arc especially dangerous,
and if such conditions cannot be prevented, the anes-
thetist must be very careful that the patient does not
suddenly make a deep respiration of a strong vapor,
for just a single inspiration of this character may lie
followed by fatal results. Under no circumstances,
should the induction be unduly hastened, as some-
FlG. 227. — Junker's Inhaler.
times it requires seven or eight minutes to anesthetize
completely with chloroform. Junker's Inhaler (Fig.
227) or one of its various modifications is very useful
in administering chloroform, especially in operations
within or about the mouth, nose, or pharynx. In
inducing the anesthesia a face mask is employed, and
the vapor is slowly pumped through the tubing by
compressing the bulb during inspiration. After full
anesthesia is secured, if the operation is of such a
character that the face mask would interfere with
the work of the surgeon the end of the efferent tube
should be connected with a curved metal tube or to
a gag with anesthetic tubes or to a nasal catheter
(Fig. 222), and the vapor thus forced into the respira-
tory passages.
In using a Junker inhaler care must be exercised
not to compress the bulb too rapidly or too vigor-
ously, for liquid chloroform may be easily
forced into the patient's respiratory pas-
sages. Several deaths from this accident
have been reported.
The Trendelenburg apparatus (Fig. 228)
is sometimes used for the administration of
chloroform when a tracheotomy has previ-
ously been performed. The anesthetic is
added by the drop method.
The Harcourt inhaler (Fig. 229) is quite
extensively used in England, and very ac-
curately regulates the percentage of chloro-
form vapor, it being practically impossible
to exceed the maximum limit of two per
cent. Inasmuch as with this inhaler air
is always well mixed with the vapor, and
any strength of vapor up to two per cent.
can be obtained, it affords a very safe
means for the administration of chloroform when a
face mask may be continuously applied.
Chloroform mixtures, such as A. C. E. and C. E.,
and chloroform preparations, such as anesthol, should
always be administered by the open system, as the
chloroform content makes it unsafe to limit in any
way the oxygen supply, and, at the same time, renders
it imperative that the strength of vapor be as constant
as possible, so as not to exceed the limit of safety.
When air is passed through any of these mixtures or
preparations to vaporize them the unequal rates of
volatility of the several ingredients cause the vapor to
Vol. I.— 25
vary in composition. All of these anesthetics are
administered in somewhat larger quantities than
chloroform, but is lesser quantities than ether.
The advantages oi the chloroform mixtures and
preparations are that they are less irritating to the
respiratory tract than ether, and less depressing than
chloroform.
The s ial advantages claimed forane thol (li per
cent, ethyl chloride, 35.89 per cent, chloroform, and
47.11 per cent, ether) are: Ashorl induction without
excitement or struggling; no increase in saliva or
mucus; early recoverj of consciousness; and no
irritation of limns or kidneys. [ts specific
gravity is 1045, being close to that of the
blood;' and its boiling-point is 104° F., be-
ing close to the temperature of the blood.
Alkaloidal Anesthesia. — For many
centuries past (see the introductory para-
graph) more or less complete analgesia and
anesthesia were secured by the administra-
tion of various preparations of different
plains and herbs. However, throughalack
of knowledge, either in preparation or ad-
ministration, this primitive and primal
form of anesthesia was then never widely
utilized for surgical purposes, and for many
years was completely superceded by the
inhalation anesthesia already outlined.
The advent of the modern laboratory
means of investigation, combined with
more careful clinical observation clearly showing
the detrimental and far-reaching remote effects
of the inhalation anesthetics usually employed,
has led to a partial reversion, at least, to the original
method of attempted anesthesia, refined, of course,
by modern means of preparation and methods of ad-
ministration. To-day it is the physiologically tested
alkaloid rather than uncertain and inert substances;
it is the hypodermic solution, not the decoction.
The alkaloids most commonly used for this pur-
pose are morphine, atropine, hyoscine, and scopolam-
ine. As hyoscine and scopolamine are so nearly, if
not entirely identical in both composition and physio-
logical action, many authorities consider them identi-
cal, and that view is here followed.
The effect of hyoscine alone is quite uncertain, but
when combined 'with such an active syngerist as
Fig. 228. — Trendelenburg's Trachea Tampon and Inhaler.
morphine the anesthetic action is positive, though
not reliable unless excessive amounts are given.
For complete anesthesia one-fourth grain of mor-
phine and one one-hundredth grain of hyoscine are
given hypodermically, three hours before the time set
for the operation and repeated at the end of two hours
in the original or decreased dosage, according to the
patient's condition. Fifteen minutes before the opera-
tion another injection is given, if the patient is not
already anesthetized. While quite a number of
successful reports have been made by a number of
writers of such use of these anesthetics, there have
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Anesthesia, General Surgical
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
likewise been quite a number of failures and fatalities
reported. Accordingly, this method for the induction
of complete surgical anesthesia is quite generally
condemned. But while the dose of alkaloids alone
for the production of complete surgical anesthesia
is so large and is attended with so much danger
that their use for this purpose has been practically
abandoned, the toxicity is so low in medium dosage
that they are quite generally employed for analgesia,
and as a preliminary to the inhalation anesthetics.
For these purposes a single, medium-sized dose
is given hypodermically. In obstetrical practice,
in which the com-
bination of mor-
phine and hyoscine
has been so widely
lauded by enthu-
siasts, both the
child and mother
need to be closely
watched for several
hours, and the dose
of hyoscine usually
recommended i s
too large to be safe.
In general it may
be said that the
maximum dose for
the robust adult
male is one-fourth
grain morphine,
and one one-hun-
dredth grain hyos-
cine, and for the
female about two-
third s of this
amount, and lesser
amounts, of course,
where the individ-
ual is under-sized,
or where the phys-
ical condition is
impaired, or the
patient is above
fifty years of age;
and this medica-
tion should not be repeated for at least several hours.
The value of morphine alone, or combined with some
other alkaloid, as a preliminary to other anesthetics, has
been discussed elsewhere in this article. It may be
further said that this practice is approved by the
leading anesthetists throughout the civilized world.
There is, therefore, a decided and growing tendency to
combine the alkaloidal and inhalation anesthetics in
the most approved production of modern anesthesia.
Electric Anesthesia. — Electric anesthesia is in-
duced by a direct current interrupted a great number
of times per minute, and connected to the body by
electrodes. It is important that the potential of the
current be limited to a little more than that required
for the anesthesia, for otherwise it is very easy to
electrocute instead of only to anesthetize the subject.
The number of interruptions for anesthesia should be
6,000 to 7,000 per minute, and the period of the
passage of the current one-tenth of the entire time.
Storage batteries afford the best form of direct current.
Apparatus. — The special paraphernalia needed are
storage batteries and connections, a rheostat, two
meters, one for voltage, and the other for amperage,
a make-and-break switch, electrodes, and a Leduc or
Robinovitch interrupter.
Technique. — The negative pole is connected to the
head electrode and the positive pole is connected to
the electrode applied at the lower end of the spine.
It is quite important that the cathode should always
be applied to the head, for if the anode is applied
there instead, respiration is impeded, and death is
much more likely to follow, even with the same
Fig. 229. — Harcourt's Chloroform
Inhaler.
potential. Before applying the electrodes, in animal
experimentation, the fur, at the point of application
is first cut away and the skin shaved, care being exer-
cised not to cut the skin. The shaved spots are
washed with alcohol, and then covered with a thin
layer of cotton wet with saline solution. The elec-
trodes are then applied to the wet cotton, and the
circuit is closed on a low potential. As the voltage is
increased, there is slight struggling of the animal, but
loss of consciousness soon follows. If the potential
is increased too much, respiration becomes labored
and convulsions follow, and this state can be relieved
only by reducing the voltage. The respiration is
therefore the best single guide in the proper main-
tenance of electric anesthesia, just as it is with the
inhalation anesthetics.
Utility. — Thus far electric anesthesia for surgical
purposes has been used chiefly for experimental work
on animals, and when skilfully handled it is a very
safe form of anesthesia. The postanesthetic effects
are practically nil. Recovery takes place as soon as
the current is opened. Johnson reports one case in
the human subject, successfully anesthetized for
forty-five minutes for the amputation of several toes.
Raymond C. Coburx.
Anesthesia, Local. — General anesthesia and spinal
anesthesia (or analgesia) are studied elsewhere in
this work under these respective headings. Before
discussing local anesthesia it may be as well, in view
of the increasing tendency toward accurate terminol-
ogy, to say that quite frequently, now, analgesia is
employed rather than anesthesia, as indicating,
properly, a condition of absence of pain; whereas
anesthesia really means only absence of common
sensation. After the employment of both spinal and
local means against painful operating it is not unusual
for a measure of common sensation to be retained in
the region in question, whereas pain may be wholly
absent (analgesia).
The subject of local as distinguished from general
anesthesia is one of increasing importance, year by
year. Far more operations are done by such help (in-
cluding spinal analgesia) at present than was the
case even a few years ago. The main reason for this
change is the fear so general among all mankind of
being forced into unconsciousness; and this is as
prevalent among physicians as laymen. Argument,
proving the almost invariable safety of ether, chloro-
form, etc., in skilled hands, does not change the fact
that people often dread the oblivion more than the
knife. In the earlier years of the local use of cocaine
and a few other drugs in surgery there were enough
mistakes made and unsatisfactory results from one or
another cause to justify the limitation of "minor
anesthesia" to minor work; but latterly, with our
present knowledge of ways and means, there are few
fields of operative endeavor that have not been
successfully invaded by the surgeon, his patient
feeling no pain, although entirely conscious, and often
chatting interestedly meantime. It follows from this,
that many a patient needing a radical cure of hernia,
or interval appendicitis operation — to mention one
or two among large numbers — will to-day readily
submit to being operated upon, who would formerly
have hesitated and postponed, chiefly because of the
major anesthesia dread, until operation became com-
pulsory, and very possibly until too late for safe surgery.
Of course there are exceptions, both in kind of
operation under discussion and in nature of patient
in question. It would take us too far afield to go
into these. There will always remain an abundant
field for major anesthesia; but nevertheless the rapid
development of local analgesia instead of that demand-
ing unconsciousness is a noticeable sign of the times.
To discuss our topic in an orderly way let us study
it as follows: Local anesthesia produced by aid of
cold, of light, of sinusoidal electric energy, by analgesic
386
REFERENCE IIAXIHtook ( >F Till' MEDICAL SCIENCES
Anesthesia, Local
tr
chemicals applied to skin or raucous membrane, or con-
veyed in deeper parts by aid of the hypodermic needle,
i ric catapnoresis and by intravenous injection
(,nii.— In increasing degree of intensity we
ibility by application of ice-water or ice,
iray of benzine or rhigolene or gasoline, by
of ethyl chloride, by application of carbonic-
snow, or by liquid air.
Ihe last named is destructiv< — is too inter elj
cold for practical purposes. Even C0 2 ice turns the
^ k i r i a corpse-white instantly, ami contact with it for
longer than a few seconds will not only freeze but will
destiny vitality -and it is an ideal agent for this
purpose in attacking superficial growths. Ethyl
chloride as to degree of cold, may be said to represent
a mean between extremes, ami is our choice for local
esia by chilling. Applied as a spray ii pro-
duces the corpse-white, which means insensibility, in
econds, but if cutting deeply — as to the bone in
felon — is needed, the freezing must be continued some
longer. If, however, several minutes, of
solidly frozen flesh result from its prolonged use, the
tatient may complain of the aching, just as from
rost-hite or chilblains subsequently. Where benzine
or rhigolene spray, or ice-application must be de-
pended upon for freezing it is best to begin, wherever
Eossible, by cording firmly; for example, with felon,
y snapping an elastic band several times about the
finger at its palmar juncture. Thus the chilled blood
is not -wept away and replaced by heated for some
time' before freezing occurs, and considerable suffer-
ing is spared the patient by the saving in time of
exposure to the cold.
Thi method of local anesthesia under discussion
(i.e. freezing by any means) should be employed, in
operating, for only one purpose, namely, to make one
or several cuts for the relief of pus or of inflammatory
tension. It is not a desirable choice where there
needs to be careful dissection — the flesh being frozen
solid as deeply as the knife is to penetrate, if pain is
to be entirely obviated.
Analgesic Drugs. — Water. — Under this second
heading water should first be mentioned, because for
rations it has been recognized as having analgesic
qualities. In Bartholow's Materia Medica (Third
Edition, 1S79), under the heading of Aquapuncture,
for example, it is affirmed that some physicians in
giving a hypodermic injection of a watery solution of
morphine attribute the subsequent relief from pain
more to the water than to the morphine! While by
no means going so far as this, the writer, in common
with many practitioners can claim often to have
observed in severe sciatica, for instance, much relief
from pure water injected by needle either into or in
contact with the sciatic nerve.
Balsted, nearly thirty years ago, suggested and
employed water for this purpose, injecting it, for ex-
ample, all about and beneath superficial tumors,
which could be then removed painlessly. In the arti-
cle on Subcutaneous Emphysema in the first edition
of this Handbook the present writer detailed his ex-
periments upon his own person in an endeavor to
rtain whether mere pressure alone upon the
"ry nerve-endings would suffice to benumb, or
whether water has an analgesic property inherent in
itself; and reached the latter conclusion.
The addition of even a very small proportion of
any one of quite a number of other drugs greatly
helps to render more effective this power of water.
Before studying these seriatim, let me say that
it is well for the general practitioner, occasionally
called upon to do some major operation in emergency,
to remember that without rendering the patient
unconscious, and by the use of simple means readily
at hand, a very fair degree of success in blunting pain
may be attained. The writer well recollects assisting
Dr. John A. Wyeth twenty-five years ago, in ampu-
tating a en; ii,, I arm at the shoulder-joint. The
pat ient . a middle-age< l.m inesl hesia.
Instead he drank nearly a tumblerful oi .and
received by needle nearly a half grain of morphine.
lie was maudlin and cheerful throughout; hi
showed no suffering— and he had no -hock sub-
equently, making a good recovery. Ucohol u ed
in this way v, a eery
of major ane the ia.
I.oc.-d applications of the volatile oih are among
the best known and oldest mean- of benumbii
suffering nerve. Each and everj volatile oil possi
analgesic qualities, but some surpass other- in this
,1. Oil of cloves, for example, applied within
the cavity of an aching tooth, upon a bit oi cotton,
usually gives prompt relief, 'linger for intestinal
colic — dependent for effect upon it- oil is as well-
known an instance. Menthol in say ten per cent.
solution in alcohol gives much relief in tteur
uffering, alike from the analgesic power of its
volatile oil and because of vigorous eounterirrita-
tion. Of course sundry other instances of this gen-
eral principle could be adduced.
Chief in importance among drugs for local anesthesia
is cocaine, usually in the form of the hydrochlorate.
It may now be obtained in both the natural and
synthetic forms. It is soluble in 0.4 parts water at
77° F. Except in very strong watery solution it has
no antiseptic power, and in any strength ordinarily
used it quickly develops fungus, rendering it irritant
and unfit for use. Therefore, it is best to make a
fresh solution each time it is to be employed, al-
though a saturated solution of boric acid in water
will keep it quite well for an indefinite period. Boil-
ing decomposes it into ecgonine and other alkaloids
all of which have some little anesthetic power, 1 nit
much less than the undecomposed cocaine. A simple
and reliable plan of making readily one's solutions of
it afresh is as follows: Boil in a test-tube say 100
minims of water; remove from the flame, and the
instant ebullition ceases the temperature will be
fractionally lower than the boiling-point. Instantly
drop in a hypodermic tablet of gr. J, if a half per
cent, solution be required, and so on. These tabids
are made by all responsible dealers in a most careful
and cleanly way, to avoid a bad reputation for
hypodermic abscesses from their goods, and the heat
is still enough within the boiled water, if used instantly
as stated, to render safely sterile such tablets in this
solution.
Cocaine is unquestionably the most anesthetic of
known remedies for use in this manner, but it is
likewise the most dangerous; first from acute poisoning
from an overdose, and second because of the great
risk of inducing a habit hard to be overcome and
ruinous to the health, if its adminisaration is repeated
more than a few times. The smallest fatal dose, with
sound organs, seems to be about one grain, in the adult,
though much more than this has often been absorbed
without trouble, particularly when injected in highly
diluted solution. One of the most striking character-
istics of cocaine activity, and in which it differs from
almost all the other anesthetic remedies intended for
hypodermic usage, is its power to cause vigorous con-
traction of blood-vessels. For instance, given an
acute coryza, the patient being wholly unable to
breathe through the nostrils because of mechanical
obstruction of the nasal air-passages from great
congestion of the mucous membrane and turbinate
bodies; if the interior of a nose so affected be sprayed
with a cocaine solution, within a few minutes a mu-
cous pallor will have replaced the angr}- redness, and
the breathing through the nose will have become
quite free. And yet this would be a very objec-
tionable mode of treatment, for within a half hour
or so the congestion would return — indeed, worse
than ever, because of the violence done the nerve-
mechanism of the vessels. Also perhaps the chief
387
Anesthesia, Local
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
way in which the cocaine habit has been started
is by the employment of weak cocaine snuffs and solu-
tions intranasally in futile attempts, commonly by
advertising quacks, to cure catarrhal conditions.
There are a few instances, however, in which this
contractile power of cocaine may be used wisely and
with advantage to the patient. Especially is this
true of complete urinary retention due to a temporary
congested or inflammatory stricture superadded to
a more or less tight-calibered true or organic one.
Here filiform bougies as well as the smallest soft
catheters having failed to gain entrance to the bladder,
the intraurethral injection of a one- or two-per-cent.
cocaine solution, held for some minutes pressed
backward against the obstructed region, quite regu-
larly results in permitting, for a few minutes, as free
emptying of the bladder as before the congestive
trouble was acquired; and a small catheter or fil-
iforms can be passed, painlessly too, to be temporarily
retained after the congestion returns.
Injection of adrenalin in solution would do the
same thing, but without the anesthetic effect also
resultant from the cocaine.
We have dwelt upon this power of cocaine over
blood-vessel caliber chiefly to emphasize its responsi-
bility for most of the dangerous symptoms consequent
upon cocaine poisoning from overdosage. Contrac-
tion of the blood-vessels everywhere in the brain
doubtless results, but the danger is chiefly because of
this effect upon those vessels at the base of the brain,
and hence supplying blood to the respiratory center.
Death occurs, if at all, from failure of respiration —
save in cases where the heart is not normal. The
patient becomes pale, breaks out into a cold per-
spiration, often is nauseated, complains of dizziness,
is seen to breathe with some difficulty and irregularity,
and has a rapid — sometimes a slow — and feeble
pulse. Convulsions sometimes precede coma. The
treatment consists in the use of stimulants, vasodi-
lators, and a good sized hypodermic injection of
morphine. Why the latter should be so valuable —
as it unquestionably is — the writer does not know;
for morphine is not a vasodilator. Trinitrin by
needle and amyl nitrite by inhalation are of value
as such dilators, also atropine as a direct respiratory
stimulant. Artificial respiration is of course indicated
when breathing fails; but both in prevention and
in treatment one may safely rely largely upon the
free use of alcohol, remembering alike its stimulant
effect and its striking power in full doses to dilate
blood-vessels, especially of the brain and face. The
writer never fails to give a drink of whiskey — unless
there is some moral scruple — prior to using cocaine
in surgery, and attributes to this measure of pre-
vention, as well as caution in dosage, his never having
personally had to deal with really serious symptoms
from this drug.
While upon this phase of the subject it is well to
call attention to the seeming contradiction between
the weak dosage at present almost always used in
cocaine hypodermic injection, and the concentration
in which it is employed by nasal specialists prepara-
tory to cutting or sawing work within the nose.
Twenty-per-cent. strength is an every-day matter,
and some such operators prefer to apply — as being
safer — cocaine hydrochloride in powder form, undi-
luted, to the mucous membrane about to be operated
upon. The explanation is found in this extreme
contractile power of the drug over vessels; and the
greater the concentration the more striking and
almost instantaneous is this effect, the blood-vessels
being reduced to the merest threads, and the mucous
parts to the most extreme pallor. In consequence
this poison cannot be absorbed and carried into the
general circulation.
In ordinary local analgesic usage — in preparation for
operation elsewhere than within the nose — the writer
seldom employs a strength greater than one-half per
cent, in the skin, and one-fourth per cent, in the deeper
tissues. Indeed it is often used far more dilute even
t han this. One part in a thousand of water or of nor-
mal saline solution is not rare when we wish to diffuse
the anesthetic effect over a large area, and one to five
or even ten thousand is a proportion employed by some
surgeons. The only objection to such a large bulk of
injected fluid is the distortion of normal relationships,
anatomically speaking, and at times this is not a triv-
ial objection.
Schleich, who was first to point out the value of
cocaine in such high dilution, has, for hypodermic
injection, prepared after considerable experimenta-
tion the following solutions, known respectively as
the strong, the normal (for average use) and the weak:
Sol. I.
Cocalni hydrochlorici 0.2
Morphinse hydrochlorici 0.025
Natr. chloral, sterilisat 0.2
Aquas destill. sterilisat ]ad 100.0
Addeacid. carbol. (5 per cent.) gtt. 2
Sol. II.
0.1
0.025
0.2
100.0
Ktt. 2
Sol. III.
0.01
0.005
0.2
100.0
gtt. 2
It must be noted that to accomplish a painless
cutting of the skin the drug, in whatever degree of
solution, must be in-
u
%&p
^%<
pv.
jected into, not beneath,
the skin. Beginners in
surgery commonly do
not do this in such
way as to give a max
mum of prompt anesthe-
sia with a minimum of
prior annoyance.
It is now well recog-
nized that Schleich was
in error in adding mor-
phine to his solutions for
local anesthesia. So far
from being an advantage,
the morphine has no local
anesthetic properties
whatever. Indeed, it is
to a very slight degree
an irritant, and has a
tendency to cause a
troublesome after-edema
of the tissues. It is well,
however, to dilute the
cocaine solution for in-
fill ration work with a
little chloride of sodium.
About three-quarters of
one per cent, of it makes
a satisfactorily isotonic
solution; and, particu-
larly in dealing with in-
flamed or highly sensi-
tive tissues, this is dis-
tinctly more soothing
than dissolving the co-
caine or other analgesic
agent in plain sterile
water.
As in inexperienced
hands the method by
edematization (infiltra-
tion) is apt to give un-
satisfactory results, be-
cause not thoroughly
done, it may be well
to give Schleich's own
vivid description: "The
infiltrated area must project high over the normal
level of the surrounding tissues, taking the form of
&s0
Fia. 230. — Showing Injection
Along a Line of Incision in Skin.
X, X 1 , X 2 , etc., first, second, third,
etc., points of injection. After the
first puncture, A, the needle is
always inserted in the edge of the
area last anesthetized. (From
Schleich.)
388
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Anesthesia, Local
si. edematous, broad-based sessile tumor. On in-
cision the tissues should have a glassy or jelly-like
appearance, the tissue fibrils being spread out, and
ii„. mi surface weeping like that of a cucumber or an
over-ripe melon. An infiltrated penis, lip, <>r ear
lobule musl appear as it affected with elephantiasis,
and pendulous tumors such as hemorrhoids, fibromas,
sarcomas, become often ten times their former size.
The >kia over such tissues becomes like silky papi r
and almost transparent like glass. The tough,
elastic cutis vera naturally opposes considerable
tance to this distention, but even with it a
ienl edema is much more intense than that
i in any pathological conditions." In a word,
the tissues musl be distended to their utmost to
produce sal isfactory anesthesia by this, the in lilt rat ion
method.
The writer prefers, for infiltration, toanyoi i he t hive
Schleich formula' those of Struthers,. which follow, and
particularly No. •"■.
No. 1.
Cocaine hydrochloride 1 grain.
Solution of adrenalin chloride ' 1 in loom . . . 12 drops.
Solution of sodium chloride (0.75 percent.).. 2 ounces.
No. 2.
Eucaine lactate 1 grain.
Solution of adrenalin chloride I in 1000).... 5 drops.
Solution of sodium chloride (0.75 percent.).. 10 drams.
No. 3.
Cocaine hydrochloride 1 grain.
Eucaine lactate 1 grain.
Solution of adrenalin chloride (1 in 10001 .... 12 drops.
Si lution of sodium chloride 10.75 per cent.).. 3 ounces.
The syringe and needles, as also the glass measure
for preparing solutions, must be sterilized in plain
water or saline solution, but not in soda solution, for
soda breaks up the cocaine or eucaine and destroys
their analgesic properties.
The needle — always small in caliber and very sharp —
is passed into the skin at a first point proximal to the
region inflamed, or to any region requiring cutting.
The injection of some drops into the skin, ju.st
beneath the cuticle, almost instantly produces a
roundish very pallid area called a "wheal." Into
this wheal the needle may now be advanced without
sensation of discomfort resulting, and at its farther
border a further wheal is produced in the same way.
Thus continue until a pallid and insensitive area is
produced as far as the knife is to reach. Beneath
to benumb the more effectually the operative area sup-
plied by the nerve in question n is always to b o
injected at a point well proximal to the field of its
operative nerve supply), and b) b a means of trying
to prevent shock, received through the sensory, hence
afferent, fibers of the nen nerves in question,
about to be divided at operation. If at some proximal
level nerve blocking can l>e accomplished, then the
blow of a major operation cannot for the time being
be conveyed to the vasotonic or shock center in the
brain. The trouble is that within an hour Ol pp '
operationem the effects of cocaine nerve blocking
pass ofi as the drug is taken up in the genera] cir-
culation and the shock is only postponed for this
brief period. An agent capable of maintaining such
nerve blocking for a day or longer is s -tiling still
to be searched for. Quinine and urea-hydrochlorate
nen e blocking — to be discussed later on — gives promise
of this.
Fig. 231. — Showing Injection Below Abscess Near Surface of the Skin.
X, X, points of injection. (From Schleich.)
this area infiltration may be used as desired. Let it
be noted, however, that whenever in process of cut-
ting any blood-vessel or sensory nerve is exposed,
such will probably require a special additional
injection to prevent pain before section. Blood-
vessels are unquestionably more sensitive to pain
than most other structures except sensory nerves.
"Nerve blocking" is a name used to cover the em-
ployment of a special technique for either of two pur-
poses. It implies the injection directly into a nerve
containing sensory fibers of a rather stronger cocaine
solution than that used for any infiltration, thereby (a)
Fig. 232. — Showing Injection Around a Tumor (in this case a
ganglion) with Curved Needle. G, (ianglion; N. skin; T, tendon
and sheath; a, 6, c, etc., first, second, third, etc., points of in-
jection. (From Schleich.)
It is worthy of careful note that cocaine anesthesia
is invariably distal from the point of nerve blocking.
For example, if into the ulnar nerve behind the inner
condyle at the elbow cocaine is injected in effective
strength — a few drops will suffice — within a few min-
utes we can amputate the little finger painlessly.
But if we expose this nerve at any level even in the
least proximal from the point so
blocked, it will be found just as
sensitive as ever.
This explains the otherwise
rather surprising ineffectiveness
of cocaine solutions, even the
strongest, conveyed into the
cavity of a tooth, to attempt
thereby obtunding pain when the
dentist resumes his excavating.
Only the surfaces of the tiny
nerve fibrils within the dentine
actually exposed are in the least.
affected. The first few strokes of
his sharp bone cutting implement
remove this surface, and as the anesthesia from
cocaine never travels backward toward the brain, but
only distally, the pain is presently as bad as before.
The writer many years ago before the New York
Institute of Stomatology described, as a result of his
experiments, methods whereby, during extracting or
excavating, cocaine can be introduced so as effectually
to block the pain-bearing power of the dental nerves,
both upper and lower.
For the four upper incisors, take a thin pad of
absorbent cotton, saturated with a cocaine solution
varying from two per cent, to a little stronger, and
E, Abscess;
3S9
Anesthesia, Local
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
pack this with the little finger end, or a narrow
spatula, upon the floor of the nose, at the front.
Within ten minutes as a rule the insensibility is
readily observable in these four teeth.
It is well known that from the second bicuspid to
the last molar the roots of the teeth are close in con-
tact with the floor of the antrum of Highmore. Now
by injecting a cocaine solution into this antrum
through its natural opening in the outer wall of the
nose — middle meatus — in a few minutes benumbing
follows.
Where the opening is not readily found, with a
stout, short hypodermic needle a passage can, by a
single light tap, be forced through the extremely
thin bone constituting the front wall of the sinus — just
above the roots of the first molar teeth, by choice —
and thus injection into the antrum accomplished.
As to the teeth in the lower jaw, all those behind
the mental foramen can be reached by obtunding the
inferior dental nerve by aid of a very long hypoder-
mic needle passed through the cheek at right angles,
through the sigmoid notch of the mandible just
below the zygomatic arch. Of course more space
for the ready accomplishment of this step will be
gained if meanwhile the lower jaw be held apart from
its fellow.
As to the front teeth, injection directly into the
mental foramen, to be found directly beneath the
second bicuspid tooth, will satisfactorily prepare
them for work.
It is nowadays quite customary for dentists to
extract painlessly, and in dealing with certain very
sensitive patients, to excavate without causing
suffering, by use of cocaine solutions — or of eucaine /J
or of novocain — combined, for the longer effect, with
a little adrenalin, and injecting this directly into or
in contact with the nerves about to enter the roots
of the teeth, by aid of very slender hypodermic
needles of platinum, and permitting of bending to any
desired curve without breaking.
It is worth mentioning that cocaine is undesirable
for use as a means of relieving inflammation by
its application, however dilute. Dr. Carl Koller, who
is the discoverer of the anesthetic power of this drug,
has pointed out that in ophthalmia for instance, the
prolonged use of such solution as a soothing agent for
the local pain may result in superficial ulcers of
the cornea.
To Dr. J. Leonard Corning we owe the first demon-
stration of the means whereby in operating upon any
extremity, now, we are enabled to hold the cocaine
solution in place until we can at our leisure complete
the operation, instead of, as formerly, having to
inject again and again, the circulation sweeping
away our anesthetic agent and the anesthesia there-
with. This is the simple device of cording proxi-
mally to the operative field.
In freezing, be it remembered that if we cord at all
we do it first, and then freeze. The reverse should
be the case when employing any drug by hypodermic
means preparatory to cutting; for here we inject first
and immediately afterward cord. During the fraction
of a minute intervening between the injection and the
cording the circulation will convey our chemical
to tissues round about the points of injection; whereas
had we first corded, then injected, the solution would
lie in the track of the needle or thereabouts and
anesthesia would be less satisfactorily accomplished.
The addition of a certain amount of adrenalin to
the cocaine solution, or indeed to any of the other
drugs used likewise in operation, materially helps
us in regions where cording is impossible, |,%- producing
a strong degree of local anemia not obtainable by the
weaker proportions of cocaine and not obtainable
at all otherwise by almost all of the other local
anesthetics. Indeed, hi one sense the adrenalin may
be said, in operations upon head, neck, and trunk,
to take the place of cording elsewhere, in that it
effectually holds the analgesic agent in place where it
is needed.
It may here be noted that the addition of a'ntipy-
rine to a cocaine solution prolongs very noticeably its
anesthetic effects. The strength of the antipyrine
may be as high as four per cent., but in this proportion
it smarts somewhat. If only one to two per cent, be
employed this objection is not observable when
it is combined with cocaine.
Cocaine is freely absorbed from a mucous surface
but not from the skin. This explains why it is useless,
in whatever concentration of solution, when intro-
duced within the external auditory meatus for the
relief of earache, or prior to cutting the ear drum
which is covered with skin, not with mucous membrane.
Tropacocaine Hydrochloride. — This is obtainable
both from the small-leaved coca plant of Java, and
by synthesis. It is quite expensive, compared with
cocaine, and is relatively much weaker. It has chiefly
been used in spinal analgesia up to the present time.
The writer has thus employed it in his service at the
City Hospital (New York City) in over 500 instances
without death or serious symptoms resulting. He
has regularly used for this purpose gr. ij. dissolved in
normal saline solution 5j. and finds that this can
usually be relied upon to produce within ten minutes
or less a perfectly satisfactory analgesia lasting upon
the average one hour. And this is devoid also of the
nausea and vomiting so frequently attendant upon
the early stages of spinal analgesia produced by the
use of cocaine solutions. The only drawback is the
occasional severe headache following and sometimes
lasting a day or even longer; but this objection seems to
attend the employment of other spinal analgesics,
an ideal one of which has not yet in this single respect
been found. Very large doses of phenacetin, repeated,
are perhaps as good a way as any of treating such
headaches.
Tropacocaine is freely soluble in water, keeps well
in solution, and is not decomposed by boiling.
Novocain is soluble in one part of water. May be
boiled without decomposition, and its solution keeps
well. It is a local anesthetic of much value, and far
less toxic than is cocaine. Its effect is greatly enhanced
by the addition of adrenalin to the solution; and
numerous firms now prepare tablets combining these
agents in various proportions. Novocain itself 1 as
no contractile power over blood-vessels. This drug,
in the combination mentioned, is being much more
used of late, and the reports are uniformly favorable.
It is employed in from one-half or two-per-cent.
strength usually, but has been used even in twenty per
cent. It has been absorbed up to gr. vij. or viij. with-
out trouble, so feeble is its toxicity. Tablets contain-
ing gr. J novocain and gr. ■*%■$ synthetic supra-
renin are obtainable on I he market andareineverj way
satisfactory. One such tablet in oj. of sterile water
makes a solution of slightly more than 0.5-per-cent.
strength, and is amply sufficient for ordinary opera-
tions upon skin and muscular tissues. Less than this
strength suffices for work upon mucous membrane and
the tissues just beneath it.
Eucaine beta, and lactate of eucaine, which latter is
more freely soluble in water, is a most excellent drug
for producing anesthetic solutions for local use. It
is practically devoid of poisonous properties. Thirty
grains have been injected and absorbed without pro-
ducing toxic symptoms (Kiessel). It is somewhat
less anesthetic in power than is cocaine, weight for
weight, but this objection is easily overcome by
using it in stronger solutions than the latter. It is
slower in developing its analgesic effect than is cocaine.
Two per cent, is perhaps an average strength, and it
stands boiling well, and keeps well. The addition of
adrenalin to its solution is of distinct advantage in
maintaining and prolonging the analgesic effect.
By itself eucaine has no power to contract blood-
vessels, even perhaps somewhat dilating them, rather.
390
REFERENi E HAXDHOOK OF TIIF. MEDICAL S< II Si ES
LnesthesUt! Local
Pennington recommends the following
R
Boil.
Beta-eucaine lactate sr. iij.
Sodium chloride. . gi
Bolu "i Buprarenal chloride, full strength, tljx.
ed water o,. s. ad ?,.
Tor hypodennio use.
In as great strength as five per cent, the writer
cannot commend eucaine beta for local anesl
because in this percentage injected beneath the fore-
skin in a case of circumcision it caused sloughing of
the skin.
and Quinine Hydrochloride. — In this com-
ition we have a very old and reliable means of
treating ugly types of malarial infection successfully,
in doses of gr. xv and more of the quinine by hypo-
dermic. To the writer's knowledge, here in New
York. Dr. \Y. II. Thomson (who is believed to have
originated the thought) and other eminent physicians
more than thirty years ago used this plan. And they
recognized and spoke of the striking degree of local
anesthesia which resulted. It will ever be a source of
wonderment to the writer that nobody "put two and
two together" and thought of making use of this
benumbing as a means of avoiding the agony of tin-
knife. It was long years afterward before cocaine
anesthesia was proclaimed to the world, and in the
interval, as before then, we used to put our pan
of necessity, as far under major anesthetic uncon-
sciousness to remove a sliver or cinder from the cornea
as to amputate a thigh.
Only within the past very few years has analgesia
from this source been recognized as of practical
surgical value. Tablets of various strengths arc
now upon the market. These are freely soluble in
water, and stand boiling well; but, as with cocaine.
a fungus or mould forns if allowed to remain long in
solution after exposure to the air.
An ordinary tablet is one containing urea and
quinine hydrochloride gr. ss. This is dissolved in
5i. of water, and though often used stronger, for it is
not poisonous in any dosage, it is somewhat irritant in
increasing strengths of solution. Indeed, because of
such irritant property it is not advised usually
for local anesthesia where one hopes and expects to
obtain healing by primary union.
The surprising thing about the employment of
this anesthetic, wherein chiefly it differs from any and
all others for local employment by hypodermic is the
la( anesthesia; but
200 hours is not surprising, although not always
obtainable.
By reference tn the earlier remarks ("under heading
of Cocaine) upon Nerve Blocking against Shock, it
will be readily seen how much more likely is so la-ting
an effect upon the afferent nerve fibers to prove
essful and life saving than any anesthetic the
effects of which are gone within an hour or a very
few hours at longest.
',' I lie. — This drug, soluble in eight
ami one-half pans water, is sometimes used alone
(without the combination with urea), and is eff(
in two per cent, solution. Dr. B. 1). Sheedy of New
York uses it upon adults thus, prior to tonsillectomy.
In five per cent, strength we have more bleeding, dis-
tinctly, than without its use, and also post-operative
inflammatory reaction. This seems evidence of its
tendency to irritate, and a greater strength of solu-
tion than two per cent, is not advocated. It is
prompt in producing its analgesic effect, and is of
course practically devoid of danger of systemic
poisoning in any desired dosage.
Stovaine H ydrochlorate. — This is a synthetic prod-
uct, freely soluble in water. Is an "effective local
anesthetic, but dilates the blood-vessels — the more
reason for combining it in solution with adrenalin.
It rather tends to stimulate the heart action, and is
only from one-third to one-half as toxic as cocaine.
The dosage varies from three-quarters of one per
cent, which is usual for hypodermic use, up to five or
ten per cent, when employed upon mucous membranes
chiefly.
It has largely, perhaps mainly, been advocated in
spinal analgesia, and Jonnesco has strongly advocated
its employment thus, combined with a small per-
centage of strychnine, which he claims adds to its
benumbing power.
Holocaine. H ydrochlorate.— This is soluble in fifty
parts of water. It has an even quicker anesthetic
effect than cocaine, and its solutions in water keep well,
as it is strongly bactericidal. It is, however, more
toxic than cocaine. A oue-per-cent. solution has just
about the same analgesic power as cocaine (Wharton).
Because of its more poisonous properties it is used
chiefly upon mucous membranes, especially the
conjunctiva. It has no effect upon the size of the
pupil.
Alypin. — This occurs in a white crystalline powder,
extremely soluble in water — even hygroscopic. Its
solutions may be sterilized by boiling for not longer
than five minutes. Locally applied to the eye it
causes congestion of the blood-vessels, but no myd-
riasis nor disturbance of the accommodation. It is
less toxic than cocaine, but about equal to it in local
anesthetic power. Is used upon the mucous mem-
branes in ten-per-cent. solution. For hypodermic
injection a one- to four-per-cent. strength may be
employed. Not more than gr. ij. should be absorbed
at one time. It has largely been employed in spinal
analgesia, chiefly in Germany.
Orthoform (new). — This occurs as a fine, white, taste-
less and odorless, crystalline powder, moderately solu-
ble in water. Is decomposed by boiling water. Is a
local anesthetic of much power and value but acts
only upon mucous or broken or ulcerated surfaces.
It is somewhat antiseptic, and is practically devoid
of poisonous properties.
It is used as an antiseptic and to relieve the pain
of burns, wounds, ulcers, excoriations, etc. The
writer can strongly commend it, having for years
391
Anesthesia, Local
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
applied it to newly operated rectal and intranasal
surfaces, in ten- to twenty-pcr-cent. strength rubbed
on with vaseline, also as a dusting powder to painful
ulcerations. Its analgesic power is longer main-
tained, as compared with all other local anesthetics,
(except quinine and urea hydrochloride) for twenty-
four to forty-eight hours after operation, for example.
The only difference between the old and new ortho-
form is that the latter is more readily soluble in
water.
Anesthesia. — This occurs as a white, odorless, taste-
less, crystalline powder, almost insoluble in cold water.
By prolonged boiling is decomposed. Is a local
anesthetic similar in effect to cocaine, but without
its local irritant action and its toxicity. On account
of its insolubility its anesthetic effect is only super-
ficial, but is more prolonged than that of cocaine.
Xcrrociilhic. — This is the hydrochloride of an alka-
loid derived from gasu-basu, an Indian plant. It
occurs as a yellow hygroscopic powder, readily
soluble in water. It is used ehieflj' in dentistry as a
local anesthetic, in a 0.1-per-cent. solution; upon the
eye, in 0.01-per-cent. strength.
Brenzcain (guaiacol benzyl ester). — This occurs as
white crystals, insoluble in water. Is said to possess
the advantages of guaiacol without its irritant, action,
and is used in the same manner as the other guaiacol
preparations. Its chief value is in producing anesthe-
sia locally by aid of cataphoresis.
Phenol (carbolic acid). — A deliquescent white
powder, its solutions becoming pink and subsequently
dark red upon prolonged exposure to light. Soluble in
water, when deliquesced, to the extent of five per cent.
Is studied under the present heading only because of
its quite striking benumbing qualities. In watery
solution of from two up to five per cent., it soon
obtunds local sensibility of skin or mucous surfaces,
but is too poisonous for safe usage beneath the skin
in this manner. Application of alcohol, if promptly
employed, neutralizes its poisonous effects. Not
more than gr. j.-ij. should be absorbed at one time.
Pantopon. — This is a reddish powder, a mixture of
all the active principles found in opium, in their
several relative proportions. Is soluble freely in
water, and supplied to the market in ampoules of a
clear watery solution, of an average dose each; or
else a mixture may be prepared for hypodermic
usage of seventy-five per cent, water and twenty-five
per cent, glycerin, as to the menstruum. Gr. § is an
ordinary dose of the powder; corresponds (about) to
gr. J morphine, in strength. It, however, affects tin'
respiratory center much less than does morphine,
and has not the unpleasant after effects of morphine.
It is desirable — but not essential — to combine for
hypodermic use with each gr. $ of pantopon gr. j-J^ of
scopolamine. The result is very satisfactory. Biirgi
has pointed out that whenever two narcotics are
injected simultaneously, the effect is more potent
than when a dose of one alone, equal in strength to t he
combination, is injected.
Pantopon is not alone used to relieve local pain,
but is a very desirable means of preparing the pal ient
for major anesthesia, injected an hour beforehand.
Acoin. — This is a white, very bitter powder, soluble
in seventeen parts of water. Is very sensitive to
alkalies and to light. Is a local anesthetic, employed
in one-per-cent. solution.
Benzoyl peroxide (or superoxide). — This occurs as
permanent, non-deliquescent, white, odorless prisms,
slightly soluble in water. Is a mild Ipcal anesthetic,
but a strong disinfectant. Is used either pure, in
ten-per-cent. ointment, or in a saturated solution in
olive oil.
Chloretone (chlorbutanol, acetone chloroform) oc-
curs as a white, crystalline, volatile compound,
having a camphoraceous odor and taste. It is soluble
in water. Is a weak local anesthetic, an antiseptic,
and a hypnotic similar to chloral. Is used as a mild
392
local anesthetic, in dentistry chiefly; also inwardly to
soothe gastric irritability. Dose, gr. v.-xx.
Chloral-menthol is produced by triturating equal
parts of chloral hydrate and menthol in a mortar
and then heating in a water-bath until liquefied.
It occurs as a colorless, oily liquid, with a distinct
mint-like odor and warm taste. Is used as a local
anesthetic and counterirritant, chiefly in treating
neuralgia.
Cliloral-camphor. — This is a thick, almost colorless
liquid, with a strong camphoraceous odor and biting
taste. Is the result of prolonged trituration of cam-
phor with chloral hydrate in equal proportions. It
is botli locally analgesic and counterirritant, and is
rather a favorite application to the skin in cases of
obdurate tic douloureux. We can strongly commi ,,,[
the following as an improvement upon chloral-cam-
phor unmodified.
H Camphor 3 ij
Chloral hydrate 5 iv
Olei betula 1 5 iij
Ext. fl. cannabis ind 5 ij
Alcohol q. s. ad 5 iij
M. S. "Pain paint."
Phenol-camphor. — The curious property of camphor
wherebyit prevents phenol from causing sloughing,
even in equal parts, is worthy of notice. If to these
we add glycerin c.p., making a mixture of equal parts
each of camphor, phenol, and glycerin, we have a most
excellent dressing for an unclean wound — acting as a
powerful antiseptic, and also stopping the pain and
tenderness which is one of the most striking clinical
features distinguishing the course of an infected
wound from one, however large, which is aseptic
If used in a wound of the latter class the presence
alike of carbolic acid and of glycerin will cause the
wound to discharge serum freely, and thus necessitate
drainage at first.
Used upon the skin the camphor-phenol-glycerin
combination constitutes a really excellent liniment
against the pain of neuritis, rheumatism, etc., and
is one of the best antipruritics.
Propepsin. — This is a white, tasteless powder, non-
crystalline, almost insoluble in water, slightly less
poisonous than cocaine. Because of its relative
insolubility in water, propaesin is used, like orthoform,
upon mucous membranes and on raw surfaces, chiefly.
Sodium Bicarbonate. — Ordinary baking soda. This
chemical is soluble in water, one part in twelve. It
is our main reliance to soothe the suffering attendant
upon burns, and fortunately is at, hand where burns
are oftenest produced — the kitchen. Saturated in
cold water or else applied supersaturated, as a kind
of mud, it is very comforting and moderately an-
algesic and is to a slight degree antiseptic. Most bi-
salts are acid, but this is exceptional, being slightly
alkaline in reaction.
As another and striking instance of its employ-
ment in surgery under our present heading, we may
mention that after operating upon a lacerated cervix
uteri, or its amputation, numerous operators adopt
the custom of packing the upper portion of the vagina
with sodium bicarbonate in order that there may
be no after-pain or tenderness.
By whatever drug the surgeon decides to produce
local anesthesia, the following sensible statement
(Struthers) should be borne in mind. It is well not
to pinch or prick the skin over the injection-area and
ask the patient if pain is felt. A certain amount of
tactile sensibility is nearly always retained; and
patients are apt, when nervous, to misinterpret their
sensations and in reply mislead the operator. If the
injections have been properly made, the skin will be
absolutely analgesic, though not anesthetic. It is a
good rule after waiting the necessary time, to cover
the patient's face with a handkerchief or towel to pre-
vent a view of the operation, and to proceed with the
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Anesthesia, Local
incision at once without asking any questions, it is
:l good working rule to ask no questions as to pain
during operation, in order to avoid any suggestion
tli-it one is uncertain of the power of the drug to pre-
vent pain. Should real pain be felt, the patient may
safely be trusted to intimate it by word or gesture,
without being asked.
Venous Local Anesthesia. — This method, an ex-
cellent and successful one, was first advocated publicly
by Bier of Berlin, in 1908. The technique follows,
modified by reversing the order of pr tdure;
it seeming to the writer self-evident that the exposure
of the vein should first be done while full of blood,
and hence easily found; and that thru the double
constriction of the limb should follow this step.
Any large superficial vein is to be exposed by dis-
ion: the internal saphenous, not far from the level
of the knee, in cases where excision of this joint is
templated, for instance. Next apply a stout
rubber bandage as in the Esmarch method of obtain-
ing anemia, carrying this to a point well above the
region of operation. Undo it from below, leaving it,
shutting off all blood supply at the highest (most
proximal) level.
By a second rubber bandage we constrict the limb
tightly at a level away from — distal to — the region
operation. We now have an entirely anemic
interval of limb varying from a few inches in vertical
ut to much more, according to cutting-room
led. In the middle of this space lies the exposed
and of course empty vein referred to.
This is next cut," obliquely, partly across — enough
to receive the nozzle of an ordinary saline-infusion
cannula; and this is tied in securely. The anesthetic
in somtion (to be farther mentioned later on) is now
injected by aid of a sterile syringe.
Bier thinks it of small importance whether the
fluid lie injected proximally or distally; if anything,
he rather inclines to prefer the latter; which of course
means that under steady and firm pressure all the
veins in this region will have their valves overcome,
so that within a few minutes all the interval between
the two bandages will have become analgesic.
Bier prefers a half of one per cent, of novocain
dissolved in physiological salt solution. For exci-
sion of a knee he injects of this lin-SO c.c; for
excision of an elbow, 40-50 c.c. — and so on.
The cutting being completed, before suturing he
desires to get rid of some of the chemical rather than
to have it all absorbed. For this purpose he first
entirely removes the lower — distal — rubber bandage,
and then loosens the proximal one enough to permit
general congestion of the limb below, and some
bleeding from the arterioles; removing the constric-
tion entirely when he judges that enough novocain
has been thus washed out. However, novocain is
certainly among the safer of the newer anesthetics;
it is far less poisonous than is cocaine, for example.
Light. — The local anesthetic effect of light is one of
the most striking of those produced by exposure of
the body to the actinic end of the spectrum — the
violet and ultra-violet rays, chiefly, being responsible
therefor. This is best accomplished by the use of the
Minin light (A. W. Minin, at present Surgeon-
General of the Russian Army). This lamp, aided
by a parabolic reflector, for concentration, conveys
the violet rays phis those just beyond and faintly
but distinctly visible against a white background.
The "step-off" rays, as Douglas H. Stewart ap-
propriately terms these last; and he names the color
of the Minin bulb "royal purple."
.Minin affirms that the therapeutic value of his lamp
is perhaps even greater in treating surgical injuries
and conditions than in handling internal diseases. As
to the former, the analgesic power is strikingly
manifested, permitting operation, suturing, etc., to be
performed painlessly after some ten minutes or so
of exposure. The al ption of subcutaneous and
interstitial hemorrhages and also of inflammatory
exudates is quite readily accomplished.
As to the analgesic relief of non-surgical afflictic
the power of tin- IilIiI i- also remarkable; for ex-
ample, nil pains from pleuri y, from articular rheuma-
tism, from cutaneous inflammation and that of the
deeper cellular tissue di appear entirely after a
single thorough treatment, or reappeai greatly di-
minished after a longer or shorter interval of time.
He says that it is true that neuralgias make an ex-
ception to this claim of benefit, and that pains of this
nature may even become aggravated following the
first seance; but that after the second sitting a dis-
tinct improvement can usually be noticed.
The writer, in neuralgia due to neuritis and peri-
neuritis — obstinate sciatica of this nature, for a
striking example — has upon tl ther hand repeat-
edly observed the most rapid and really wonderful
relief from tin' u-e of the Minin light; and it would
seem that we should distinguish, as to its value,
between neuralgia due to inflammatory action anil
neuralgia not a neuritis but most commonly die to
anemia — or as Romberg phrased it, " a prayer of
the nerves for more red blood" — and hence best treated
by hematinics, especially chalybeates.
Although the Minin royal-purple bulb is preferable,
yet it is well worth knowing that by use of the or-
dinary sixteen candle-power Edison incandescent
bulb of colorless glass we can produce a fairly good
analgesia locally in the course of from twenty minutes
to a half-hour's exposure; and that this is indeed a
better degree of analgesia than is obtainable by use
of any blue-glass bulb upon the market. These latter
crcen out the violet, the ''step-off," and ultra-
violet rays — the power of which is by no means
lost to use with the Edison light, which contains all
the ray- of ordinary sunlight except the ultra-violet.
The glass of the Edison bulb screens these out,
unfortunately.
There is one striking difference readily noticeable
between the activit3 r of the royal purple lamp and the
Edison, namely, that the former contracts blood-
vessels and thus depletes a granulating surface of its
blood, whereas the white light congests it.
The local analgesic effect of light, as just discussed,
is not in any way due to its accompanying heat.
Indeed, it acts best when held far enough away to
avoid discomfort from the increased temperature.
Furthermore, under analgesia by light, healing by
primary union is promoted and aided — a thing which
cannot be said of infiltration anesthesia by any drug,
though some of them do no harm.
Electric Phoresis. — This term is applied to the
passage by a galvanic current of crystalline sub-
stances in solution through the skin and indeed even
through the entire thickness of a limb or the body.
By this device local anesthesia may be produced,
although it is of more value as a means of relieving
deep-seated pain than as a practical surgical agent —
both because of the expense and the time involved.
Non-colloid (i.e. crystalline) chemicals may be divisible
for the purpose under discussion into those electro-
positive and those electro-negative. Cocaine is
electro-positive for example. Cocaine hydrochlride is
applied in concentrated solution (twenty-per-cent.
strength in water, for instance) to the positive pole
(anode). The current being turned on, and the
negative pole (cathode) being placed upon any in-
different spot — say upon the opposite side of the
limb — and the acid will remain at the positive pole
while the active base goes to the negative ditto. This
is called cataphoresis.
If upon the contrary we wish to administer for
some different purpose an electro-negative remedy — ■
for example, arsenic in the form of arsenite of
potassium — this, in concentrated solution, should be
393
Anesthesia, Local
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
placed upon the negative pole, the other pole being as
before placed at any indifferent point, and with the
electric action the arsenic as arsenous acid goes to the
positive pole, while the potassium — the base — re-
mains at the negative pole (anaphoresis) .
For local anesthesia by cataphoresis, begin by re-
moving the natural oil from the skin by washing with
ether or benzene. Then apply upon an electrode, in
solution, as just described, cocaine muriate, or aconi-
tine, or helleborin, or menthol. An alcoholic solu-
tion may be employed where the drug to be used
is more freely soluble in this than in water. Chloro-
form dissolved in water is sometimes used where both
a local analgesic and a counterirritant action are
desired.
Electrification. — Sinusoidal alternating electric
currents of sufficiently high frequency, and in which
the positive and negative phases are nearly equal,
possess the power of producing local anesthesia.
After the frequency has reached 5,000 complete
alternations per second the muscular contraction so
familiar with medical batteries and other alternating
currents decreases, and at 25,000 alternations per
second a current passing from the elbow to the hand
completely deadens that portion of the limb, and
needles may be passed through the flesh without
being felt. When subjected to currents of such high
frequency the sensory nerves appear to lose the power
of transmitting sensations.
The sinusoidal current is often anesthetic when all
other currents are not.
Dourner and Oudin believe that the anesthesia
described by d' Arson val (a sinusoidal current), and
recommended by him for surgical operations, is the
first stage toward cell-death which is quite analogous
to the anesthesia caused by freezing.
Vibratory Massage. — There are numerous ma-
chines upon the market, mostly driven by electricity,
for this purpose. It is used for a number of other
indications to discusss which would take us afield;
but it is worth remembering that vibratory massage
is often effectual, and quite promptly so in relief of
the local pain and tenderness of nerra'gia, and of sub-
acute and chronic rheumatism. The effective dosage
must be learned by individual experience.
Robert H. M. Dawbaen.
Anesthesia, Spinal. — Spinal anesthesia, sometimes
called subarachnoid, medullary, or lumbar anesthesia,
is insensibility to pain produced by the injection of
an analgesic substance into the arachnoid cavity of
the spinal cord. The process was first demonstrated
by Dr. J. Leonard Corning, of New York, in 1885,
and since that date, this method of inducing anes-
thesia has been carefully elaborated, and has been
practised in thousands of recorded cases by numerous
observers both in America and in Europe, where it is
much more popular than it is in this country.
A large number of drugs, capable of causing loss of
sensation by contact with the unsheathed roots of the
spinal nerves, have been used for this purpose, prin-
cipally, cocaine, stovaine, tropacocaine, novocaine,
eucaine, nirvanin, alypin, morphine, antipyrine, mag-
nesium sulphate, etc. In the early history of spinal
anesthesia, cocaine was almost exclusively employed,
but, on account of its admitted dangers, its use has
been practically abandoned and it has been super-
seded by other substances which are closely allied
to it, both chemically and therapeutically, but which
have proven far less toxic and consequently less
dangerous. Of these preparations, stovaine, tropa-
cocaine and novocain, especially the first two and,
perhaps, in the order named, are used much more
than any other representatives of this class. Tin'
usual dose of cocaine for a robust adult — male or
female — is 0.02 to 0.03 (i to J gr.) dissolved in
394
sterile water or in the spinal fluid itself. Smaller
doses are recommended for j'oung, very old, or very
feeble persons. A two-per-cent. solution is ordi-
narily employed — a smaller quantity of a stronger
solution being generally preferred to an equivalent
dose of a weaker solution.
Stovaine is readily soluble in water and the so-
lution, if desired, may be sterilized by boiling with-
out appreciable injury, although some doubt has been
expressed on this point. It is a vasodilator, is
slightly irritating to the tissues and has very decided
effect upon the motor nerves — causing paresis more
or less profound. It is this property which pro-
vokes distrust in its safety for high anesthesia, on
account of the danger of producing paralysis of the
respiratory muscles. The usual dose for an adult,
either male or female, is 0.03 to 0.06 or 0.1 (J to 1
or 14 gr.) dissolved in 1 c.c. (10 minims) of water,
of physiological salt solution, or of the spinal fluid.
The dose for a child under five years of age is about
0.01 (J gr.).
Fig
-Showing the Location of the Spinous Process of the
Fourth Luinbar Vertebra.
Tropacocaine, like stovaine. is very soluble and
the solution may be sterilized by boiling, probably
without injurious effect. It is a vasodilator, but
it is not irritating to the tissues and it does not
affect the motor nerves. The adult dose is 0.03 to
0.06 or 0.1 (J to 1 or li gr.). It may be dissolved in
water, in physiological salt solution or in the spinal
fluid.
Novocain is also soluble in water, in normal salt
solution and in the spinal fluid. It, too, may be
sterilized by boiling the aqueous solutions, probably
without material injury. The motor nerves are only
slightly affected bv it. The dose is 0.05 to 0.1 or
even 0.15 (} to H or 2\ gr.).
Magnesium sulphate exerts a remarkable influence
when injected into the subarachnoid space. Lim-
ited anesthesia ensues in about forty-five minutes
and deep, general anesthesia, with paralysis of the
lees and abolition of the tendon reflexes, follows after
three or four hours. This state may continue for
several hours and, although analgesia may be com-
plete, the tactile sense sometimes remains, and the
REFEREM I! IIAXnmioK OF THE MEDICAL SCIEN(
Anesthesia, Spinal
vital reflexes are not disturbed. Under its influi
abdominal and pelvic operations and various opera-
tions upon the lower extremities have been success-
fully performed; ii is, moreover, stated that with a
Li ienl « 1 < >—< - . operations upon any pari of the body
may be rendered painless. The results of the sub-
dural injection of the magnesium salt have not been
uniform but, on the contrary, have proved extremely
variable and uncertain, and the aftereffects have
occasionally been distressing. .V twenty-five-per-
cent, thoroughly sterile aqueous solution of a chem-
ically pure salt is used. The dose usually recom-
ded is 0.02 to 0.03 (J to J gr.) for every two
pounds of the patient's weight.
Tlie several anesthetic substances which arc com-
monly employed — stovaine, troparocaine and QOVO-
— are all freely soluble in water, in normal salt
solution, and in the spinal fluid withdrawn into the
Syringe at the time of the operation. It is claimed
that attempts to sterilize these drugs are unneces-
sary, as they themselves are antiseptic, and the
exact effect upon the activity of the drug caused by
boiling the solution is regarded by some as an open
question, but the water used as a solvent and the con-
tainers should be absolutely sterile.
Flo. 234. — Oblique Insertion of the Xeedle for Spinal Anesthesia.
Some operators believe that the specific gravity
of the anesthetic solution should be greater than
that of the spinal fluid. This may be effected, in
part, by using a solution not too dilute, or by the
addition to the solution of five per cent, of glucose
or of dextrine. The advantage claimed for the
heavier solution is, that it is not so diffusible as a
lighter solution, and that it will not ascend to the
upper portions of the canal unless forced up under
the influence of gravity by elevating the hips or by-
depressing the shoulders of the patient. The heavier
solution tends to pool at the most dependent part
of the canal and in this manner the height of the
anesthesia may be regulated by posture. The addi-
tion of adrenalin or of atropine to the injection is ap-
proved or rejected according to the individual views of
the operator. Strychnine in the solution or the hypo-
dermic use of scopolamine and morphine, preced-
ing the injection, is regarded as an advantage or
as indispensable by some and is declined by others.
All agree, however, that the anesthetic solutions
should be freshly made — preferably, at the time of
the operation.
In performing the puncture, the instruments, the
hands of the operator and the skin over the back
and the loins of the patient should be prepared as
carefully as for a major operation. Any of the lum-
bar interspaces may be selected for the puncture,
but the third or fourth is usually chosen. It has
been done as high as the sixth cervical vertebra,
but puncture in the cervical region or, indeed, in the
dorsal region is considered extra hazardous, and it is
generally admitted that under ordinary circumstances,
puncture in the lumbar region, even when high anal-
gesia is desired, is equally effective and is safest and
best. The spinous process of the fourth lumbar
vertebra may be located by drawing a transverse
line to connect the inn iliac crests; it may then be
accurately defined by deep palpation, li"- eat of
puncture may be frozen by ethyl chloride or some
other local ane thetic n he ski
the only sensitive tissue penetrated with the point
of a bistoury. The patient should -it upon the
of the table or, by preference, lie upon either side,
with the body well curved forward. The needle may
I Iltered ]US( beneath the spinOUS prOCeSS in the
median line and pre! ed firmly a little upward and
ard, or it may be entered half an inch to the
right or to the left of the median line and passed
obliquely toward the spinal canal (] ig. 234). When the
point of the needle enter-, the space, which in a well
developed adult i- about two ami a half inches below
the surface, a sense of diminished resistance will be
noticed, ami the spinal fluid will How from the outer
end, drop by drop, or in a steady stream. '1 he
escape of the fluid is the only conclusive evidi
that the cavity has been reached, and if the fluid
! noi appear after the point of the needle is sup-
posed to have 'ill. i-'d the -pace, the solution should
nol !"• injected, but the needle may be rotated or
pushed a little further, a stylet may be passed, tin;
patient may cough or make a slight straining effort,
or gentle aspiration by means of a syringe may be
employed. When the fluid begins to How the
finger should be placed over the end of the needle
and the syringe containing the warm solution, or the
dry anesthetic substance if the spinal fluid is to be
used as the solvent, should be attached. Operators
of experience disagree as to the advisability of allow-
ing a few drops of the spinal fluid to escape before
throwing in the solution, some alleging that the nor-
mal quantity of the fluid in the cavity should not be
disturbed, but that the amount withdrawn should
equal or slightly exceed the volume introduced, while
others assert that severe headaches and various un-
pleasant effects are infrequent if the spinal fluid is
not wasted. If a solution is used, after satisfactory
assurance as to the position of the needle, the piston
should be slowly depressed, but if a powder or a
tablet is to be dissolved in the spinal fluid, the piston,
already closed, should first be withdrawn, until the
barrel containing the anesthetic, with a capacity of
2 c.c. (32 minims), is about half filled with the fluid,
which readily dissolves the anesthetic, and then the
solution should be gradually returned into the space,
the needle removed and the puncture sealed. The
patient is then gently laid upon his back with the
[dps and the shoulders at such relative elevation as
may be appropriate for the desired extension upward,
or for the limitation, of the level of the anesthetic
zone.
The anesthetic effect of a lumbar injection is gen-
erally felt in the lower portions of the body in three
to five or ten minutes and gradually extends upward
coincidently with the upward diffusion, in the spinal
fluid, of the anesthetic solution. This diffusion, which
is a determining factor in the level of the anesthetic
influence, is regulated by gravity, and is controlled
by the weight of the anesthetic solution as compared
with that of the spinal fluid, and by the posture of the
patient. Besides the question of gravity and of the
patient's position, the height of the anesthesia — the
extent to which it rises — is influenced by the point
of insertion and by the quantity of t he anesthetic
substance used. The high injection, however, is not
necessary to high anesthesia, but a full dose, eleva-
tion of the hips and a little more time, may be re-
quired for a high effect when the puncture is made in
the lumbar region, which is, by all means, the proper
place for the injection. The usual duration of spinal
anesthesia is from thirty minutes to two hours, and,
in some instances, even longer. In testing the pa-
tient to ascertain the progress of the anesthesia, it is
important to remember that paralysis of the muscles
in the anesthetic area does not always occur and that
395
Anesthesia, Spinal
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
the tactile sense may remain after analgesia has been
completely developed.
An imperfect anesthesia may follow incomplete
penetration of the membranes so that the lumen of
the needle is not well within the cavity, thus allowing
a portion of the solution, when it is discharged, to be
lost in the tissues, or a one-sided anesthesia may
result from maintaining the lateral position of the
patient, causing the nerve roots of one side only
to be bathed in the anesthetic solution. A total
absence of anesthesia following an injection is
usually due to failure to enter the cavity. It may,
however, be caused by inert drugs, by an insufficient
dose, or, possibly but not likely, by idiosyncrasy of
the individual. In the event of partial or of imperfect
anesthesia succeeding the injection, or of insufficient
duration of the anesthesia, repetition of the injection or
inhalation anesthesia in the discretion of the operator,
may be practised, or a combination of the two methods,
which is wholly unobjectionable, may be used.
Consciousness of the patient under anesthesia,
frequently urged as an argument in favor of spinal
analgesia may, very rarely, be an advantage, but in
the vast majority of cases it is a positive disadvantage.
The cooperation, the assent, or the dissent of the
patient is seldom required during the progress of an
operation, and his knowledge of what is transpiring
may result in unfortunate embarrassment to the
operator, especially in the presence of an unexpected
emergency. The field of the operation should always
be screened from the patient's view by some suitable
device attached to the operating table, rather than
by a mask or by a bandage placed across his eyes.
Some enthusiastic supporters of spinal anesthesia
attribute to it the power, if promptly invoked, to
prevent, to limit, or to arrest surgical shock or shock
from severe injuries, and claim for it moreover, bene-
fits beyond the range of strictly surgical procedures.
It has been used, with varying success, in the treat-
ment of tetanus, and it has been employed also, in
obstetric practice for the purpose of lessening the
pains of parturition. The injection is advised dur-
ing the second stage, and it is said that the pain is
relieved, while, at the same time, the force of the
uterine contractions is not diminished, but that vol-
untary effort, on the other hand, is increased— the
suffering being absent — so that the duration of the
labor is thereby actually decreased.
The after-effects of a spinal injection are sometimes
more or less severe and protracted, and they may
be very serious and really alarming. Among these,
are headache, dizziness, mental confusion, inco-
herence, fever, delirium, nausea, vomiting, coma, par-
esis, retarded or suspended respiration, rigidity of
the cervical muscles, pallor, tremor, sweating, incon-
tinence of feces, retention of urine, panting, shock,
restlessness, cramps, rigors, cyanosis, rapid pulse,
subnormal temperature, collapse, etc. Any or several
of these symptoms may occur during or after anes-
thesia without warning and without obvious reason.
The work of Professor Thomas Jonnesco, of Bucha-
rest, an ardent advocate and a most daring exponent
of spinal anesthesia, lias recently attracted wide
attention. The novel points in his method provide,
first, that the puncture for high anesthesia — that is,
for the arms, thorax, neck, and head — should be made
between the first and second dorsal vertebrae, rather
than in the lumbar region and, second, that in I lie
production of spinal anesthesia, strychnine should
invariably be added to the solution of either stovaine,
which he prefers, or of tropacocaine or novocain,
which he approves — claiming that this precaution
averts the danger of respiratory paralysis and fully
sustains the circulation. For low anesthesia — that is.
below i he diaphragm — the site selected for the punct-
ure is the dorsolumbar interspace. Injections at these
two sites suffice for all regions, and coverevery portion
of the body. After the injection, the patient is
changed from a sitting to a dorsal position, with the
relative height of the hips and of the shoulders regu-
lated according to the desired level of the anes-
thesia. The dose, both of the anesthetic employed
and of the strychine, should be smaller by one-half
to two-thirds in the upper dorsal puncture than in
the dorsolumbar puncture, but at either site, whether
high or low, the dose should always be adjusted to
the age and the general physical condition of the
patient, although the variation on this account in
the quantity of the strychnine is not relatively great.
His usual adult dose, in dorsal puncture, is stovaine,
0.03 (i gr.), strychnine 0.0005 (^ gr.). In the
dorsolumbar puncture, stovaine, 0.06 to 0.1 (1 to 1J
gr.), strychnine, 0.001 ( T i ¥ gr.). The injection
should always consist of 1 c. c. (16 minims) of a freshly
made solution of varying strength, within certain
limits, in the discretion of the operator.
In his practice, age does not seem to bar spinal
anesthesia. It is applicable alike to the infant and
to the octogenarian. He reports many successful
cases ranging from one year and nine months to
seventy-five years.
The claim that the presence of strychnine in the
solution injected obviates the danger of respiratory
paralysis is not generally accepted, and the alleged
safety of high anesthesia — whether induced by the
dorsal or by the lumbar puncture — is stoutly contested
and is vigorously denied. Few men of mature
judgment regard spinal anesthesia as applicable to
all operative cases, but it is generally conceded on
the part of surgeons with large practical experience
that, while its field is limited, it may be successfully
employed when general anesthesia would involve
extraordinary risks, as in very old or very feeble
persons, in alcoholics or diabetics, or in the subjects
of pulmonary, cardiac, renal, or hepatic disease, and
that in certain cases and under certain conditions,
it may be considered an available substitute for
inhalation anesthesia, and as a useful and reasonably
safe recourse in operations below the diaphragm,
although it has not proved entirely satisfactory or
uniformly efficient in abdominal section.
Caution should be observed in the application of
spinal anesthesia to cases of extreme anemia, asthenia,
toxemia, or infection, and if it should be used under
these unfavorable circumstances, the ordinary dose
should be reduced. James B. Baird.
Anethol (C,„H,.,0). — The active constituent of oil of
anise, of which it constitutes about ninety per cent.,
of oil of star anise, which contains somewhat less of it,
and of oil of fennel, which contains about sixty per
cent, of it. It occurs both as a solid and as a liquid,
the former in colorless crystalline plates. Its specific
gravity at 25° C. is 0.985." and it melts at 21° to 22° C.
It is freely soluble in alcohol and slowly in water. Its
odor and taste are purely those of anise, and it may
be used with advantage in doses of one to ten grains as
a substitute for the above-named oils.
H. H. Rusby.
Aneurysm, External. — An aneurysm of an artery is
a circumscribed tumor composed of a sac, the cavity
of which communicates with the lumen of the artery
and contains liquid or coagulated blood. The sac may
be formed in whole or in part of the distended wall of
the artery, or of the condensed adjoining tissues.
Definitions and Classification. — The terminol-
ogy of the affection has been much confused by a lack
of agreement in the use of terms and in the meaning
attached to them. Most of these terms are intended
to indicate differences in the composition of the wall
of the sac, some of which cannot be recognized with
certainty on direct examination, and are not marked
by any corresponding clinical differences.
Internal and External. — Internal aneurysms are
306
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Aneurysm! External
those situated within the thoracic or abdominal
oavity; external aneurysms are those formed at the
expense of arteries lying outside these cavities.
I \tedical is sometimes used as a synonym of internal;
surgical, of external.)
Spontaneous and Traumatic. — Spontaneous aneu-
rysms are those thai have arisen in consequence ol
rjisi ase <>r gradual change in the wall of an artery. A
italic aneurj sm is one which has formed in CO
[Ce of sudden mechanical ili\i.-i< m or injury of the
wall of an artery, as by a knife or splinter of bone.
The following anatomical classification, adopted
by Holmes, is tlie one in i mon use. The distinc-
tion made between "true" and "false" aneurysms
is anatomically justified, but the terms an- likely to
mislead, for "true" aneurysms, in the narrow sense
of the term — i.e. aneurysms whose walls are every-
where composed of all the coats of the artery- arc rare
and always small. The common form of aneurysm
■ ugs io the class termed "false," those in which
on,' of the coals of the artery takes part in the
formation of the wall of the sac.
I. Common orencysted aneurysm, subdivided into —
(a) Aneurysmal dilatation, or fusiform aneurysm.
Iln artery is dilated for some distance, and the wall
of the dilated portion preserves its three coats.
(6) True aneurysm. The sac is formed throughout
by all the coats of the artery dilated at only one point.
(c) False aneurysm. The sac is formed by only
one or two of the coats of the artery, the middle one
having disappeared or being unrecognizable in con-
BBQuence of change.
( *>*~ it has an epithelial surface
■' ■j^MMjS^itL °f tlat cells and a deeper
! isJ/wBP ^^Sk structure of flat cells sepa-
He'^wM ~^» rated by a fibrillary sub-
»~ stance. A similar struc-
ture is found also upon the
surface of thrombi, as after
the ligature of an artery,
and it must, therefore, be
deemed not simply a dis-
tended intima, but rather
a layer of newly formed
tissue. Traces of tlie mid-
dle coat may be found at
different parts of the
aneurysmal sac, especially
in the neighborhood of its
neck, where, indeed, they
may form a continuous
layer with that of the
artery; but in the more
di-teiided portions of the
sac they are entirely ab-
sent, and it appears to be
well established that there is no hyperplasia of the
muscular and elastic tissues which compose this coat,
but that their elements undergo not only degeneration
but also mechanical separation, and they have practi-
cally no share in the formation of the wall.
The new tissue may itself either undergo fatty degen-
eration, or become atheromatous or calcified. As the
sac enlarges it may become thinned at some point and
burst, with escape of its contents into the adjoining
tissues ("ruptured aneurysm"); and when, in its
growth, it reaches and presses upon firm, unyielding
tissues like bone, the latter undergo absorption.
Bone disappears under this pressure by rarefaction
that is, a general rarefying osteitis is set up, charac-
terized by the enlargement of the vascular canals of the
bone, by multiplication of the cellular elements, and
by disappearance of the earthy salts, but without
production of pus. Other tissues may become in-
flamed under the same irritation, and the inflamma-
tion may be plastic, with production of adhesions,
397
Fig. 235. — Aneurysm of the
Femoral Artery. The walls of
the sac consist only of the adven-
titia (a) and intima ib) ', the mus-
cidaris (c) remains only at the
entrance of the sac. (Weber.)
Aneurysm, External
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
or ulcerative. Thus, adjoining serous surfaces unite
(pleura, pericardium, peritoneum), or rupture may
take place through ulceration of the walls of the
trachea or of the esophagus, or of the wall of any
other cavity that is pressed upon. These openings
may be large or small, and may give rise to repeated
small hemorrhages, or may cause death instantly by
a free one, either external or internal.
The growth of the sac takes place in the direction of
least resistance, but this direction is determined
rather by the distensibility of the wall itself than by
the resistance of the surrounding parts. Thus, the
wall may be comparatively firm on the side adjoining
a cavity, and growth may be slow in that direction,
while at another point where it rests against bone
the latter may be rapidly absorbed and even perfo-
rated, as is seen in the sternum, and this perforation
will be followed by rapid enlargement of the aneu-
rysm through the opening. Aneurysms of the limbs
seldom rupture through the overlying skin, probably
because they receive treatment before their growth
has reached such a point; but those of the thoracic
aorta and innominate not infrequently end by ulcera-
tion of the skin and fatal external hemorrhage. An
aortic aneurysm reaches the surface either by growth
upward into the neck or through the sternum, or
between the ribs to the surface of the chest. The
absorption of the bodies of the vertebra; by thoracic
or abdominal aneurysms gives rise to some of the most
painful symptoms of this fatal and painful affection.
In two cases quoted by Mr. Holmes from Dr. Gairdner
tin- spontaneous opening of an aneurysm through the
skin was followed by the healing of the opening, and
in one of them apparently by the cure of the disease;
but such a result is so entirely exceptional that it
deserves mention only as a surgical curiosity. When
an aneurysm has ruptured externally or internally,
the progress in the immense majority of cases is from
bad to worse if the hemorrhage is not immediately
fatal. The bleeding may be arrested by syncope or
by the plugging of the orifice by a clot, but it recurs
again and again, and ultimately proves fatal, unless
the recurrence can be prevented by treatment.
The pressure of the growing tumor not only leads to
the condensation and absorption of the tissues pressed
upon, but it also causes much pain, either by stretching
nerves or by provoking a neuritis, and it may inter-
fere with the circulation of a part or limb by closing
a vein or even an artery, and thus lead to gangrene.
The blood contained within an aneurysm is usually
in part liquid and in part clotted, and "the inner sur-
face of the wall of the sac is lined with layers of gray-
ish, opaque fibrin of irregular thickness and extent.
These layers may be comparatively thin, or they may
fill the greater part of the cavity. They are produced
by gradual deposit of the fibrin on the wall, so that
those layers that are nearest the wall are the oldest,
and also the shortest, because the sac has usually
increased m size since they were deposited. They
occasionally undergo degeneration and break down
into a granular detritus, forming small cavities filled
with a pulpy mass. Ordinarily the connection be-
tween the wall of the sac and the adjoining layers of
fibrin is one merely by contact, and there is no
growth of tissue from the former into the latter.
This condition seems to be true at least of all grow-
ing aneurysms, but in those that have undergone spon-
taneous cure, or have been cured by treatment,
the development of new tissue is observed. This
firm, laminated fibrin is called the "active clot";
the soft, dark clot, or "passive clot," which is fre-
quently found loose in the cavity of the sac, is prob-
ably a postmortem formation in most cases.
The growth of an aneurysm may be stayed, and a
practical cure obtained, by the deposit of sufficient
laminated fibrin either to fill its cavity or thoroughly
to protect its wall from the distending effect of the
blood pressure, and this is thought to be the mode
398
of cure by most methods of treatment. It seems
extremely improbable that this laminated fibrin is a
later stage of a "passive" clot; there is every reason
to believe that it is gradually deposited as such by
the blood in consequence of changes or peculiar con-
ditions in the lining membrane of the sac, or in the
rapidity of the circulation. Under ordinary condi-
tions this deposition does not take place rapidly
enough to effect a cure; it occurs at some parts of the
sac and not at others; its union with the sac is slight,
and the blood can readily insinuate itself between
the two at the edge of the layers, and as the sac en-
larges fresh portions are created and left uncovered
to undergo subsequent distention. If the conditions
are modified by operative or other treatment that
diminishes the volume and force of the stream of
blood, time may be given to the tissues of the sac at
the edge of the clot to become more intimately adher-
ent to the latter, and thus to make the clot a per-
manent protection against further increase. This
is effected by granulations from the lining membrane,
« Inch spread into the clot and over its surface, making
it, as it were, a part of the wall of the sac, binding
down its edges, and covering it with
a smooth epithelial layer. The union
between the walls and the layers of
fibrin appears to be very slight, and
limited to those layers immediately
adjoining the wall, and there is no
evidence that new vessels extend
from the wall or between the layers
of the fibrinous clot. Some aneu-
rysms, after a long period of rest ami
apparent cure, have begun again to
pulsate and to enlarge, and this fact
can be explained only on the theory
of a simple mechanical obstruction
that has persisted during the period
of quiescence, and has then yielded
and allowed the reentrance of blood,
the insinuation of blood between the
layers of fibrin and the wall.
A cure may also follow the sudden
formation of a soft "passive" clot.
This fact has been demonstrated by
examinations made after the rapid
cure of aneurysms by the use of the
elastic bandage. The first case is
reported by Mr. Wagstaffe in the
Transactions of the London Patho-
logical Society, vol. xxix., p. 72; it
was a case of popliteal aneurysm
cured a few months before the pa-
At the autopsy the sac was found
to measure two inches in length and one inch in
diameter, and to contain a central blood clot
measuring one by one-half inch, and surrounded by
fibrous tissue which was continuous with the sac
and artery. This tissue was abundantly supplied with
blood-vessels, and the artery was permanently closed
above and below. The process is probably as follows:
In consequence of the arrest of the current of bl I,
whether by a distal plug, or by ligature, or by com-
pression, the blood within the sac clots, and it proba-
bly does so more promptly than within normal vessels
because of the character of the inner surface of the wall
of the sac. This clot fills the sac, and probably extends
for a variable distance into the artery above and below
the opening. This extension prevents the reentrance
of blood into the sac even if the obstruction that led
to the formation of the clot is afterward removed,
and the latter then undergoes those changes with
which we are familiar in clots formed outside the body.
It divides into two portions, a central, shrunken, firm
clot, composed of corpuscles and fibrin, and an ex-
ternal layer of serum. The latter is absorbed b}' the
neighboring tissues, and the sac correspondingly re-
tracts, and its wall thickens by this retraction and
Fig. 236.— Sec-
tion of an Aneu-
rysmal Sac Con-
taining a Clot Sur-
rounded by Organ-
ized Fibrous Tis-
sue. (Wagstaffe.)
tie nt's death.
REFERENCE HANDBOOK 0] THE MEDICAL SCIENCES
Ani'iii} sm, External
possibly by a hyperplasia of its cellular element
provoked by the irritation excited by the clot,
irritation involves also the adjoining wall of the
artery, as is proved by the changes that occur even
in normal vessels into which clots have extended.
The intima thickens and sends oul cellular prolo
. which perforate I hi' clot ami spread over M -
surface; these new cells soon constitute a completely
ned and resistant plug structurally continuoi
with the wall of the artery, and provided with a
00th epithelial surface. The artery is now a-
ipletel) and permanently closed on each side of
aneurysm as if ligatures had been placed upon it
there, and the clot is left free to undergo its natural
retrogressive changes, and the aneurysm is relieved
distending pressure of the arterial stream.
Complete absorption of the serum reduces the clot
to less than half its original size, and this reduction
lowly carried further by molecular disintegration
rption of the corpuscles and fibrin.
This conception of the process is supported by our
knowledge of the changes which occnr in blood that
has clot t i'd within the body under ot her circumstances,
by certain clinical features observed in aneurysms
that are undergoing or have undergone cure, and by
the examination of specimens. Thus, in a case of
popliteal aneurysm cured by the application of the
rubber bandage, a non-pulsating area of fluctuation
appeared in the sac a day or two after the operation,
and slowly disappeared as the tumor diminished;
there can be but little doubt that it was due to the
pressure of serum exuded from the clot more rapidly
than it was absorbed by the surrounding tissues.
Again, in .Mr. Wagstaffe's case above referred to, there
was found a central blood clot of comparatively small
size, closely surrounded by the thickened sac, and the
artery was permanently occluded by fibrous tissue
continuous with its wall and with that of the sac; and
in Reid's case (Lancet, August 5, 1876), the first one
cured by the use of the elastic bandage, a similar
condition of the parts was found: a central blood
clot, dark in color and of cheesy consistency; a con-
tracted but thin sac with a few partly adherent
layers of laminated fibrin; and the artery occluded by
fibrous tissue for a distance of two and one-half inches
above the sac.
The transformation of an obliterated aneurysm into
a blood cyst after many years has been observed in one
case, which is apparently unique. It is reported by
Reinhold ("Ihaug. Dissert.," Marburg, 1SS2; abstract
in Ci ntralblatt fur Chirurgie, 1SS2, p. 571). It was a
traumatic varicose aneurysm of the popliteal artery
and vein successfully treated by ligature of the fem-
oral artery and by compression of the sac. Nine
years afterward a large, tense cyst formed, containing
crystals of cholesterin and hematin, and suppurated
after multiple punctures; it was then laid open, and
several old blood clots and a few calcified fragments
were turned out.
Causes. — Anything which reduces the power of
resistance possessed by the arterial wall below what
is sufficient effectively to oppose, the distending force
of the blood may be an immediate or a predisposing
cause of aneurysm. A sudden increase of intravascu-
lar pressure may combine with preexisting weakness of
the wall to produce an aneurysm, but in the great
majority of cases the change which leads to this pro-
duction lies in the wall alone. Mr. Holmes quotes two
cases in which the formation of an abdominal aneurysm
appeared to have been the direct consequence of the
emotion experienced by a criminal on receiving a
severe sentence. Weakness of the wall may be lim-
ited to a single large or small area, or may exist at
many points, with the production of a corresponding
number of aneurysms. This latter condition is termed
the aneurysmal diathesis, and although the affection
is usually single, as many as sixty-three aneurysms
have been found in one individual. The weakness
of the wall i i ! ill of change in i he innei and
i ii cially the middle, coats of thi I this
change maj be either the hyaline degeneration above
described, or the one known an atheroma. Among
the predisposing causes, therefore, mu I bi con
all those w hich lead to degi aeral ion of th
wall. The statistics collected i>.\ Mr. Crisp show
that of 551 spontaneous aneu : all kinds, only
two were of the pulmonary artery. 1 7."i of tic tho
aorta, fifty-nine of the abdominal aorta, 137 of the
popliteal artery, sixty-six of the femoral, twenty-
four of the carotid, twenty-three of the subclavian,
t wenty of t he innominate, ami eighteen of t he axillary.
The disease is mosl common between the ages of
thirty and fifty year-, and i- verj rare in childhood;
have I n operated upon at eight and nine
years. Broca claimed that the liability to aneurysm
increased with advancing years in the arteries above
i he diaphragm, and diminished in those below it.
Aneurysms of the arteries of the extremities are much
less frequent in women than in men. but there ap-
pears to be no such difference as regards internal
aneurysms. This unequal distribution as regards the
artery, the age, and the sex, indicates some of the
. both general and special. Among the gen-
eral causes are habits of life and peculiarities of con-
stitution -which increase the arterial tension or diminish
the strength of the arterial walls; the special ones are
anatomical peculiarities and local lesions, changes,
and injuries.
The habits of life which act as predisposing causes
are excess in the use of alcoholic drinks, and occupa-
tions which call for the exertion of much muscular
effort. The influence of syphilis has been alleged.
Modern methods of diagnosis of syphilis ought to give
us more accurate data; in the same way the more
vigorous action of salvarsan may give better results
than the older usually inefficacious mercurial treat-
ment. The gouty or rheumatic diathesis predis-
poses to it. The influence of muscular effort, so
far at least as regards external aneurysms, is shown
by the greater prevalence among males than among
females, and the greater frequency during the prime
of life, notwithstanding the fact that degenerations
of the arterial walls are more common in advanced
life. Follin quotes in support of the influence of
alcohol a remarkable statement made to him by the
Dublin surgeon, Colics, to the effect that while the
Father Mathew Temperance Societies flourished in
Ireland, aneurysms were much less frequently seen
than before or since that time.
The anatomical peculiarities which influence the
occurrence of an aneurysm are changes in the direction
of an artery (as the arch of the aorta), normal enlarge-
ments of its caliber (as at the upper end of the car-
otid), bifurcations, and the neighborhood of joints
which are habitually and violently extended and
flexed (as the knee and hip). The local changes
which are to be regarded as exciting causes are the
changes already described as occurring in the arterial
wall and other changes or injuries which diminish its
power of resistance or break its continuity. Thus the
sharp edge of a calcified atheromatous patch may cut
through the intima and admit the blood into the rent,
with the subsequent formation of a real aneurysm,
or of the variety known as dissecting aneurysm. Or
the middle coat may be ruptured by being over-
stretched, and the part thus weakened will be ex-
panded to form an aneurysm; or ulcerative in-
flammation outside the vessel may weaken, or even
perforate its wall, leading, in the former case, to the
formation of a typical aneurysm, and in the latter,
to the transformation of an abscess into an aneurysm.
Or, rarely, the process set up by a ligature upon an
artery may extend beyond what is needed for the
sealing of the vessel, and so weaken the adjoining
portion by modifying its middle coat that it yields
under the pressure of the blood and expands into an
399
Aneurysm, External
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
aneurysm. Or an embolus may lodge in an artery
and lead to the same result by the same process; this
seems to be especially probable when the embolus
has formed during ulcerative endocarditis, and the
explanation is to be found in the septic or virulent
qualities then possessed by the embolus. Four
cases of this kind were reported by Dr. James F.
Goodhart, in the Transactions of the London Patho-
logical Society, 1S77, vol. xxviii., p. 98: in three of
them the aneurysm occupied the middle cerebral
artery, or one of its branches; in the others, the
posterior cerebral artery.
Symptoms and Progress. — When an aneurysm
forms suddenly by rupture or perforation of an artery,
or in consequence of a violent effort or emotion, its
formation is accompanied by sharp pain and the
more or less prompt appearance of a tumor, if it is so
situated that a tumor is recognizable. But ordi-
uarily the formation is slow, and the patient's attenl ion
is first attracted by the presence of a tumor. This is
situated in the line of an artery, is not adherent to
the skin, is slightly movable, smooth and regular in
outline, usually globular or ovoid, soft and compressi-
ble, and pulsates synchronously with the heart. If
steady pressure is made upon it, its size may be more
or less diminished while the pressure is made, but it
immediately regains its former volume when the
pressure is removed. If it is grasped between the
thumb and fingers or between the two hands, the
pulsation is found to be expansile, that is. the fingers
or hands are pushed apart by it, not simply lifted by
it. If the ear is placed upon it a sound is heard
corresponding to the pulsation; this is the aneurysmal
bruit; and while it may vary somewhat in character
in different cases, it is usually harsh rather than soft
or blowing; it may be limited to the time occupied by
the pulsation, or may extend over the entire interval
from the beginning of one pulsation to that of the
next. If pressure is made upon the artery above the
tumor, the latter diminishes somewhat in size, and
the pulsation and bruit cease. The pulsation in the
distal branches of the artery may be normal or
diminished; and if the tumor presses upon the corre-
sponding vein, the limb may be edematous and
swollen. The compressibility and softness of the
tumor are modified by the amount of laminated fibrin
within the sac.
Pain may accompany aneurysm when once formed
and is due either to stretching of nerves or to pressure
upon, and inflammatory processes excited in them
and other adjoining tissues.
The tendency of an aneurysm is to increase in size;
for the absence from the wall of the sac of a muscular
coat the most efficient agent to withstand the expand-
ing blood pressure, leaves the wall unprovided with
any tissue able successfully to oppose this pressure.
The growth may be rapid or slow, according to cir-
cumstances, chief among which are the size of the
opening by which the sac communicates with the
artery, the firmness of the surrounding tissues, and
the readiness with which the blood in the aneurysm
clots or deposits laminated fibrin upon its wall.
The enlargement may be uniform, or more marked
at some points, and may take place more rapidly at
certain times than at others.
The natural tendency of an aneurysm is to spread
and finally to rupture, either by gradual weakening
of its wall or by ulceration into a natural adjoining
cavity or through the skin. As it approaches the
surface the skin becomes tense, adherent, and
inflamed, and may ulcerate or become gangrenous.
The subcutaneous tissues may be similarly affected,
and thus an abscess may form between the sac and
the skin, into which the aneurysm may rupture
either before or after the abscess has opened exter-
nally. The inflammatory process outside the sac has
been thought to favor coagulation of the blood within
it, and thus to lead to a temporary or even a perma-
nent arrest of the disease; but ordinarily free hemor-
rhage follows the rupture and requires extreme
measures for its arrest, if indeed arrest is possible.
The most favorable, and one of the possible termi-
nations of aneurysm, is its spontaneous cure by coagu-
lation of the blood within it. Some of the conditions
which provoke or favor this occurrence have already
been referred to. They may all be classified under
three heads: (1) Those which favor clotting in the
sac by retardation or arrest of the current through it;
(2) those which increase the coagulability of (lie
blood; (3) those which provoke coagulation through
change in or about the wall of the sac.
(1) Retardation or arrest of the current; and (2)
Conditions which increase the coagulability of the blood.
It has been abundantly proved, both clinically and
by the study of specimens, that total arrest of the
current in the sac is not necessary for the coagulation
of the blood contained in it, but that a partial arrest
or slowing, effected by influences acting upon the
general circulation or only upon the blood occupying
portions of the sac, may either begin the process or
promote the extension of the process after it has been
begun. Most aneurysms of any size contain lami-
nated fibrin adherent to some portion of the wall,
and some are found completely filled with it, or so
nearly filled as to leave only a small canal through
which the current is maintained. When these clots
are small, they habitually occupy those portions of
the sac in which the circulation was apparently the
least rapid, and it has been observed that the adoption
of measures or the occurrence of changes which have
diminished the rate of flow, or the quantity of blood
passed through the vessel upon which the aneurysm
is situated, has been followed by a gradual cure
through the deposition of fibrin. The permanency
of such a cure depends upon the maintenance of the
reduction in the rate or volume of the blood current,
or upon the creation of such relations between the
clot and the wall of the sac that the former becomes
a permanent part of the latter and protects all por-
tions of it from the action of the expanding force of
the blood. These relations consist in the formation
of a membrane by proliferation of the cellular ele-
ments of the intima of the artery, and the spread of
this membrane over the edges and perhaps over the
whole of the exposed surface of the clot, in such a way
as to prevent the insinuation of the blood between
the clot and the wall, and to give a smooth epithelial
surface over which the blood passes without depos-
iting additional fibrin.
The causes of retardation or arrest are various.
They may be found in the shape of the sac, in the
general condition or habits of the patient, or in special
modifications of the flow through the artery itself.
Pouched sacs, or sacs with small necks, are more
favorable to the occurrence of clotting than are
fusiform dilatations or sacs with large, free openings,
because the blood that enters does not immediately
leave them, but forms a sort of eddy beside the general
stream in which the current is slow or almost nil.
Of the causes arising in the general condition or
habits of the patient, the first and most important is
continuous rest in bed for Weeks or months, combined
with a light, non-stimulating diet. Other causes,
which may also act by increasing the coagulability of
the blood, are bleeding, either large or small and
repeated, and the internal use of various drugs, such
as digitalis, tartar emetic, veratrum viride, iodide of
potassium, acetate of lead, ergot, and the chloride
of barium. Cures have followed the use of each of
these measures, alone or in combination, but it is
not always easy to determine how much credit is to
be awarded to "the treatment in any one case.
Retardation or arrest of the flow may also be caused
by obstruction of the orifice of the sac, if it is small, or
of the artery above or below the aneurysm. The
most common agency in producing this change is the
400
REFERENCE HANDBOOK OF THF MEDICAL SCIENCES
Aneurysm, External
detachment of a fragment of fibrin from the wall of
the sac and its lodgment in the neck of the s:ir, or
in the artery below. The latter occurence is habitu-
ally accompanied by severe pain in the limb, and is
evidenced by arresl of pulsation in the distal branches
( if the artery. A euro by this mechanism has been
observed a number of limes, and it forms the basis
of a method of treatment suggested by Sir William
Ferguson, in which the forcible detacl nt of a clot
from the wall is sought to be effected. If the de-
tached 'lot is small, it may lodge on the spur of a
bifurcation, and then grow in size by additional de-
posits of fibrin until it obstructs one or both of the
branches, and in such a case retardation precedes
complete aires!.
This possibility of the detachment of small clots
and their passage into the distal branches of the
artery involves the risk of other changes far different
from the cure of the aneurysm. The arrest, of the
circulation may lead to gangrene of the lower portion
of the limb, total or partial, according to the seat
of the obliteration; and if the aneurysm is situated
upon the arch of the aorta or upon one of the vessels
going to the head, the emboli may lodge in the vessels
of the brain and cause death promptly.
When there is merely retardation of the current the
cine takes place by the gradual deposit of lamina led
fibrin: and when there is total arrest, it takes place
probably by coagulation in mass of all the blood
within the sac, and the subsequent shrinking of the
clot and sealing of the vessel by the production of
fibrous tissue, as has been described above.
Another alleged cause of retardation of the stream
is pressure of the tumor upon the proximal portion
of th ' artery, but no cases have been reported in
which this mechanism has been demonstrated. Its
supposed possibility rests upon theoretical grounds
alone, and while it may be admitted as a possibility,
there is but little reason to believe it has ever taken
place.
(3) Conditions which provoke coagulation through
change in or about the wall of the sac. Inflammation
of the sac, or of the tissues immediately overlying
it, is alleged by Broca and others to be a cause of
coagulation within it and of consequent cure. Mr.
Holmes thinks this assertion has never been demon-
strated, and attributes the cure, in the eases that
have been cited in support of the theory, to impaction
of a clot. There is no doubt that inflammation
about an artery or vein can and does often lead to
the formation of a thrombus within the vessel, but
the conditions in an aneurysmal sac are so different
that it is perhaps unjustifiable to argue from a sup-
posed analogy.
The sudden formation of a soft elot within an
aneurysm may excite inflammation and suppuration
of the sac with subsequent rupture. In a few cases
this process has been followed by a cure; but the
cure must be attributed to the obstruction of the
vessel, either by the original clot previous to the
rupture, or by a secondary clot after the hemorrhage
that has followed the rupture.
In like manner, tardy suppuration may follow cure,
and after an aneurysm has remained quiescent and
shrunken, in fact cured, for months or even years,
such suppuration may lead to the casting out the clot
in whole or in part.
Changes in laminated fibrin after the cure of an
aneurysm are slight and gradual, and rarely amount
to more than a diminution in size by shrinking; some-
times the fibrin becomes soft, and sometimes lime
salts are deposited in it. A unique case of later trans-
formation into a blood cyst has been mentioned above.
Diagnosis. — The typical symptoms of aneurysm are
the existence of a more or less well-defined tumor
that pulsates synchronously with the beat of the heart,
has a distinct intermittent bruit, and diminishes in
size while pressure is made upon it or upon the proxi-
Vol. I.— 26
mal portion of the artery from which it arises. Hut
these signs may lie variously modified or abolished
by the varying conditions that have been described
above, or may be undemonstrable because of the
position of the tumor, or may be simulated by those
of other affections. An additional sign is Minn-limes
found in a difference In the character of the pulse in
the distal branches of the artery when compared
with thai in the branches of the corresponding artery
of the outer side, a difference that may be recognized
by the linger, but much more certainly by the
sphygmograph.
The symptoms in external aneurysm may be
modified by the partial or complete consolidation
of its contents, or by the temporary obstruction of its
orifice, either of which occurrences may greatly
diminish Or arrest, the pulsation and bruit.
The affections with which an aneurysm is most
likely to be Confounded are solid or liquid tumors
overlying an artery and very vascular tumors lying
in or near the course of a large artery. In all, the
common signs an' a pulsating tumor with bruit, and
the circumstance that the pulsation and bruit may be
arrested by pressure on the artery. The pulsation of
an aneurysm is expansive, the tumor enlarging later-
ally at each pulsation; that of an overlying tumor is a
simple lifting of the entire mass; but this difference
cannot always be recognized with certainty, or if the
fingers cannot be pressed down to the widest part of
I he tumor, the simple rising of the sloping sides of the
globular mass between them forces them apart and
simulates lateral expansion. A bruit may be caused
in an artery or vein by pressure upon it. In a vein
such a bruit is harsh and continuous; in an artery it is
intermittent and more "blowing" in character than
that of an aneurysm.
In the case of a suspected liquid collection simulat-
ing aneurysm, the diagnosis may be aided by aspira-
tion with a fine needle. An aneurysm has been
mistaken for an abscess frequently enough to make
great caution necessary in the diagnosis and treat-
ment of any supposed abscess lying in the course of
a large artery. The fingers should always be pressed
deeply into the swelling in search of pulsation, and
even if an abscess is certainly present, it should
be remembered that it may have formed over an
aneurysm.
As pulsation and bruit have their origin in the stream
of blood brought by the artery, pressure upon the
proximal portion of the vessel will arrest them,
whether they belong to an aneurysm or are simply
communicated through a tumor. Vascular tumors,
especially those arising from bone, often have well-
marked pulsation and bruit: but their pulsation is less
"heaving" or massive" than in aneurysm, and the
bruit is rarely well marked. The diagnosis may be
extremely difficult, or only possible by the aid of
exceptional explorations. In a case of large pulsating
tumor of the gluteal region, under the care of Prof.
Henry B. Sands, in the Roosevelt Hospital, New
York, in 1880, the diagnosis of aneurysm was made by
passing the hand into the rectum, and thus learning
that the internal iliac artery was enlarged, the
enlargement increasing from above downward to the
sacrosciatic notch. The frequent presence, in vascular
tumors, of large collections of blood contained within
sacs formed by the rupture or dilatation of capillaries
or small vessels, increases the resemblance to an
aneurysm.
An aneurysm which has just ruptured into the
adjoining tissues does not pulsate, and may have no
bruit; under such circumstances the diagnosis must
be made by the history of the case, the preexistence
of a pulsating tumor, and the cessation of the pulsa-
tion coincidently with a marked change in the shape
and size of the tumor. In like manner, where an
artery has just been ruptured or perforated and the
blood has been effused into the adjoining tissues,
401
Aneurysm, External
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
pulsation and bruit are not present until after the
effusion has become circumscribed by a distinct
firm wall composed of the condensed tissues ("trau-
matic aneurysm" or "ruptured artery").
For the differential diagnosis of arteriovenous aneu-
rysm and cirsoid aneurysm or arterial varix, vide infra.
Prognosis. — The gravity of the prognosis varies
with the artery involved, and the size and character of
the aneurysm. In internal aneurysms the prognosis
is very grave; in external aneurysms it is commonly
much less so, since in most of them suitable treatment
offers a reasonable hope of cure.
Treatment. Medical treatment. — The medical treat-
ment of aneurysm, especially of internal aneurysms,
consists in absolute rest in the recumbent position,
maintained for weeks or months, combined with a
restricted diet, and aided, perhaps, by the use of vari-
ous drugs. The absolute rest and the low diet are un-
questionably the most efficient part of the treatment,
and the drugs, even those for which most has been
claimed, are only adjuvants of uncertain and often
very doubtful utility. Systematic treatment of this
kind dates from the time of Valsalva, and even in his
hands the rest was subordinate to repeated venesec-
tion, which he carried to such an extent that rest in
bed was a matter not of choice, but of necessity.
This active depletion was never regarded with much
favor, and as it was long deemed an essential part of
treatment by rest, the latter shared in the disfavor of
its associate, and patients affected with internal
aneurysms were habitually looked upon as beyond
the reach of art, and the interference of the physician
was restricted to relief of pain and the occasional
employment of drugs from which it was thought some
benefit might possibly accrue. To Mr. Tufnell of
Dublin belongs the credit of demonstrating the value
of absolute rest in bed and restricted diet in pro-
moting a cure or affording great relief. He insisted
upon the absolute maintenance of the recumbent
posture, and restricted the amount of food to about
eight ounces of solid food and six ounces of liquid
daily, the solid food being bread, butter, and meat,
the liquid, milk and a little claret wine.
Of drugs, the iodide of potassium has been most
employed, in doses of from half an ounce to one ounce
daily. A number of cases of aortic aneurysm appar-
ently cured or greatly relieved by its use have been
reported. Salvarsan might be useful in certain cases.
Digitalis, veratrum viride, and ergot have also been
used, with the object of slowing the circulation;
occasional supposed cures or temporary arrests by
their agency have been reported, but they are not
regarded with favor by the authors of systematic
treatises on the subject. Ergot is given internally
in the form of the fluid extract, or subcutaneously
as ergotine. Mr. Holmes regards the acetate of lead as
offering the best promise. Dr. F. Flint reported a
case of aneurysm of the abdominal aorta apparently
cured by the use of the chloride of barium in doses of
from one-fifth to three-fifths of a grain three times
daily for about five months, after Tufnell 's method
had entirely failed. The most rapid improvement
coincided with the smallest dose.
Surgical methods of treatment may be grouped in
three classes:
1. Radical obliteration of the sac by opening it and
tying the artery immediately above and below its
point of communication with the aneurysm. This
is known as the "old method," or the "method of
Antyllus." Under the same head may be included
the method of extirpation of the sac. with ligature of
the artery above and below; and the Matas operations:
(a) Obliterative endoaneurysmorrhaphy; (6) Recon-
structive endoaneurysmorrhaphy. (See under Ar-
teries, Surgery of the.) Suture of each opening
in arteriovenous aneurysm or excision of the
injured vessel with end-to-end Union of the two
segments, or implantation between them of a segment
of another vessel (vein). See Binnie, Operative
Surgery, fifth edition.
2. Permanent or temporary arrest of the afferent
stream at a point on the proximal side somewhat
removed from the aneurysm, (a) Ligature of the
artery (Anel's method, or the Hunterian method).
tin Compression of the artery — direct, indirect, digi-
tal, or tentative by apparatus whose pressure can
be regulated or by apparatus which can be re-
moved, (c) Esmarch's elastic bandage, (d) Flexion
of the limb.
3. Permanent arrest or obstruction of the stream
on the distal side, (a) Distal ligature. (6) Manipula-
tion to produce an embolus or impacted clot.
4. Rapid coagulation of the blood in the sac (with
or without temporary arrest of the stream), (a) Co-
agulating injections. (6) Introduction of solid bodies,
(c) Galvanopuncture and the introduction of a wire
plus galvanism.
5. Promotion of the formation of a laminated clot
by irritation of the wall — "needling."
1. The "old method" (or the method of Antyllus).
The aneurysms with which the ancient surgeons had
mainly to deal, or at least those to which operative in-
terference was mainly limited, were traumatic an-
eurysms at the bend of the elbow following venesec-
tion. It has been claimed for them that they knew
and practised the method of cure by ligature of the
artery in continuity above the sac, but Hodgson's
statement, which is quoted by Holmes in support
of this claim, does not fully and accurately present
the practice. Ligature of the brachial artery "three
or four finger-breadths below the axilla" was indeed
recommended by Aetius in the fifth century, but only
as a preliminary to the opening of the sac at the elbow
and the application of another ligature there, and
solely with the object of preventing hemorrhage
during the operation proper. The main "object of
treatment was to remove the clot, which was thought
to be a source of danger, and to prevent subsequent
hemorrhage by obliterating the artery or closing the
opening by which it communicated with the sac.
The operation appears to have fallen into disuse and
not to have been revived until about the seventeenth
century, when it was again used with various modifica-
tions, but at first only in traumatic aneurysms at the
elbow. It appears to have been first used in popliteal
aneurysm by Keyslere; the date of his first operation
is not known; his second and third were done in 1747
and 174S respectively. His first three cases were
successful; the fourth ended fatally.
The method of operation as practised in popliteal
and brachial aneurysms until the end of the eight-
eenth century, was to control the artery by a tourni-
quet or the fingers, divide the sac by a longitudinal
incision, turn out the clots, find the point of communi-
cation with the artery, isolate the latter, and tic it
above and below the opening. The cavity was then
packed with lint and allowed to fill by granulation.
The difficulties and the dangers were great.
The frequency of secondarj' hemorrhage was
thought by Hunter to be due to the diseased condition
of the arterial wall near the sac, where the ligature was
applied, and this has always been deemed one of the
most weighty reasons for preferring the Hunterian
method, in which the ligature is placed upon a more
distant and presumably healthy part of the artery.
It must be remembered, however, that secondary
hemorrhage was much more common in former days,
after all operations in which a large artery was tied,
than it is at present, when it has become very rare
after ligature with catgut or aseptic silk; and that
arteries so degenerated, or even calcified, that they
broke when the ligature was drawn tightly, 1
remained securely closed by slighter pressure, and
the wounds have healed without accident. .Mere-
over, recent experience with the catgut ligature in the
"old" operation and in extirpation of the sac has
402
REFERENCE EANDBOOK OF THE MEDICAL SCIENCES
\neiirysm. External
shown that the chance of s ndary hemorrhage is
!-. The objection raised against the old method,
the condition of the adjoining arterial wall is
altered, cannot properly be urged in the case of a
traumatic aneurysm; and the only other possible
objections are, that the operation is more difficult and
the wound larger.
Syme's method of operating when the artery could
oot be controlled on the proximal side of the sac was
to make an incision into the tumor just large enough
to admit his finger, with which he then felt for and
compressed the opening in the vessel. If he could not
thus find the opening, he enlarged the incision and
then introduced a second and third finger, and. in
, , 1M — so says Holmes — the entire hand. When
the opening was found and commanded, he si ill
further enlarged the incison, turned out the clots, and
denuded and tied the artery above and below.
Extirpation of the sac is now done as for the re-
moval of a tumor. The mass is exposed by a long
incision, the artery is tied above and then below, and
the >ae is dissected out with great can- to a\ oid injury
to the vein. The water operation is described in the
article on ' ry of the.
2. Permanent or temporary arrest of the afferent
stream at a point on the proximal side somewhat re-
moved from the sac.
Ligature by Anel's method, or the Hunterian
The question of priority in the introduction
of the method of ty-ing the artery above the sac, as
Fig. 237. — Different Forms nf Ligatures for Aneurysm, a, Ariel's;
b, Hunter's; c, Brasdor's; d, Warurop's; e, Antyllus's.
now practised, has given rise to much controversy,
but must here be dealt with very briefly. It is
claimed by the French for Anel, a French surgeon
itising in Rome in 1710, and by the English for
John Hunter in 17S5. The reader who is curious in
the matter is referred to Broca (" Des aneVrysmes, "
Paris, 1856), to Holmes ("A System of Surgery "1,
and to a paper by the writer in the New York Medical
Journal, November 1, 1SS4. The facts, in brief, are
as follows: January 30, 1710, Anel treated a traumatic
aneurysm at the bend of the elbow by tying the artery
close above the sac without opening the latter, and
thereby effected a cure. The patient was a priest.
The case gave rise to much discussion, the account of
it was reprinted in several books and journals, and the
method was subsequently used, before 1785, in at
least three other eases, in one of which the ligature
was applied about two inches above the sac (Broca. p.
446). June 22, 1785, Desault (after having a few
months previously sought to cure an axillary aneu-
rysm by compression of the subclavian) treated a
popliteal aneurysm by tying the artery. " immediately
below the ring of the third adductor," that is, at th ■
point where the femoral artery ends and the popliteal
artery begins; the aneurysm was cured, and the
patient died eleven months later of disease of thelower
end of the tibia. December 12, 1785, John Hunter
treated a popliteal aneurysm by tying the femoral
artery and vein "rather below- the middle of the
thigh."* In tl ing March, 1786, Di
Inning knowledge of Huntei operated upon
another anil tied the artery at a -till higher point,
dividing the sartori i e it.
Bunter repeated the operation four times within
four years following hi ie vein as
. i lie artery, except in the last I wo; I >ei aull
shortly after his owe second case.
These facts are riot disputed; the controversy lias
arisen over the principles which are thought to I
led, in the minds of the different opi \ne|,
Desault, and Hunter), to the adoption of the method.
It is claimed by the English (Guthrie, Holmes) that
Anel did not know what he was doing, did not
appreciate the importance of the method, the m
by which it affected a cure, and it- applicability to
I aneurysms than those at the elbow, and that,
as he used it. it was radically defective in placing the
ligature too close to the sac, and without the interven-
tion between I he tun of any collateral branch given off
from the artery; that, in short, it wa a mere happy
e, stumbled upon without reflection, and passed
without appreciation; that Desault's, in like manner,
was a mere experiment, but that Hunter's was the
result of profound reflection and reasoning upon the
nature of the disease and the manner in which coagu-
lation of the blood in the sac is effected, and especially
of his knowledge of the fact thai complete shutting
off of the current from the sac was not necessary. The
original reports, on examination, do not appear to
justify any of these claims, which seem to have no
more solid basis than ignorance of what Anel and
Desault really thought, and the crediting of Hunter,
before his operation, with knowledge which he ob-
tained at a later period. Hunter's identification with
the operation was in large part the result of his
exceptional authority at the time, the publicity which
attended or was given to the act, the frequent
repetitions, and the generalization which promptly
followed it, and also of the great ability with which he
set forth the principles upon which it rested. These in
themselves are an ample title to recognition and re-
spect, and Hunter's glory may well be left to rest on
them without robbing others of their just due.
Three months after Desault's first operation, and
three months before Hunter's first operation, at a
consultation held in London on a ease of femoral
aneurysm as large as an orange, in which Hunter
took part, all agreed that it was impossible to resort
to the operation ordinarily practised upon aneurysms,
and recommended pressure on the artery in the groin;
the attempt was made, and abandoned because of
the pain it caused. It is apparent that at this time
Hunter had not developed his method. The argu-
ments that led Hunter to tie the femoral artery for
popliteal aneurysm, according to Home, his pupil,
assistant, and reporter (loc. cit., p. 145), were "that
the disease often extends along the artery for some
way from the sac; and that the cause of failure in the
common operation arises from tying a diseased
artery, which is incapable of union in the time neces-
sary for the separating of the ligature."
If the artery should afterward give way [if tied just
above the sac] there will not be a sufficient length of
vessel remaining to allow of its being again secured
in the ham. To follow the artery up through the
insertion of the triceps muscle, to get at a portion of
it where it is sound, becomes a very disagreeable part
of the operation; and to make an incision upon the
fore part of the thigh, to get at and secure the femoral
artery, would be breaking new ground, a thing to be
avoided, if possible, in all operations. Mr. Hunter,
from having made these observations, was led to
* Everard Home, in Transactions of a Society for the Improve-
ment of Medical and Surgical Knowledge, London, 1793, p. 148.
This appears to be the first official publication of the case; the paper
is not dated, but it is printed between two which are dated Sep-
tember, 17S9, and September, 1790, respectively.
403
Aneurysm, External
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
propose that in this operation the artery should be
taken up in the anterior part of the thigh, at some
distance from the diseased part, so as to diminish the
risk of hemorrhage and admit of the artery being
more readily secured, should any such accident
happen. The force of the circulation being thus
taken off from the aneurysmal sac, the progress of the
disease would be stopped; and he thought it probable
that, if the parts were left to themselves, the sac with
its contents might be absorbed and the whole of the
tumor removed; which would render any opening
into the sac unnecessary."
It is plain, from this, that Hunter's idea in seeking
the artery at a higher point was simply to avoid
secondary hemorrhage and to make its treatment.
if it should occur, easier; and the extent to which
this idea preoccupied his mind is shown in the strange
additional precautions he took in the matter of the
ligature itself. He tied the artery with four ligature-;,
" but so slightly as only to compress the sides together.
The reason for having four ligatures was
to compress such a length of artery as might make up
for the want of tightness, it being wished to avoid
great pressure on the vessel at any one part."
According to Holmes, "the great merit of Hunter
consists in his having seen, first, that it was not
necessary to turn the clots out of the aneurysmal
tumor; and, second, that it was not neces-
sary to stop the circulation through it absolutely, but
only, as he said, 'to take off the force of the circula-
tion.' " The first of these was certainly appreciated
by Anel and Desault, for they saw their patients get
well; the second is difficult to explain if it is based
upon the fact that the ligatures were tied loosely,
for they certainly were intended to, and did, cut out,
and therefore occluded the artery entirely; and in
Hunter's subsequent operations he used a single
ligature and tied it tightly, so that if this was his
opinion and object at first, he subsequently aban-
doned it. The idea, moreover, is expressed by Home
(loc. cit., p. 150) as a conclusion drawn from what
was found at the autopsy eleven months later: "The
conclusion to be drawn from the above account
appears a very important one, viz., That simply
taking off the force of the circulation from the aneu-
rysmal artery is sufficient to effect a cure of the dis-
ease, or at least to put a stop to its progress." It
seems much more reasonable to infer that Hunter's
object in tying the ligatures loosely was to give the
artery more time to become sealed before the ligature
cut through. (See the first quotation from Home
given above.)
The statement has been generally quoted as mean-
ing that Hunter proposed to leave one or more col-
lateral branches between the ligature and the sac,
but there is nothing in the account of the operation
or of the autopsy to justify such an opinion. "The
femoral artery was impervious from its giving off
the arteria profunda as low as the part included in
the ligature, and at that part there was an ossifica-
tion for about an inch and a half along the course of
the artery Below this part the femoral
artery was pervious down to the aneurysmal sac,
and contained blood, but did not communicate with
the sac itself, having become impervious just at the en-
trance [italics ours]. ...... The popliteal artery,
a little way below the aneurysmal sac, was joined
by a small branch, very much contracted, which
must have arisen from the profunda, or the trunk of
the femoral artery." This is the only collateral
branch mentioned, and one cannot see how the conclu-
sion is to be avoided that even if the phrase "to take
off the force of the circulation" meant any more than
"to arrest" or "cut off" the circulation, it meant
only that the artery was left containing blood, and
that this blood was in communication with that
brought to the lower part of the same artery by col-
laterals coming from above the ligature. It would be
interesting, too, to know by what "profound reason-
ing Hunter excogitated the principle" (Holmes) of
including the vein in the ligature with the artery.
Even if Hunter afterward declared the presence of
a collateral branch between the ligature and the sac
to be a favorable condition, it does not affect the
original conception; and furthermore, the existence
of such a collateral branch is not essential to the
method, and it is not found when the carotid or
femoral is tied, or in some cases when the external
iliac or subclavian is. In short the method as now
employed is to place the ligature at the nearest con-
venient point, sufficiently far above the sac to find
the artery probably healthy; and the claim that has
been made that complete arrest of the circulation
is more dangerous than partial arrest, because it
leads to the formation of a passive clot which is
likely to provoke suppuration of the sac, has been
proved, especially by the experience with the Esmarch
bandage, to be incorrect, or at least the danger of
exciting suppuration is much less than was claimed.
The changes within the sac by which a cure is effected
after ligature are similar to those above described as
effecting a spontaneous cure. The closure of the
artery relieves the sac from all expanding pressure,
except the slight amount which may be exerted by
the blood that comes into the artery below the sac or
between it and the ligature through collateral branches.
The pressure being removed, the sac shrinks, the
blood within it either coagulates in mass, forming a
dark passive clot, or a slight movement persists in it
and laminated fibrin is deposited on the wall. Pulsa-
tion in the sac ceases as soon as the ligature is tied,
and usually remains permanently absent, but in
si ime cases it returns after a longer or shorter interval
and lasts for a few hours or days. This return is
due to the freedom and rapidity with which the col-
lateral circulation is established. The blood leaves
the artery through the branches given off above the
ligature, which dilate to accommodate the increased
supply, makes its way through the minute terminal
branches and capillaries into the terminals of the
branches given off from the main artery below the
ligature, passes through them in the retrograde
direction, and thus regains the main artery to be
distributed as before through its terminal branches.
The greater the length of artery that has been
obliterated by the ligature and disease, the greater the
difficulty of the reestablishment of the circulation, and
thus it is found that when two or three aneurysms are
situated upon a single artery, or when, on account of
secondary hemorrhage, a second ligature has been
placed upon the artery at a higher point, the proba-
bility is great that the circulation will be reestab-
lished too slowly or imperfectly to preserve the life of
the tissues, and the occurrence of gangrene is to be
feared.
The method of operation is to expose the artery
by a suitable incision, denude it just sufficiently to
allow an aneurysm needle to be passed under it, and
to tie it with a sterile ligature. Silk may be used,
but most surgeons prefer today the thoroughly
reliable catgut; when moderately chromicised this
remains unchanged ten days or more.
The chief dangers of the operation are secondary
hemorrhage and gangrene. Before the introduction
of the antiseptic method these dangers were so
great that the mortality, after ligature of the fem-
oral, for example, was about twenty-five per cent.
They are now very much less. In twenty-nine eases of
ligature of the principal arteries with catgut, by
New York surgeons, collected by Stimson in 1880
(.4m. Jour, of the Mid. Sciences, January, 1S81),
there was no secondary hemorrhage, and only one
ease of gangrene; the latter was of the foot, after
ligature of the common iliac artery, and was followed
by recovery. The diminution of the risk of secondary
hemorrhage is plainly due to the avoidance of sup-
404
REFERENCE HANDBOOK OF THE MEDICAL SI II NCES
Aneurysm, External
Duration about the ligature, and the freedom from
gangrene appears to be the result of the same rapidity
and ease oi healing, through diminution of the inter-
ference with the \Ou by the inflammatory process.
The attempt has been several times made to dimin-
ish i hi' chance nf I lie occurrence of gangrene by rep
edly compressing the artery above the aneurysm for
several days before tying it, in the hope of thereby
lually enlarging the collaterals, and belter fitting
them for carrying on the circulation when if is finally
thrown entirely upon them. The result lias not
liorne out the expectation; on the contrary, gangrene
has followed the attempt in a larger proportion of
cases than when the artery lias been tied without
preliminary compression. A satisfactory explanation
lot been found.
i n her ill results of the ligature of the main artery of
a limb may be permanent deterioration of its nutrition,
of nerve and muscular power, persistent or
recurrent ulceration of the skin, and suppuration of
the sac.
In order to diminish the chances of the occurrence
of gangrene, the limb should be wrapped in cotton
immediately after the operation, and kept thus pro-
tected from losing heat until the circulation is shown
to be fully reestablished. If its temperature is found
main too low, external heat should be cautiously
applied in the form of hot bottles, bricks, or sand, but
care must be taken that the heat thus applied is not
much above the normal body heat, lest it should
cause blisters. Good results have been reported
from the use of baking by suitable apparatus. The
temperature can be raised to 300°, provided moisture
is excluded.
Suppuration of the sac may occur, and either cause
spontaneous rupture or make an incision necessary.
The opening may be followed by dangerous hemor-
rhage, or the communication between the sac and the
patent portion of the artery may have previously
become permanently obliterated. Sometimes pres-
sure is sufficient to arrest the hemorrhage and lead to a
final cure by granulation: in other cases, the clots will
have to be turned out and all bleeding points secured,
or a second ligature may be applied between the first
one and the sac. A second ligature above the first
greatly exposes to gangrene.
If pulsation returns permanently in the sac and the
tumor again begins to grow, several courses are open
to the surgeon. If the aneurysm is at the knee,
groin, or elbow, flexion should first be tried, and this
failing, perhaps galvanopuncture. If resort to opera-
tion becomes necessary, the artery may be tied again
between the first ligature and the sac, or the "old
operation" of incision into the sac and ligature of all
vessels entering it may be done. Both methods have
proved successful.
The numerous statistics that have been collected of
the various results following treatment by ligature do
not furnish a fair basis for estimating the chances
after ligature with antiseptic catgut or with silk, and
treatment of the wound by modern methods. There
is, therefore, good reason to believe that the operation
has become, under antiseptic methods of treatment,
much less serious than it formerly was.
In like manner the aseptic ligature has caused the
entire abandonment of various devices (metallic
ligature, artery constrictor) designed to diminish the
chance of the occurrence of secondary hemorrhage,
except for the methods of Halsted and Matas whereby
compression is produced by metallic bands which
can be removed or their pressure effects modified.
iM Compression of the artery, direct, indirect, and
digital. Direct compression is made upon the artery
by acupressure needles or wires, threads, or forceps,
after incision of the skin and exposure of the vessel;
indirect compression is made by suitable instruments
or weights resting on the surface over the artery;
digital compression is made by the fingers.
Indirect eompre sion is an older method even than
ligature of the artery, and was em ployed, alt hough un-
successfully, by Desault in the treatment ol an axillary
aneurysm a few month before he first treated a
popliteal aneurysm by ligature, as mentioned above.
It is claimed for Hunter, al o, that he was the real
originator of the treatment bj eompre -inn, because
In- showed that complete arre I ol the circulation was
unnecessary, and that the compression might be
partial or intermittent, and because all previous
operators sought to effect a cure by obliterating the
artery .it the point pressed upon, a statement which
does not appear to be bo] in m! by the report- ol their
However that may be, the for r theory that
a passive clot was a source of danger, and that persist-
ent pressure upon the artery to arrest the circulation
for several hours was, therefore, a more dangerous
method than intermittent or inc plete arrest,
which would give a laminated clot of slow formation,
is now abandoned, and, as a rule, when compression
is used, it is with t he aid of anesthesia or morphine, is
forcible enough completely to arrest pulsation in the
-ae. and is continued until the contents of the sac
have coagulated. Intermittent, incomplete arrest
is occasionally used under exceptional circumstances.
In a few cases in which pressure above the sac could
not be made, complete arrest of the circulation below
it, usually by the elastic bandage, has effected a cure.
See Distal Ligature, below.)
The method of cure by this means varies in the
different cases; in some it is by the deposit of laminated
clot, in others by a soft passive clot. The changes
in the aneurysmal sac are the same as those above
described, and the dangers of the method are the same
as after ligature, with the exception of secondary
hemorrhage. A unique consequence, reported by
Pemberton, was the formation of a communication
several months afterward between the artery and
vein at the point where pressure had been made,
resulting in an arteriovenous aneurysm that finally
caused the patient's death.
The operative methods include the use of weights
or of special instruments having the general character
of a truss. The latter are numerous and varied, but
all consist essentially of a branch to make counter-
pressure without circular constriction of the limb, and
of a pad which can be screwed or bound down upon
the artery with suitable force. For weights, bags of
-hot are used, or pieces of lead moulded to fit the
parts. They may be allowed to rest entirely upon
the limb, or may be suspended by an elastic cord.
Prolonged complete arrest of the current requires
the aid of anesthesia, for the pressure soon becomes
very painful; anesthesia may be safely prolonged for
many hours. It is well to aid the control of the circu-
lation above by pressure also below, or by tightly
bandaging the limb below the aneurysm.
Digital pressure, which had previously been em-
ployed in two cases as an aid to compression by instru-
ments, was first used as the sole means of cure by
Jonathan Knight, of New Haven, Conn. The case
was one of popliteal aneurysm, and a cure was
effected in about two days. The plan has since been
employed in a large number of cases, and with a large
measure of success. Fischer's statistics, quoted by
Holmes, contain ninety cases, with seventy-six com-
plete cures, and eight deaths; six of these deaths
occurred after subsequent ligature, the remaining
two after amputation. In about one-third of the
successful cases the cure was effected within twenty-
four hours.
Digital pressure can be made only with the aid of a
considerable number of assistants, and it is usual to
employ them in pairs, one making pressure while the
other feels for pulsation in the sac. The skin should
be covered with French chalk at the point where the
pressure is made, and the assistants should be carefully
instructed as to the amount of pressure needed and
405
Aneurysm, External
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
the place where, and direction in which, it should be
made. When the change is made from one assistant
to another, the latter should place his finger or thumb
upon the artery immediately above or below that of
the one whom he replaces, and this one should not
remove his finger until after the artery is duly com-
pressed by the other. Ether or morphine should be
used u hen the patient begins to complain of the pain.
(c) Compression by Esmarch's elastic bandage.
This method was first employed in 1S75 by Walter
Reid, of the British navy, in a case of popliteal
aneurysm. The bandage was applied tightly to the
leg, loosely over the tumor, and then tightly over the
lower third of the thigh; then the cord was put on and
the bandage removed. At the expiration of fifty
minutes the pain had become so great that the cord
was removed, two Carte's compressors on the upper
portion of the femoral artery having been substituted.
At the expiration of three hours from the commence-
ment the aneurysm was found to be pulseless; inter-
mittent pressure was kept up for two days, and then
the patient was pronounced cured. The condition
of the parts found at the death of the patient a few
months later, and the method by which this treatment
appears to effect a cure, have been described above.
In January, 1881, Stimson collected sixty-two cases
treated by this method, which may be grouped in three
classes according to differences in detail. In the first
class, fifty-two cases, Reid's method was followed ex-
actly or very closely; in the second class, five cases,
the rubber tubing or the elastic bandage was used
repeatedly and alternately with the tourniquet or
digital pressure to arrest the circulation for several
hours; in the third class, five cases, the bandage was
used for a short time daily for many successive days,
without any compression of the artery in the intervals,
or with a tourniquet loosely applied. In the first
class there were twenty-eight cures, twenty-two
failures, and two deaths; and of the cures twenty-
four were obtained by a single attempt continued for
about an hour on the average, the extremes of time
being fifty minutes and three and one-half hours, and
four by two attempts each, separated by an interval
of from one to four days. After the removal of the
bandage the artery was compressed with a tourni-
quet or the fingers, usually for a few hours, but in one
case for only one hour, and in another for five days.
In two or three cases pulsation returned in the aneu-
rysm on the following day, and was then definitely
arrested by compression for a few hours. In twelve
of the twenty-two failures the same method was used
in nineteen different attempts; in the remaining ten
with eighteen attempts, no pressure seems to have
been made after the removal of the bandage. In at
least five of the twelve the method was skilfully em-
ployed, with every detail used in most of the success-
ful cases; they show, therefore, when added to the
twenty-eight cases treated successfully by this
method, that it may be expected to fail in at least
fifteen per cent, of the cases. As for the remaining
failures, there is some reason to suppose that the
method was not carried out with as much care and
attention to details as it was in the others.
A very important fact is that the method appears
not to involve- any serious risk, and not to diminish
the chances of success if resort is subsequently had
to the ligature. Of the two fatal cases, in one the
bandage Was applied twice with an interval of three
days, and retained in the last trial for nearly eight
hours. The patient died twenty-seven hours after-
ward with symptoms of heart failure or shock, the
dorsum of the foot remaining cold. In the other the
aneurysm (of the anterior tibial artery) had ruptured
externally, and amputation was strongly urged, but
refused by the patient; gangrene of the foot and lower
part of the leg followed, and the patient died dur-
ing the second week. The circumstances in each
i.i i- were quite exceptional. Bryant applied the
bandage twice for three hours each time, with an
interval of four days, in a case of popliteal aneurysm
in a man forty-five years old. A fortnight after
the second attempt he tied the femoral artery with
catgut, the wound healed by immediate union, but
"anemic gangrene" followed and the leg was ampu-
tated. This is the only instance of gangrene in the
sixteen cases in which the ligature was resorted to
after the bandage had failed to produce a cure.
The conclusion to be drawn from all these cases
seems to be that we have in the elastic bandage an
efficient means for safely shortening the duration of
the treatment by compression of popliteal and some
femoral aneurysms. The greater efficiency, the
more speedy action of the method is apparently due
mainly, if not entirely, to the arrest of the circulation
through the collateral channels as well as through
the main artery, thus securing absolute stagnation of
the contents of the sac. Consequently the rubber
tubing, which is drawn tightly twice or three times
about the limb above the aneurysm, is to be deemed
the efficient part; and the principal, perhaps the sole
benefit from the bandage is that of making a less
severe constriction by the tubing sufficient.
The method of carrying out this procedure is
simple: thus, in popliteal aneurysm, the bandage
should be applied tightly to the leg, loosely over the
aneurysm, and tightly again above it, and the bandage
or the tubing should be kept in place for one or two
hours; then the artery should be compressed by a
tourniquet or the fingers for several hours afterward,
the compression being occasionally intermitted for a
moment to see if pulsation returns in the sac. If
pulsation returns within a few hours, the artery
must be again compressed. The introduction of
needles or a coagulating injection might be proper in
connection with a second trial after a failure. Matas
{Annals of Surgery, vol. lii., p. 126) describes an
elaboration of this test.
(d) Compression by flexion of the limb. When an
aneurysm is situated at the bend of a joint, pulsation
in it may sometimes be diminished or arrested by
flexion of the joint, and this fact has been occasionally
utilized, either as the principal means of treatment or
as an adjuvant thereto.
The method appears to have been first suggested by
Fleury, a French surgeon, in a paper published in the
Journal de Chirurgie, in 1846, as an inference from his
success in curing a wound of the brachial artery at the
elbow by flexion. In 18.52 the suggestion was put into
practice by Thierry in a case of traumatic aneurysm
at the elbow, and in 1857 a large popliteal aneurysm
was cured by flexion of the knee by Maunoir of
Geneva. He tried at first to keep the leg forcibly
Hexed upon the thigh, but the patient could not
endure the pain, so he had to be content with keeping
it partly flexed by a strap crossing the shoulders,
while the patient went about on crutches. This
was kept up about three weeks, at the end of which
time the tumor had ceased to pulsate.
Flexion has been used successfully in aneurysms of
the popliteal artery, at the groin, and at the elbow.
Of forty-nine cases of popliteal aneurysm treated by
flexion, analyzed by Liegeois, twenty-six were cured,
in eleven of which flexion alone was used, in eleven
others flexion in combination with other means, and
in four flexion after other means had failed. It \\:is
first used at the groin by Gurdon Buck at the New
York Hospital in an aneurysm which had recurred
sixteen months after apparent cure by compression.
Pressure on the external iliac did not arrest the
pulsation, and flexion was tried as the only alternative
lor treatment by laying open the sac. In a case of
inguinal aneurysm treated by Eldridge, of Yokohama,
a cure was obtained by keeping the thigh flexed upmi
the pelvis for twenty days.
In making use of the method it seems to be usually
necessary to carry the flexion to a point at which it
406
REFERENCE HANDBOOK OF THE MFDH'W. SCIENCES
Aneurysm, External
markedly diminishes the pulsation in the tumor, ami
perhaps arrests ii entirely, and then to keep the limb
in tins position for a long time by suitable bandage oi
apparatus. It is well, also, in popliteal aneurysm, to
bandage the leg up to the knee to prevent swelling.
The turrits of the method lie in the facility with u hich
it can be carried out, and in the freedom from the
chance of accidents if care is taken not to make too
ible pressure.
:>. Permanent arrest or obstruction of the stream on
the distal side.
By distal ligature (Brasdor's and Wardrop's
methods). Distal ligature, firsl suggested by Brasdor
and Desanlt toward the end of the eighteenth century,
was first performed by Deschamps in 1798; the femoral
v was tied in the middle of the thigh for the cure
of a large aneurysm, the upper border of which was
less than a finger's breadth below Poupart's ligament.
As rupture of the sac threatened on the fourth day,
the artery was compressed on the pubis, the sac
opened, and the vessel tied above and below; the
patient died eight hours afterward. The operation
was next performed by Sir Astley Cooper, who tied the
common femoral artery below the epigastric for a
large aneurysm of the external iliac; the patient
recovered from the operation, but the aneurysm
continued to pulsate and soon afterward ruptured.
In 1825 Wardrop obtained the first success, tying the
< ommon carotid on the distal side of a large aneurysm
in a woman fifty-seven years old. Wardrop's efforts
to popularize the operation, and especially his
extension of it to aneurysms of the innominate artery,
have permanently associated his name with it as
distinctive of that form in which the current is not
completely arrested, but continues only through
branches given off from the artery between the
ligature and the sac; while the name of Brasdor is
given to that form in which there are no such branches
and the arrest of the current is complete.
The operation is practically limited to aneurysms at
the root of the neck, those of the common carotid,
subclavian, and innominate. In some cases in which
an aneurysm of the arch of the aorta has been mistaken
for an innominate aneurysm, and the carotid and the
subclavian in its third portion have been tied, marked
relief of symptoms has followed, and in two or three
cases the left carotid has been tied for recognized
aortic aneurysm. The operation benefits by arresting
or retarding the circulation in the vessel and sac and
thus favoring the formation of a laminated clot. The
anticipation that the pressure within the sac would
be increased by the distal ligature has proved un-
founded, and the first effect of the operation has
often been an immediate decrease in the size of the
aneurysm and in the force of its pulsation.
The proportion of successes previous to the introduc-
tion of the antiseptic ligature was very small, but with
the introduction of this form of ligature the operation
entered upon a new career of usefulness and of appli-
cability to cases that had been beyond aid by surgical
art. In eight cases of ligature of the carotid' and sub-
clavian for innominate aneurysm in which catgut was
used, death was caused by the operation in only one,
and other successes have been since reported. Monod
and Yanverts collected seventy-nine cases, the results
being operative mortality S. 5 per cent., lasting improve-
ment 60. S per cent., failures 21.7 per cent. It is, of
course, less certain in its action than ligature on the
proximal side, and its use will therefore be restricted
to cases in which the proximal ligature or compression
i* impossible or too dangerous — in other words, to
aneurysms at the root of the neck, and perhaps of the
external or common iliac. It is to be judged not
by comparison of its proportion of successes with that
of other methods, but rather as a grave alternative
in a limited class of cases that are open to few other
means of treatment, and that lead inevitably, if left
to themselves, to prompt and certain death.
Manipulation or malaxation of the aneur;
This method, introduced by l erguson in L852 and
employed twice by him, rests upon the same print
as the distal ligature — arrest or diminution of the
current by an obstacle placed upon the distal side of
ac. In this method thi is a fragment
of old clot mechanically displaced from the wall of the
and lodged within the artery. This displacement
of a clot is thought to be the mechanism by which
many of the so-called spontaneous cures have been
obtained. The conditions essential to its employ-
ment are the presence of enough laminated clot in the
sac to make the detachment of a piece of sufficient
size possible and practicable by external manipulation,
and the impossibility of safely resorting to other
methods of treatment. The latter condition limits
the method to a small number of cases, mainly those
situated upon the subclavian artery. It is inapplicable
to those situated upon the carotid, because of the
certainty that small fragments will pass into the arter-
ies of the brain and become cerebral emboli, with
consequent paralysis.
4. Rapid coagulation of the blood in the sac, with
or without temporary arrest of the stream.
(a) Coagulating injections. This also is a method
of very limited applicability, and is only mentioned
for the sake of historical record; it can be used only
as an adjuvant to other methods, or in exceptional
cases, as of recurrence or of pouched aneurysms.
Hydrate of chloral has been recently recommended.
(6) Introduction of solid bodies. A few attempts
have been made to induce coagulation of the blood
in an aneurysm by permanently or temporarily
introducing foreign bodies, such as wire, needles,
horsehair, catgut. The method rests upon the well-
known facts that, if freshly drawn blood is whipped
with a bundle of fine rods, the fibrin collects upon
them, and that firm clot forms upon a foreign body
introduced into an artery or vein. With one or two
exceptions these attempts have been made upon
aneurysms that were not open to treatment by any
of the methods of ligature or compression, such as
aneurysms of the aorta and subclavian. The first
case of permanent introduction was that of Mr. Moore;
the first of temporary introduction of needles, those
of Rizzoli and Malago. All these methods are obso-
lete to-da3 7 and have been replaced by the Moore-
Corradi method of introducing gold wire into the
aneurysm and performing electrolysis. Good reports
have been given by Lusk,Stuart, and Finney (Annals
of Surgery, May, 1912).
(c) Galvanopuncture. In this method the con-
stant galvanic current is employed to produce rapid
coagulation of the blood in the sac. The details of
the operation, as employed in different cases, vary
greatly. Most operators will to-day prefer to use
the wiring method already referred to.
5. Promotion of the formation of a laminated clot
by irritation of the wall, "needling." This, recently
introduced by Macewen, has led in a number of cases
to marked reduction of the symptoms and even
apparent cure. A long, stiff needle is pushed through
the sac until its point reaches the opposite side where
it is moved to and fro so as to scratch the surface.
By changing its direction several areas may be thus
irritated without withdrawal and reintroduction of
the needle.
Traumatic Aneurysm, and Rupture op an - Ar-
tery. — A traumatic aneurysm is one which owes its
formation to a wound of the artery that has divided
all its coats, or to an injury (stretching, bruising) that
has divided one or more of them. The common cause
is a penetrating or punctured wound; less common
causes are overstretching in the neighborhood of a
joint and fracture. The continuity of the artery is
usually not entirely destroyed, and while some of its
blood escapes into the adjoining tissues the remainder
407
Aneurysm, External
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
continues within it and is distributed through its
branches. The effused blood is in part absorbed,
and in part coagulates; and after a time a distinct
sac forms about it, by condensation of the tissues,
and it then differs in no essential way from the com-
mon encysted form of aneurysm. Its symptoms and
it- subsequent course are then the same, but during
the stage of formation of the sac the condition is
associated with dangers peculiar to itself. There
is the history of the injury, absence or diminution of
pulsation in distal branches, local swelling and
ecchymosis, and sometimes marked lowering of the
temperature of the limb. There is usually a bruit
but no pulsation in the swelling at first, but, after
the sac has formed, the expansive pulsation charac-
teristic of an aneurysm is present.
During the formative stage of the sac the injury is
peculiarly amenable to treatment by direct pressure
at the seat of injury; and often after the sac has
formed a cure may be effected by the same means.
This is the one important practical point of difference
between traumatic and spontaneous aneurysms.
When the injury is associated with fracture of a
bone the immediate treatment, unless the symptoms
are very alarming, should be confined to securing the
repair of the fracture and to limiting the extravasa-
tion of blood by suitable pressure, and the treatment
of the aneurysm should be postponed, if possible,
until after the bone has united. The presence of the
extravasated blood is not a serious obstacle to this
repair, while the conversion of the fracture into a
compound one by an incision made to secure the
wounded artery may have very serious consequences.
Exceptionally, the extravasation may be so free as
to endanger the vitality of the limb by its interference
with the circulation, and under such circumstances
the surgeon may be compelled to turn out the clots
and secure the vessel, or even to amputate. This is
much more likely to be the case in complete rupture
of the artery, when none of the blood brought by
the artery is carried past the injury into its distal
branches, but all is poured out into the tissues, and,
being bound down by the enveloping fascia, exerts a
pressure which checks the venous flow and prevents
the establishment of collateral circulation. This con-
dition is characterized by great and uniform swelling,
absence of pulse, and notable loss of temperature in
the limb.
Arteriovenous Aneurysm. — When an abnormal
direct communication is established between the
trunk of an artery and that of a neighboring vein,
the condition is known as an arteriovenous aneu-
rysm. When the two vessels remain in close con-
tact, and the blood passes directly from the artery
into the vein,
the variety is
known as aneu-
rysmal varix,
the prominent
feature being a
varicose dilata-
tion of the vein.
When, on the
other hand, an
aneurysmal
pouch is formed
by condensation of the adjoining tissues, the variety is
known as a varicose aneurysm, or as an arteriovenous
aneurysm in the narrow sense. In the great majority
of cases of varicose aneurysm the aneurysmal sac is
intermediate between the artery and the vein, and
blood passes through it on its way from the former to
the latter. Broca describes a sub-variety, in which
the artery and vein communicate directly with each
other and there is an aneurysmal pouch lying on the
opposite side df the artery. Probably tile distinction
could not be made during life. In some of the classi-
Fig. 23S. — Arteriovenous Aneurysm. (Bell.)
fications any case that presents a distinct aneurysmal
tumor, whether enclosed by a sac of new formation
or by one formed by circumscribed dilatation of the
vein, is called a varicose aneurysm; but the latter
variety, that in which the aneurysm is formed by
dilatation of the vein, seems to be much more closely
allied in every way to aneurysmal varix.
The common cause of this affection is a wound
involving both the artery and the vein; but in some
cases the communication forms by ulceration of the
wall of the vein where it is pressed upon by an aneu-
rysm, and in one case (reported by Pemberton in
Med.-Chirurg. Trans., vol. xliv., p. 189) an arterio-
venous aneurysm formed at the groin ten months
after prolonged instrumental pressure had been
made at that point to cure a popliteal aneurysm.
The most frequent cause by far, in the past, has been
the wounding of the artery in venesection at the
elbow. The usual cause in recent times is a gunshot
or stab wound. Another occasional cause is fracture
of the base of the skull, by which the carotid artery
is torn in the cavernous sinus. Spontaneous forma-
tion by rupture of an aneurysm into a vein i.s rare, and
almost confined to thoracic and abdominal aneurysms.
The 'pathological changes which are found in this
class of aneurysms vary greatly in their details,
according to the character and extent of the primary
injury and of the communication between the vessels,
and to the distance of the vessels from the heart.
The principal factor in the production of these changes
is the extent to which the intraarterial pressure is
transferred to and exerted upon the wall of the vein
and the aneurysmal sac; and this is determined by the
size of the opening in the artery and by the resistance
offered to the return of the blood through the vein to
the heart. Hence, when the communication is be-
tween an artery and a large venous trunk, such as the
internal jugular, which can readily carry away the
excess of blood almost as rapidly as it is supplied, the
distending force is not much exerted and the obstruc-
tive changes in the vein are slight; but when the
communication is between an artery and a vein in one
of the extremities, or in the head, an immense aneu-
rysmal pouch may be formed or the veins may become
greatly dilated and varicose. The pouch usually has
a smooth internal surface and contains little or no
stratified clot, and when it is formed in great part by
dilatation of the vein, the orifices of other veins open-
ing into it are seen at various points, and these veins
are enlarged and their walls thickened.
The artery below the point of communication is
smaller than normal, and if it has been entirely
divided by the original injury, the lower portion may
be occluded at the point of division; the end of the
upper portion is kept open by the stream of blood.
The symptoms vary somewhat with the pathological
changes; there may be a well-defined pulsating tumor,
presenting the usual features of an aneurysm and the
special ones peculiar to this variety, or there may be
simply a diffused swelling of the region, or the super-
ficial adjoining veins may be markedly varicose. The
special features are the bruit and the thrill. The
bruit is continuous, with a systolic reinforcement: it
is most intense immediately over the point of commu-
nication between the vessels, and becomes less, or
may be changed into an intermittent murmur, as the
distance from this point increases. This apparent
intermittence is due simply to the fact that the por-
tion of the murmur which corresponds in time to the
contraction of the heart is louder than the rest, and is
heard at, a distance at which the latter has become
inaudible. In some cases the murmur could be heard
at a great distance along the vessels; thus in one
quoted by Follin, it could be heard from the elbow to
the heart; in another (of the femoral), from the head
to the feet. The thrill is a peculiar sensation given to
the hand when laid upon the aneurysm, a vibration
that has been compared to the purring of a cat.
408
KKIT.KKMT. HANDBOOK OF Till: Ml. UK AL SCIENCES
Ani-ur; -in. External
The interference with the circulation below the
point of communication is commonly well marked, and
i- shown by swelling of the limb which is not edema,
but which, in some cases at least, i- an actual hyper-
trophy, and is accompanied by a permanent elevation
of i he temperature of the limb, by a greater growth of
hair upon it. and in one case by an increase of an inch
in lengl h. There is a feeling of numbness or of act ual
pain in the limb, increased by its use, and there may
be a marked loss of muscular power, and sometimes
persistent ulcers or eczema.
The lesion may fail to become apparent until some-
time after the receipt of the injury (four years in one
case), and commonly it remains stationary after
havin.s reached a certain development. Thus,, situ-
ated upon the great vessels, the carotid and internal
jugular for example, seldom cause any inconvenience
he patient. In a few cases the opening into the
vein has closed spontaneously, and the aneurysm has
been thus transformed into a simple arterial one.
Treatment. — In recent cases carefully graduated.
direct pressure has sometimes availed to close the
opening, and this may be aided by compression of the
artery above. Operative interference in the past,
which has included a variety of methods, has proved
exceptionally dangerous, but the statistics for obvious
reasons have lost much of their value with the improve-
ment in operative methods and in the treatment of
grounds. The operations may be divided into two
main classes, according as the sac is or is not opened,
and in the latter class they will further vary accord-
ing to the number of the ligatures applied.
The question of interference will be determined by
the extent of the disability and the number of vessels
involved in the lesion. In the forearm or on the scalp
it is usually practicable to tie all the vessels, arterial
and venous, that are involved, and thus effect a
radical cure. In the neck (carotid and jugular) the
history of recorded cases shows that the lesion rarely
causes more than a moderate amount of inconvenience
that can be easily borne by the patient.
Ligature of the artery alone on the proximal side,
in arteriovenous aneurysm of the lower extremity, has
proved remarkably fatal by gangrene. In twelve
cases collected by Van Buren, the external iliac was
tied in five and the common femoral in two and gang-
rene followed in all; the femoral was tied in five, and
;rene occurred in two. Monod and Vanverts
cite eighteen cases with only thirty-eight per cent, of
successes. This extraordinary frequency is presum-
ably due to the easj' return to the heart, through the
opening into the vein, of the blood brought to the
distal segment of the artery by the collateral branches;
it fails to pass on and nourish the limb. Consequently
a second ligature applied to the artery close below the
opening, diminishes the chance of gangrene. Ligature
of all the veins, as well as of the artery, suppresses all
subsequent growth of the sac or continuance of the
disease, but it adds a factor that is most important in
the production of gangrene — obstruction of the
venous flow. Moreover, the operative difficulties are
extreme. The record of cases in which the sac has
been opened and the attempt made to arrest all bleed-
ing from it, is such as to discourage any one from
undertaking it; again and again operators have had to
resort to ligatures en masse, passed by means of curved
needles, and more or less blindly, in deep, inaccessible
corners of the wound, to the actual cautery, and even
to styptics and pressure. The incision has always
been very long, and the tissues have been bruised and
lacerated by the prolonged search and dissection. The
method seems to violate all the principles that govern
modern methods of making and treating wounds, and
it does so, in the effort to attain an end that is not
only unnecessary, but introduces an element of great
additional danger. Monod and Vanverts found that
quadruple ligation of the vessels resulted in gangrene
three times out of fifteen, while incision or extirpation
nf the sac gave such a result in only two out of one
hundred and seventeen cases.
A few successes have been obtained by galvano-
puncture and by the inject inn oi coagulating solutions
without ligaturing any vessel, and quite recently, in
a few cases in which the changes were not very ex-
tensive, the sac has been successfully extirpated.
Cirsoid \\i i rysw (arterial varix; aneurysm by
anastomosis). — This name ha- been given to an
affection of the arteries, sometimes involving also the
capillaries ami even the derived veins, which differs
materially from that which constitute- the common
variety of aneurysm, and i- characterized by a uni-
form or irregular dilatation and to Ilgthening
of an artery and its branches. The affection is mo I
common in the superficial arteries of the head — the
temporal, occipital, and auricular — but it is also found
in the hand, forearm, leg, and even involving the ex-
ternal iliac artery.
The change consists in a dilatation and lengthening
of the artery, with atrophy of its middle coat and
consequent thinning of the wall, or possibly with
hypertrophy by thickening of the middle coat in the
early stages; the dilatation may make the caliber of
the vessel ten time- larger than normal, and may Ik;
uniform, but is usually accompanied by the formation
of small pouches. In consequence of the lengthening
the artery assumes a tortuous form. The change has a
marked tendency to spread in both directions, in-
volving the arterial branches and even the consecu-
tive capillaries and veins, and in the latter case it is
known as aneurysm by anastomosis or racemose
ant urysm. There is also reason to think that in
some cases the change has originated in a nevus and
has spread backward to the arteries. At the central
portion of the tumor, where the tortuous and dilated
vessels are most numerous and closely packed, there
may exist, as Lefort has pointed out, a sort of central
lake, as in cavernous angioma, or a real aneurysm
or even an arteriovenous aneurysm. The overlying
skin and soft- parts may be thinned, or thickened ami
indurated, and the underlying bone may be absorbed
in consequence of the pressure.
The principal causes are found in contusions and
preexisting erectile tumors or birth-marks, and the
change takes place most frequently at the time, or
shortly after, the age of puberty is reached. In w hat
manner or through what agency these causes act is not
known, nor why the region of the head is the common
-cat. Blake and Auchencloss in a study of the
etiology and pathology of cirsoid aneurysms ascribe
trauma as a frequent cause, and emphasize the fact
that they tend to extend centripeally, i.e. toward the
heart. Some of the microscopic findings show ap-
pearances somewhat resembling conditions seen
in a dissecting aneurysm. (Medical Record, June
24, 1011.)
The symptoms of the disease are a soft, ill-defined
swelling under the skin, in which numerous pulsating
vessels can be felt, and into which tortuous arteries
can be seen to pass. The overlying skin is reddened
or livid, either by implication of its own minute ves-
sels or by transmission of the color of the blood below
it; the tumor communicates a sort of thrill to the
hand, and a continuous murmur to the ear. In a
complete typical case four distinct varieties of changes
or lesions can be recognized: First, a cutaneous
erectile tumor, formed by dilatation of the arterial
capillaries of the skin; second a subcutaneous arterial
cir-oid tumor, formed by the dilatation of the finest
arterioles under and around the first ; third, dilatation
and tortuosity of the main arteries leading to the
tumor; fourth, dilatation of the veins coming from the
tumor, sometimes with pulsations S3 r nchronous with
those of the heart.
The affection is a serious one, because of its tendency
to increase and the danger of hemorrhage through
ulceration of the skin or an accidental injury.
409
Aneurysm, External
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Treatment has generally proved not only difficult,
bloody, and dangerous, but also unsatisfactory as re-
gards the cure of the disease. It comprises ligature of
the main trunks from which the affected arteries arise,
as of the temporal, or the external or common carotid,
in cirsoid aneurysm of the scalp; excision or incision of
the tumor; caustics; galvanopuncture and coagulating
injections, or extirpation of the main trunk leading to
the aneurysm, this latter not being touched at all. A
suitable case is an aneurysm of the temporal region
cured by excision of the external carotid to its bifur-
cation into the internal maxillary and temporal arteries
(Blake and Auchencloss, Medical Record, June 24,
1911). Lefort, who made a careful study of eighty-
three cases, says that whenever treatment has been
directed only to the afferent arteries, it has failed or
has produced only an incomplete cure; but that, on
the other hand, the obliteration of the vessels forming
the central portion of the mass has been followed by
the return of the afferent vessels to their normal con-
dition. He claims, therefore, that the treatment should
always be directed to this central portion. It in-
cludes three methods: removal or destruction of the
mass by caustics or the knife; the injection of coagulat-
ing liquids; galvanopuncture. Removal by the
knife exposes to severe hemorrhage, but, if practised
with caution, is practicable and to be recommended
when the central mass predominates. Destruction
by caustics (chloride of zinc) seems to be without
much danger of hemorrhage, but is slow and tedious
and may cause superficial necrosis of underlying bone.
Lefort recommends the injection of a solution of the
perchloride of iron, which has given nine successes in
ten cases; he prefers a five-per-cent. solution to the
stronger ones. John Duncan refers to four cases
treated by electrolysis, three of them successfully.
The variety known as aneurysm by anastomosis, in
which the capillaries and veins are also involved, is less
amenable than the others to this method of treatment.
Dissecting Aneurysm. — This is a lesion occas-
ionally found in the aorta, which has only a patho-
logical interest, since it cannot be recognized with
certainty during life and is not open to treatment.
It consists of a partial rupture of the wall of the
vessel, and the passage of the blood between its coats,
usually in the substance of the middle coat, to a
second opening into the lumen of the vessel at a
lower point, or backward to one into the pericardial
sac. The primary opening is usually in the arch of the
aorta; the second one may be in the same vessel, or
at a considerable distance in one of its branches — once
in the subclavian, once even in the popliteal. When
the flow is backward into the pericardium, death
promptly follows; in other cases the period of survival
is usually short, but may be prolonged for years, and
under such circumstances the track followed by the
blood develops a resisting wall lined with epithelium.
Lewis A. Stimson.
Charles L. Gibson.
Aneurysm, Internal. — Etiology and Pathology. —
In this article no attempt is made to discuss at
length the etiology and pathology of aneurysm in
general. It is intended rather to present in as con-
densed a form as possible the principal points bearing
upon the diagnosis and treatment of the internal
form of the disease.
Age. — Aneurysm may occur at any age but it is
most frequently found in the decade from thirty to
forty and next from forty to fifty. In children and
adolescents it is extremely rare and usually results
from an infected embolus, or in some instances from
inherited syphilis. Aneurysm becomes less frequent
with advancing years, and is then usually associated
with atheroma.
Sex. — Men are mi ire liable to the disease than women.
Peacock states that from two-thirds to four-fifths of
the cases of circumscribed aneurysm occur in males
while Crisp's extensive figures show a ratio of five to
one. The difference is no doubt to be accounted for
by the fact that men are much exposed to the efficient
promoting causes, viz., strain, laborious occupation
syphilis, and intemperance. In dissecting aneurysm
the sexes are attacked with almost equal frequency.
The development of the disease is favored by a
high blood pressure, but weakening of the arterial
wall plays a far more important role in the morbid
process. It is particularly apt to develop from
inflammatory processes in the media, resulting in
most instances from syphilis, but occasionally due to
rheumatism or other infections.
The influence of syphilis as a cause of aneurysm is
now very generally admitted, and evidence of pre-
vious luetic infection occasionally gives an important
clue to the diagnosis of obscure abdominal or thoracic
aneurysms. From forty to eighty per cent, of cases
are usually attributed to this cause, and some writers
give even a higher percentage. The syphilitic lesions
are usually very limited in extent, consisting in patches
of mesarteritis, of an inch or less in diameter, with
furrowing and scarring of the intima, occurring most
frequently in the ascending aorta. Remnants of these
patches may be found at the orifices of an aneurysm
and their specific character has been proved by the
discovery of the spirochete. An important con-
firmation of the influence of syphilis is found in the
Wassermann reaction. The figures available are
still somewhat meager, but Steinmeier has been able
to collect sixty-five cases of aneurysm, of which
seventy-five per cent, gave a positive reaction, while
several negative cases presented indubitable evidence
of the disease.
Other infections play a recognized but infrequent
part in the causation of aneurysm. Acute rheumatism
typhoid fever, pneumonia, influenza, and septic
processes frequently lead to degeneration of the
intima and, what is of much more importance, to
patches of inflammation with subsequent necrosis in
the media; these areas when yielding to the blood
pressure result in aneurysmal dilatation.
Embolomycotic aneurysms, found chiefly in malig-
nant endocarditis, and only in rare instances following
immediately on other infective processes, seldom
attain a larger size than a walnut. They occur most
frequently in the superior mesenteric, the cerebral
\ essels, and t he aorta, but the visceral arteries, as well
as the iliacs and peripheral vessels are occasionally
involved. Often occurring at an earlier age than the
chronic form of the disease, and frequently multiple,
they seldom attain a size larger than an egg, and
usually terminate rapidly by rupture and hemorrhage.
Lewis and Schrager state they most commonly origi-
nate in the intima from the lodging of infected em In > 1 1
at tlie bifurcation of arteries, and less seldom in the
media through bacterial invasion by the vasa vasorum.
Mechanical injury of the arterial coats by a sharp
pointed embolon is now regarded as unusual, and the
infective origin as much the more usual method of
production.
Traumatism. — Since blows or violent straining
efforts especially in muscular men are sometimes
sufficient to tear the intima and a portion of the
media, the greater frequency of aneurysm in the
laboring classes is, at least in part, to be attributed to
the influence of strain and effort. The tear commonly
begins over atheromatous plaques, but a healthy artery
may suffer as in the case related by Busse (Virchou's
Areliiv, 1S3). The tear may lead to a saccular
aneurysm, or in rare instances to a dissecting aneu-
rysm. Adami has pointed out the frequency with
which the latter form is associated with hyaline athero-
matous areas in the aorta. Severe, sudden pain marks
t he mi -el of the tear and later the development of aneu-
rysm or a rapidly fatal termination from hemorrhage
may occur.
410
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Aneurysm, Internal
Atheroma is the common cause of aneurysm in
elderly people, and is less seldom responsible in
earlier life. There is no apparent relation between
the extent of atheroma and the development of
irysm and most extensive lesions are extremely
common without the slightest tendency to aneurysm.
ious conditions leading to atheromatous dogenera
t ion, such as alcoholism, lead poisoning, and gout,
Elay some part in the production of aneurysm, and the
igh blood pressure, so frequently present, also
- the development of the malady.
Site. — The most frequent site is on the ascending
aorta. In Hare's statistics 570 out of 953 case oi
aortic aneurysm involved this portion of the vessel,
while the transverse arch was affected in 104 and the
descending arch in 110 instances. The abdominal
aorta suffers much less frequently than the thoracic,
the ratio being as one to ten. In the great majority
idominal cases the aorta is involved at or near the
celiac axis and the lower portion of the aorta is seldom
attacked. In Nixon's tables (St. Bartholomew's
Hosp. Hep., 1911), it is suprising how seldom an-
eurysm is found except at or in the immediate neigh-
borhood of the celiac axis.
The arteries arising from the aorta often share in the
aneurysmal process, and are less commonly affected
alone. These vessels, however, and also the cerebral
ics are involved in a considerable number of
cmbolomycotic aneurysms and also in those some-
what rare cases from acute infections.
Sacculated aneurysm is by far the most common
form. In Hare's figures there were 544 instances and
only twenty-six fusiform in the ascending arch.
Dissecting aneurysm is a rare type. Adami has
shown that it occurs in almost equal number in the
two sexes, and that it is frequently found associated
with gelatinous hyalofibrinous plaques; the blood
passes in a channel between the coats of the vessel of
which the inner wall is formed by the intima and part
of the media. This channel commonly begins in the
ascending arch and may extend along the whole
length of the aorta and even along the iliacs as in a
of Field's. The lining of the sac is often smooth
and gives at first sight the impression of a double
tube, while the branches may spring from the sac or
from the vessel itself.
The onset of these cases may be marked by sudden
violent pain which gradually subsides as the stretching
due to separation of the arterial wall subsides. The
subsequent course is variable; rupture followed by
hemorrhage with a rapidly fatal termination is
frequently found, but in a few instances the process
becomes chronic and the condition may last for
years.
Thoracic Aneurysm*. — Symptomatology. — The
existence of a dilatation at some part of the
aorta is not necessarily accompanied by manifestation
of disordered function or local distress, that is to say,
by symptoms. Unless, therefore, it mechanically in-
terferes with neighboring parts, it may continue
even for a long time unsuspected. The occurrence,
then, of symptoms which will indicate the existence
of thoracic aneurysm, depends more upon the exact
situation of the tumor than upon any other circum-
stance. The symptoms also will present wonderful
variety in accordance with the varying locality and
direction of the expansion of the growth. The
clinical history of these patients previous to the de-
velopment of the characteristic symptoms is often ex-
tremely indefinite. It is quite common to find a man
seeking advice for a loss of voice or a harsh cough, or a
thoracic pain, found to be due to an aneurysm of
some standing, and yet he will give an account of
having enjoyed excellent health in every respect
* The article on Thoracic Aneurysm by the late Dr. George
Ross, in the previous edition of the Reference Handbook,
remains as written, with but few alterations. — F. G. F.
until (perhaps quite recently) these symptoms
attracted his attention. Again, sometimes a quick
pain, wit 1 1 palpil at n in and breathle tti has been
observed at some remote period, to be followed later
OD by other symptoms of intrathoracic disorder.
Or, some laryngeal or bronchial symptoms may ha ■
b i a coming on imperceptibly for a long time pa
In many cases, belonging to one of the above types,
of men about middle age, whose general health and
nutrition remain unimpaired, suspicion of aneurysm
may very reasonably be entertained. Deepseated
aneurysms may be entirely latent, presenting no
evidence of their existence by either .symptom or
physical signs. The comparative frequency of such
cases is now being very generally recognized.
The symptoms of thoracic aneurysm, therefore, are
mainly the symptoms of intrathoracic pressure, and
mostly differ in no respect from those produced by
tumors ol different nature in the sa sit nation. The
symptoms consist of the manifestations by which we
■ •an recognize displacement of lung substance, con-
pression of the main or secondary air tubes, irritation
or destruction of nerves, obliteration of venous
channels, obstruction of the esophageal tube, or
erosion of some of the bony structures.
The principal symptoms of intrathoracic pressure
may be thus enumerated — pain, dyspnea, altered
voice, cough, stridor, headache, and disordered vision,
and lastly, paraplegia.
The pain of thoracic aneurysm is a most frequent
symptom, but very variable as to its character, degree,
and situation. In not a few cases pain of some kind
will be the first indication of existing disorder. Early
pain is usually of a somewhat lancinating nature, and
is suggestive of neuralgia. It is often complained of as
darting across some region of the chest or along
certain nerves to distant parts. When the aneurysm,
for example, is seated in or near the innominate
artery, the pain is often referred to the back of the
neck on the right side and behind the right ear;
when it is seated in the transverse arch, the pain may
be across the top of the chest and down perhaps the
entire length of one arm. Pains of this kind should
always prompt a search for internal aneurysm.
Later on in the complaint the pain is likely to be of a
steady, wearing kind, and referred to some fixed
spot, probably deep in the chest. Aneurysms
pressing backward against the vertebral column and
the spinal nerves emerging therefrom have two special
forms of pain connected with them: either a persistent
boring pain experienced in some particular part of the
spinal column, or a definite intercostal neuralgia,
having a distributive, intermittent character, and
tender spots often unusually well marked. There is
sometimes pain of a real anginoid character, ac-
companied by a sense of tightness in the chest, but
it is very seldom that attacks of true angina, with the
typical features of this complaint, are witnessed.
Pressure on the phrenic nerve has been found some-
times to be accompanied by a painful feeling of con-
striction round the lower part of the thorax, together
with dyspnea and singultus, from disturbed inner-
vation of the diaphragm.
Dyspnea is a very frequent symptom, and is of vary-
ing character and degree in accordance with the cause
to which it may be due. It may arise from compression
of a portion of the pulmonary structures, from pressure
upon the trachea, upon a main bronchus, or upon the
pneumogastric trunk or one of the recurrent nerves.
An aneurysm must have attained to a considerable size
before it can shut off a portion of a lung sufficient to
produce decided dyspnea. .Shortness of breath,
therefore, will not be much complained of in the early
stages, unless the tumor interferes with some of the
other stuctures just named. Compression of the tra-
chea commonly occurs from aneurysms of the arch, and
the dyspnea will be observed toexist both in inspiration
and in expiration. It is accompanied by enfeeble-
411
Aneurysm, Internal
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
menl of the respiratory murmur in both lungs, and the
laryngoscope shows the mechanism of the vocal cords
to be normal. Under favorable conditions a skilled
irver can detect the narrowed lumen of the trachea
by the laryngoscopic mirror, and in some instances
can even observe pulsation transmitted from the
aneurysm at the point of pressure. Standing beside
such a patient, it is quite usual to hear a rough,
raucous sound of peculiar caliber accompanying
both inspiration and expiration, especially when these
acts are performed somewhat forcibly. The dyspnea
here, as in the last-mentioned form, is very markedly
increased by even slight exertion, the chief reason, no
doubt, being that the tumor, being expansile, the in-
creased heart's action expands it, and causes it to
compress the elastic tube more firmly. In exceptional
cases of tracheal compression, paroxysms of intense
dyspnea may be occasionally witnessed, and that
without direct involvement of any of the important
nerves. Attacks of this character are apt to come on
from exertion or emotional disturbance, and are
attributed by Bristowe to more or less complete ob-
struction of the trachea by a plug of mucus. Position
will often relieve the respiratory distress considerably,
and patients very frequently, of their own accord,
rest or sleep, leaning the chest well forward to take off
the pressure from the windpipe. If a main bronchus
be compressed (and it is more often the left), the
dyspnea is not likely to be so great, and enfeebled
breathing is found in the corresponding lung. It
has long been recognized that pressure upon the impor-
tant nerves supplying the muscles of the larynx which
pass through the chest will cause dyspnea and that,
very often, of the most intense kind. Here the striking
feature is dyspnea in paroxysms. There may be
periods of comparative calm, during which there is
only a moderate shortness of breath on making some
exertion, but suddenly, with or without any exciting
cause, severe suffocative dyspnea sets in, and in some
cases actually proves fatal. This result may be
brought about by either the compression or involve-
ment of a pneumogastric nerve or a recurrent laryngeal
nerve. Sometimes nerves of both sides are implicated.
( hving to its situation in relation to the aneurysm, the
nerve of the left side is more often affected than that of
the right. When the latter is involved, it is generally
from its being disturbed by the dragging of a tumor
upon the root of the right subclavian artery. It is
held by some that this form of dyspnea may be
brought about either by spasm of the muscles supplied
by the recurrent nerve or by their paralysis. Pressure,
it is said, will either irritate or destroy a nerve.
Irritation will cause spasm, destruction, paralysis.
There does not, however, seem to be any reliable
evidence of the occurrence of spasm as a cause of
dyspnea; while, on the other hand, whenever decided
laryngeal symptoms are observed from intrathoracic
pressure, the laryngoscope nearly always shows the ex-
istence of paralysis in a greater or less degree. Uni-
lateral paralysis may exist for a long time without
marked dyspnea, but, if the opposite muscles become
affected, the liability to paroxysmal attacks becomes
developed, the flaccid cords are sucked together by
the inspiratory effort, and a suffocative condition is
induced. Why does this occur in paroxysms? It
may be that a rapid temporary enlargement of the
tumor occurs (from exertion, etc.), and that this
causes increased pressure, as a result of which the
paralysis may be rendered complete; or it may be that,
from incomplete coughing efforts, mucus collects in the
glottis, and forms a complete' barrier in the already
partially obstructed glottic opening. A rare form of
dyspnea in aneurysmal patients consists in a sim-
ulation of ordinary asthma. I have seen one such
case in a young unman in which the picture pre-
sented was exactly that of a common attack of
spasmodic asthma.
All/rations of voice are observed only when the
tumor presses upon one of the recurrent nerves, or
upon a pneumogastric trunk. The changes in the
voice consist mainly in diminution of its power and
clearness in varying degree, together with hoarseness
and sometimes a squeaky or high-pitched tone.
The loss of voice may come on quite suddenly, and
ultimately complete aphonia may result. These
laryngeal symptoms may be among the very first
complained of, thus simulating catarrhal laryngitis,
for which this condition has frequently been mis-
taken. Laryngoscopic examination almost invari-
ably shows deficient abduction of a vocal cord (more
frequently the left). If the paralysis be incomplete,
the affected cord is seen, on phonation, to fail to
reach the median line, and thus an open space is left
between the two. If it be complete, the paralyzed
band remains almost, if not quite, stationary, and the
healthy cord is seen to move rapidly across the
median line until it approaches its fellow of the
opposite side.
Stridor is specially noticed when an aneurysmal
tumor presses upon the trachea or one of the main
bronchi. It differs altogether from the stridulous.
respiratory sounds heard in cases of laryngeal disease,
and is distinguished also from them in that the
ordinary speaking voice remains unimpaired. The
stridor is usually a rough, low-pitched, growling
sound, accompanying both inspiration and expiration,
and giving the impression of originating deep within
the chest. It is markedly increased by full breathing.
This is the so-called "stridor from below" of the
older authors.
Cough very commonly occurs during the course of
a thoracic aneurysm. It is produced mainly by the
irritation from pressure of the pulmonary and laryn-
geal nerves, and is often very frequent and distressing.
If there be laryngeal paralysis the cough will proba-
bly be husky, and even suppressed. When tracheal
pressure with stridor exists, the cough becomes dry
and harsh. A peculiar ringing, brassy, croupy,
cough is very suggestive of aneurysm. The expecto-
ration at first is very small in quantity — in fact it
may be so throughout; but when there has been
much pulmonary irritation, or when a tracheo-
bronchial catarrh has been set up, large quantities
of purulent expectoration may be got rid of. Blood
sometimes appears in the sputum, and must always
be looked upon as a sign of impending danger.
Dysphagia is a symptom more often seen in con-
nection with other forms of intrathoracic tumor than
with aneurysm. It has also been clearly proven
that an aneurysm may have exerted considerable
pressure upon the esophagus and yet no resulting
dysphagia will have been observed. Certain pecul-
iarities in esophageal obstruction due to aneurysm
(as compared with that which results from other
tumors or from organic stricture) are these: that it is
variable — perhaps at one time of day nothing can be
swallowed, and again, later on, fluids or semi-solids
pass with comparative ease; and, secondly, it is
altered by position — the patient may be able, by
removing the weight of the tumor on leaning well
forward, to swallow fairly well, while the same thing
is impossible in the recumbent position.
Engorgement of the vena cava and its branches, from
pressure of the sac upon this great trunk or upon one
of the innominate veins, occurs pretty frequently.
It is indicated in the lesser degrees by undue fulness
of certain of the superficial veins of the neck, shoulder,
and front of the chest. In an extreme degree the
appearances produced are very striking. The face
is purple and congested, the eyes are suffused, the
superficial veins greatly distended with blood and
mostly tortuous. The tissues at the root of the neck
become infiltrated and present a soft, swollen appear-
ance, obliterating more or less the hollow above the
clavicle. The congestion of the internal veins,
which must simultaneously occur, causes these
412
REFERENCE HANDliOOK OF Till: MEDICAL SCIENCES
Aneurysm, Internal
patients to suffer from headache and often from
great drowsiness, ami death may take place in a
natose condition. Pressure mi the brachial veins
will cause swelling of the corresponding arm.
rence in the Size of the Pupils. — The anterior
roots of the spinal nerves from the sixth cervical to
the sixth dorsal (according to Brown-Sequard to the
ointh or tenth dorsal) supply the cervical sympathetic
filaments which pass to the iris. When an aneurysm
presses upon these nerves, then ocular symptoms arc
i veil, more or less marked according to t lie degree
of the pressure. If the pressure is slight, then irrita-
tion only is produced and. as a consequence, there
itationof the corresponding pupil. If the pressure
i- considerable, then paralysis is produced, and we
find permanent cunt raction of that pupil, occasionally
associated with enophthalmos and slight drooping of
the lid. With reference to this symptom, it must be
loped to a decided degree before any reliance can
I upon it, because the slighter differences in
between the two pupils are quite commonly
rved in healthy persons. Even when this symp-
tom is clearly made out its importance is not great
from a diagnostic point of view, for there an- generally
then present many more reliable indications of bhe
disease. But it can be used as one means to assist
in enabling us to locate more precisely the seat of the
tumor. The Argyle-Robertson pupil is occasionally
noticed and is to be regarded as a post-syphilitic
imenon.
is very often wanting, and persons with
large tumors may remain quite well nourished. Con-
siderable emaciation is, however, often seen arising
from coincident weakness of * ho digestion, want of
exercise, and continued suffering. Marked wasting
of the tissues has in rare cases, been traced to pressure
upon the thoracic duct, and again, although it
develops less rapidly, to pressure upon the esophagus
and to inanition.
Such are the chief symptoms of thoracic aneurysm,
which are the result of the intrathoracic pressure
which it must sooner or later produce, and it is to
them we must generally look for aid in establishing a
diagnosis. But there are others which must be
mentioned. It sometimes happens that the objective
- of aneurysm may be present while subjective
symptoms are entirely wanting. But the contrary
is more generally true. Various complaints will be
made before the existence of their cause can be satis-
factorily made out. .Much, of course, will depend
Upon the situation of the tumor. Patients often
first experience pains in the chest, the different charac-
ters of which have been already alluded to. As the
tumor increases in size these painful sensations may
be modified in various ways by the occurrence of
complicating inflammations of surrounding parts,
and especially of the pleura. There may also be a
distinct sensation of throbbing or pulsation in the
chest in the region of the aneurysm. Palpitation of
the heart and tightness in the chest are often associ-
al 1 with these. The patients themselves may also
observe that alterations of position have an effect in
increasing or diminishing their discomfort. Then
dyspnea of some kind is likely to occur and to be
followed by dysphagia, neuralgias, pareses, or actual
paralysis (perhaps only formication or numbness),
some anemia, diminution of strength, and sometimes
edema. An aneurysm of the chest may thus cause
death by a gradual process. Less commonly we
observe continuous increase in the tumor until it
finally ruptures and death ensues, either directly
from hemorrhage or indirectly from the effects of the
effusion of blood upon some vital organ. Rupture
is generally associated with enormous hemorrhage,
which is inevitably fatal in a few minutes or seconds.
It does happen, however, that smaller bleedings
occasionally make their appearance for some time n
may be for only a day or even for a longer time)
previous to the final gush. In the case of a gentle-
man, under the care of the writer, who died of this
disease a short time ago, small quantities (a few
ounce-) of bright arterial blood were brought up for
more than twenty-four hour- pi. -ceding the actually
udden end. In this case the aneurysm broke into
the substance of the lung, and evidently had leaked
into a small bronchus during the time mentioned.
The final rupture took place into the left main
bronchus, and was accompanied by a great spirt of
fluid blood, and followed by instant death. Hemop-
tyses sometimes occur at long interva
aneurysms, generally from associated pulmonary
conge tions.
When rupture take place, it may be accompanied
by a sense of tearing within the chest, and if the blood
does not appear externally With cough or efforts of
vomiting (through the trachea or through the esopha-
gus), then it will be recognized by the accompanying
pallor and syncope, with failure or extinction of the
pulse. Internal rupture takes place most frequently
into the pericardium, and is almost always immedi-
ately fatal, although in a case quoted by Kelynack the
patient lived for four hours. Pepper and Griffith
have published a ease of rupture into the superior
vena cava, and they have collected twenty-seven
other instances, while Fr&nkel has recorded two such
accidents recognized during life. The symptoms are
dyspnea, followed by slight proptosis, and by edema
and cyanosis of the face, neck, upper part of the
thorax, and arms. There is frequently a continuous
murmur, louder during systole and produced by the
passage of blood from the aorta into the vena cava.
1 leath in such cases is not necessarily immediate, and
has been postponed for several weeks or months after
the occurrence of the rupture. Escape into a pleural
cavity is common, and is marked by severe pain and
dyspnea, and by the presence of the physical signs of
effused fluid. I have seen one case of rupture into
the pulmonary artery when the symptoms consisted
of sudden pain, collapse, want of pulse, and tumultu-
ous action of the heart for about two hours before
death. External rupture is comparatively rare. If
such a rupture is impending, the fact will be recog-
nized by the commencing lividity and finally gangren-
ous appearance of the tensest portion of the projecting
tumor. This accident is sometimes induced by
straining or falling, or by rough handling.
Physical Signs. — The foregoing symptoms (which
are mainly those of excentric pressure) are indicative
of intrathoracic tumor of some kind, but cannot indi-
cate aneurysm specially. On observing any combina-
tion of them, we must turn to the physical signs to
determine the character of the tumor — they are, of
the two, therefore, the more important; and both
together will, in the majority of cases, enable the phy-
sician to arrive at a positive diagnosis. These phys-
ical signs are derived both directly from the tumor
itself and indirectly from an examination of the neigh-
boring organs which may have been pressed upon,
displaced, or otherwise interfered with by the encroach-
ing tumor. The signs, as regards the aneurysm, will
evidently depend mainly upon its size and its exact
position, especially as regards the surface of the
chest .
Inspection will readily demonstrate the existence of
any distinct bulging of the parietes of the chest. This
may be only a slight or ill-defined elevation of a cir-
cumscribed area, or it may be a tumor of some mag-
nitude. The elevated part, moreover, is seen to pul-
sate (almost) synchronously with the apex of the
heart. The situation of the pulsating prominence
depends upon the portion of the aorta involved, and
the direction in which it has been tending. Aneurysms
of the ascending arch are most commonly seen in the
second or third interspace of the right side. Those
of the descending aorta will most commonly' reach the
surface on the posterior or lateral wall of the chest.
413
Aneurysm, Internal
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
The skin over the prominence is usually healthy,
epf when the external tumor is large, when it may
be red or livid. There may be no elevation from the
general surface, the eye detecting only a pulsating
spot similar to that over the cardiac apex. In the
absence of these more characteristic appearances, if
the front of the chest be carefully examined, while the
patient stands sideways to the observer, a more or
less distinct systolic heaving of the chest wall can be
noticed, especially when the respiration is withheld.
This indicates usually an aneurysm of considerable
size and deeply seated. If the heart be displaced,
this fact can also be determined by the altered posi-
tion of the apex beat.
Palpation of the chest is of service only when the
tumor sufficiently approaches the chest walls. Local
fulness or bulging can be appreciated, pulsation can
be located, and the force of the impulse measured.
Fremissement, or thrill, systolic in rhythm, can also
not infrequently be felt, perhaps over the entire area
covering the tumor; and following this, sometimes a
diastolic shock may be recognized. In obscure cases,
in which a deep-seated aneurysm may be suspected,
the bimanual method of examination may prove
of great service. The patient's chest is firmly grasped
between the two extended hands laid flat upon the
surface. By this means a diffused sense of expansion
will be experienced which is extremely significant and
can be ascertained only in this way. The supra-
sternal notch should also be explored. The patient's
head being bent forward to relax the sternomastoid
muscles, one or two fingers are pressed deeply into
the fossa and beneath the manubrium sterni, when
pulsation or thrill communicated from the transverse
portion of the arch can be distinctly perceived.
Another physical sign of very great diagnostic impor-
tance, and one which is also to be obtained by the edu-
cated sense of touch, is what is now known under
the term "tracheal tugging," or Oliver's sign. To
examine for this sign proceed as follows: Let the
patient be seated upright and with the head well
thrown back, in order to put the windpipe upon the
stretch. Then with the finger and thumb of the
right hand grasp the cricoid cartilage or the lower
border of the thyroid, and make steady pressure
upward. If a deep-seated aneurysm be present which
impinges at all upon the trachea or one of its principal
divisions, then a very distinct and unmistakable
tugging downward will be felt with each systole of the
heart. When the heart is acting strongly, or when
aortic incompetence is present, considerable rhyth-
mical pulsation may be communicated to the fingers
from the adjacent carotids, but with a little care this
cannot be mistaken for the tugging directly downward
above described. I have observed a considerable
number of cases of thoracic aneurysm, cardiac and
other thoracic diseases with reference to this sign, and
I have never observed it produced by any other con-
dition but aneurysm. In one case, which I saw in
consultation, there seemed clear evidence of an
aneurysm of the transverse arch, and the presence of
stridor and paroxysmal dyspnea showed its interfer-
ence with the trachea and nerves. No tugging could
be felt. The autopsy, however, showed that the
tumor was completely filled with firm laminated fibrin,
and its pulsatile character was lost. Except in cases
of this kind (which must be of pretty long standing)
tracheal tugging may always be looked for in central
aneurysms of the chest. This sign was attributed by
MacDonnell to pulsation transmitted downward to
the left bronchus. It may, however, be present in any
instance in which the aneurysm is adherent to the
trachea, and Fraenkel has seen it in an aneurysm of
tile ascending aorta in which firm adhesions were
present between it and the trachea. A few cases are
recorded in which a tumor lying between the aorta
and bronchus lias given rise to this sign. Care must
]>r taken to distinguish a slight downward pulsation,
often felt in healthy necks, from true tugging. Hall
has described a diastolic shock following the systolic
tracheal tug.
Percussion elicits a flat note over the area through-
out which the aneurysm is in contact with the chest
wall. This area, of course, may give no idea of the
actual size of the aneurysm, for its principal bulk may
be buried beneath healthy lung tissue. A modified
dulness may sometimes be found for some distance
around the flat region. It is often impossible to
separate the dulness of the aneurysm from that o
solid organs, the heart, liver, etc". Of course, if the
tumor be entirely deep-seated, the percussion may be
everywhere normal. If also the lungs be emphyse-
matous, no information can be obtained from
percussion.
Auscultation over an aneurysm of the aorta reveals
of necessity only a systolic and a diastolic sound, such
as we hear over the vessel itself. The systolic sound,
however, may be modified, and is sometimes accom-
panied by murmur. The modification consists gen-
erally in loudness, while, at the same time, a sense of
impulse is conveyed, the so-called bruit de choc. The
diastolic sound is communicated from the aortic
valves, any increase in their tension intensifying the
second sound over the aneurysm. It is always accen-
tuated when the diastolic shock is perceptible on pal-
pation. Systolic murmurs are of tolerably frequen
occurrence. They are probably produced in one of
two ways: either by sudden alteration in the caliber uf
the vessel (causing fluid waves or eddies) or by the
vibrations produced by contained coagula or irregu-
larities in the course of the blood current.
The systolic murmur of an aneurysm is generally
blowing in character, but sometimes possesses a de-
cided musical or " cooing" quality. Its seat of maxi-
mum intensity is likely to be the central part of the
tumor, and it is not generally diffused to any very con-
siderable distance from this. The significance of the
murmur is derived from its seat of maximum intensity
being away from that usually associated wit h valvular
lesions, and from its being accompanied by a mag-
nified second sound. Heard alone (i.e. without
accentuation of the second sound) a systolic murmur
is rather indicative of some other condition than
aneurysm. Indeed, diastolic accentuation, if con-
fined to some circumscribed dull area in the neighbor-
hood of the aorta, is of more value than any murmur.
Any murmurs generated at the aortic valves and
orifice are likely to be transmitted through an aneu-
rysmal tumor as well. Often, therefore, double
aortic murmurs are to be heard in this situation.
Sometimes, however, similar to-and-fro sounds are
generated within the sac itself, their origin being
declared by their being much louder over the corre- I
sponding area than elsewhere, by being much more
restricted to this region, and by not being at all neces-
sarily associated with dilated hypertrophy of the left
ventricle. A diastolic murmur alone may, exception-
ally, be heard arising from an aneurysm, and Gerhardt
states that a diastolic murmur may sometimes be
heard in the left supraspinous area. Over the tumor
the respiratory murmur is absent, but on passing
just beyond the edges of this, the breathing sounds
are heard, but generally of a somewhat bronchial
character. In the same areas the voice will have a
bronchial resonance, although decided bronchophony
will not be found (or, at any rate, is rare).
The pulse in internal aneurysm may, or may not,
afford positive information. The arteries themselves
are frequently in a diseased condition, fibroid or
sclerotic, and may thus affect the pulse. The slate
of the heart will also have to be taken into account.
If, however, the blood be flowing into an aneurysm of
considerable size, special alterations in the blond
current in the parts on the distal side of this may ho
observed and delineated. The effect of the diverticu-
lum is to act like the empty rubber ball in the ordinary
•II I
REFERENCE HANDBOOK OF THE MEDICAL SI II A
Aneurysm, Intern. tl
syringe, i.e. to make the current more e eady
anil l |J " spasmodic and jerky. When, therefore, :i
gphygmographic tracing is taken, the curve is found
ffer from the normal our in accordance with this
hanism. The ascent of the systole is less abrupt,
more gradual, and the descent also occurs without the
game sharpness. The necessary result of this i< to
render the apex of the cur\ e more rounded, less acute
than that of the natural pulse. The larger the sac
ami the more distensible the walls, the better this
kind of tracing i- brought out, while fibrillation of the
contents and stiffening of the walls tend to obscure
these peculiarities and cause the tracing to resemble
the normal curve. The value of the bservations
is greatest when we examine at the same time the
esponding artery of the opposite side, or else the
same artery m- a branch of it i above the region of the
suspected aneurysm. It is not uncommon to fuel
such a degree of difference between the pulses of the
two sides a< may lie clearly recognized by the finger.
The differences consist in delay of the pulse and in
alteration in its volume. Delay of the pulse in the
radial artery is a diagnostic sign upon which too much
stress must not be laid, and, indeed it is very often
absent, or difficult to appreciate with the finger.
Findley. however, has shown that it may be often
detected by the clinical polygraph, and he regi
the sign as due to the blood wave passing through ah
aneurysm, and consequently of some value in local-
izing the site of the aneurysm. Diminution in the
«r of the radial pulse of one side is important as
an additional point of evidence in a case of suspected
thoracic aneurysm. Its positive value is, however,
detracted from by a consideration of the fact that the
same thing is often seen from congenital peeuliaritv
or from irregular distribution of the blood-vessels of
that arm. The latter possibility should always be
sought for, and a comparison made between the bra-
chials of the two arms. The alteration in the volume
of the pulse may be produced by twisting or distortion
of the vessel, by dragging upon it by the advancing
growth, or by partial or complete obliteration of the
lumen by the entrance into it of detached fragments
of fibrin. The only special distinguishing mark of
embolism is the suddenness with which it is apt to
occur.
Thoracic aneurysm is very frequently associated
with changes in the heart and in the circulation.
Other neighboring organs also become physically
altered by reason of the pressure, or other interference,
to which they may have been subjected. These con-
ditions can generally be recognized by physical exami-
nation. Enlargement of the heart does not arise
from aneurysm, but often occurs from the associated
arteriosclerosis, or from valvular defects, particularly
aortic incompetence. Displacement of the heart is
often seen. This is generally a downward displace-
ment only, or with some inclination to the left. When
the tumor affects the descending aorta, the heart is
displaced forward. If incompetence of the aortic
•s be present, as often occurs, its existence is
iinized by the usual physical signs. The cause
of the incompetence may be either atheroma, as above
mentioned, or the altered caliber of the root of the
aorta produced by the tumor, i.e. relative incompetence
with healthy valves near to which the expansion has
begun. Tumors near the origin of the aorta are also
liable to cause pericarditis. This occurrence has
frequently been found postmortem, and is occa-
illy witnessed during life. Byrom Bramwell
(" Diseases of the Heart and Thoracic Aorta." p. 71 1 1
says: "In any case of non-rheumatic pericarditis
occurring after the age of forty, in which the cause of
the pericarditis is obscure, I strongly suspect the pres-
ence of an aneurysm." The same author suggests
that aneurysm in the same locality may account for
certain eases in which pericarditis and angina pectoris
have been observed at the same time. Pleurisy is a
common complication, and musl be looked for either
from friction sounds or from the signs of liquid effusion,
curs st often with aneurysm of the descending
aorta. The existence of a pleurisy at the base of
one lung, followed by prolonged pain iii the
region, otherwise ted for, will certainly
sometimes lead us aright by suggesting aneurysm.
If a main bronchus be compressed, the correspond-
ing lung becomes comparatively airless, it- circuls
is impaired, and catarrhal conditions prevail. In
consequence of this the following physical signs will
be found, viz., moderate dulness on percussion and
enfeebled respiration, with or without moist i
In a few of these cases a whistling sound can be made
out over the situation of the I 'I tube.
Changes in the lungs are not uncommon in aneu-
rysm. Owing to the frequency with which the left
hus is compressed these changes are much n
frequent in the left than in the right lung. Fibroid
changes with retraction, gangrene, and suppuration
are seen and may even mask the primary disease.
i onstriction of the left bronchus by aneurysmal pres-
sure sometimes sets up bronchiectatic dilatation
below the site of stricture. Such a condition is
usually not recognized during life, but exception-
ally symptoms and signs of bronchiectasis can be
discovered.
We may now consider more particularly the chief
symptoms and physical signs which indicate an-
eurysm in the different parts of the thoracic aorta.
eurysms of the Hoot of the A< a (the Sim
Valsalva). — Those aneurysms which spring from the
very commencement of the aortic tube are not very
uncommon. They are frequently entirely latent, but
symptoms of pericarditis, or of angina pectoris, may
occur. They are quite liable to cause aortic incom-
petence. Such tumors are very dangerous, as, before
arriving at any great size, they are liable to rupture,
especially into the pericardium. Bramwell figures
(op. cit.. p. 720) a remarkable aneurysm springing
from this situation: it attained an enormous size,
perforated the sternum, formed a large external pro-
jection, and finally ruptured through the integument.
Aneurysms of the Ascending Portion of the Arch. — In
this region of the tube, dilatations, cylindrical or
spindle-shaped, are most frequent, but saccular
aneurysms also occur. The latter are then generally
situated upon the right side of the aorta. In an
early stage of dilatation we shall find altered pitch of
the percussion note to the right of the sternal margin
above the second rib, and the pulsation of the aorta
becomes stronger and more perceptible above the
sternum. As it increases, we get more decided dulness
extending to the right above the second rib. The
first sound becomes dull and the second more forcible
and clanging. A systolic murmur may then become
developed in the same area, and this, by its seat of
origin and want of diffusion, may be distinguished
from a valvular murmur. Disease of the aortic
valve frequently coexists. Aneurysm in the ascending
arch has a tendency to reach the surface of the chest,
and can therefore generally be made out with ease by
the physical signs. The locality where pulsation and
bulging are most apt to be discovered is the neighbor-
hood of the second costal cartilage of the right side.
The edge of the sternum and one or two ribs become
eroded, and the tumor, which may be of considerable
size, projects. The pulse in the vessels on the right
side will be small and delayed compared to that in the
Is on the left, if the innominate be involved.
Compression of the superior cava or right innominate
vein may happen, with resulting dilatation of the veins
of the upper half of the body or right arm. The
symptoms commonly complained of are pain and
dyspnea, perhaps cough. When the aneurysm is of
considerable size, numbness and weakness in the
right arm may occur from pressure on the brachial
plexus. The right bronchus may also be sometimes
415
Aneurysm, Internal
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
compressed. Rupture of an aneurysm in this situa-
tion occurs most frequently into the right pleural sac,
the pericardium, the lungs, or externally. In one of
my own cases, already mentioned, rupture took place
into the pulmonary artery.
Aneurysms of the Transverse Portion of the Arch. —
These may be either spindle-shaped or, more com-
monly, saccular. As they occupy that portion of the
arch of the aorta from which spring the great brachial
and cephalic branches, the latter are quite frequently
involved in the aneurysmal growth. They are com-
mon, but somewhat less so than those of the ascending
portion. Their situation is such that they, soon after
attaining any size, necessarily impinge upon some of
the important structures in the center of the thorax,
giving rise in consequence to decided evidences of
intrathoracic pressure. The presence of a pulsating
tumor in this region will also cause easily recognized
changes in the percussion of the sternum and its mar-
gins, and can further be detected by the sense of
touch behind the manubrium. Aneurysm in the
transverse arch is therefore, as a rule, readily diag-
nosed except when the tumor is quite small. Some-
times, even before any other signs have developed, the
aneurysm may be discovered by means of the finger
pressed well down behind the sternum in the jugular
fossa. As the expansion of the aorta here increases
it pushes aside the edges of the lungs, and dulness
becomes well marked over the first piece of the ster-
num, and to a variable distance on either side of this.
Then a heaving prominence makes its appearance in
the same region, and, following upon the absorption
of the sternum and upper ribs, an external tumor
becomes developed which may even reach a large
size. The radial pulses of the two sides quite fre-
quently differ in size and fail to beat with the usual
synchronism. This sign is more often met with in an-
eurysms of the arch, because here the innominate and
subclavian arteries are so apt to have their caliber
interfered with by pressure, by twisting or dilatation, or
by the entrance of eoagula. The parts most liable to
compression in these cases are the esophagus, trachea,
recurrent laryngeal nerve, and left innominate vein.
If the concave border of the arch be also involved, the
left bronchus is liable to be partially or wholly
obliterated. The signs by which these various con-
ditions can be recognized have been already considered.
Rupture occurs into the trachea, the esophagus, or the
pleural cavity, or more rarely into the mediastinum,
the pulmonary artery, or one of the large veins.
Aneurysms of the innominate artery alone are rare,
but we oftener see tumors of the arch associated with
more or less considerable dilatation of the innominate
trunk. The enlargement will be found beneath the
right sternoclavicular articulation and inner part of
the first rib, and it may extend into the neck beneath
the sternomastoid muscle. In these situations we
must look for the usual local signs, swelling, pulsation,
and bruit. The latter may be heard up the carotid.
The effect upon the distal arteries is generally well
marked. The symptoms are chiefly pain, both local
and more especially radiating up the right side of
the neck and back of the head, sometimes down the
right arm, with numbness; and if the tumor be larger,
there will be signs of compression of the trachea or the
esophagus or an innominate vein. Cases sometimes
arise in which it is extremely difficult to determine
whether the disease is confined to the innominate
artery or occupies as well a portion of the arch at the
origin of this vessel. For instance, a man came under
observation a short time ago at the Montreal General
Hospital, with a strongly pulsating tumor rising out
of the neck above the right sternoclavicular articula-
tion. Fenwick, whose patient he was, believed it
to be purely innominate. Its strict limitation to the
area near tiiis vessel, the distinctness with which the
cylindrical tumor could be defined by the examining
finger, t he interference with the pulsations in the
radials, and the absence of all signs of swelling of the
arch, as determined by most careful examination, all
seemed to favor this conclusion. This opinion was
confirmed at a consultation of several members of the
staff, and it was decided to recommend treatment by
distal ligature. This the patient refused to submit to
and was discharged. He subsequently died suddenly',
while running, from rupture into the pericardium of a
small aortic dilatation just above the valves. The
aneurysm in question was found at the autopsy to be
entirely aortic. A remarkably elongated saccular
dilatation sprang from the arch directly behind the
innominate artery (somewhat compressing it) and
appeared above the inner edge of the clavicle. The
innominate was completely pervious and of normal
size. The deception was complete and would
have given rise to a grave error of treatment
had the patient consented. Although, as in the ease
just related, mistakes of this kind are sometimes
quite unavoidable, yet, in the majority of cases, a
thorough investigation of all the symptoms and
physical signs will suffice to make a diagnosis.
Aneurysms of flic descending thoracic aorta are less
common than the others. They also may be cylin-
drical or saccular. From the depth at which they are
situated in the chest, and from the thickness of the
structures everywhere surrounding them, they are
difficult of detection, and as the symptoms from them
may be only slight and ill defined, they may con-
tinue for a long time unsuspected. Pain is, however,
seldom absent, and when due to pressure on the
nerve roots is of an extremely violent and intractable
character. It may be accompanied by hyperesthesia
or anesthesia of the skin, and MacDonnell has re-
corded an instance in which there was sweating in the
course of the nerves. This point has been already
sufficiently dwelt upon. The earliest physical signs
consist in localized dulness and pulsation to the left of
the spine, and enfeebled breathing over the same area.
Later on, a systolic bruit may be heard. ( )ccasionally,
retardation of the left femoral pulse, as compared with
that of the radial, has been observed. When of large
size, the aneurysm pushes the heart forward, and the
heaving impulse of the tumor can be felt anteriorly
through the heart. A rare symptom is dilatation of the
veins on the anterior aspect of the chest from pressure
upon the azygos and intercostal veins. Lying against
the vertebral bodies, these aneurysms very commonly
produce erosion of those structures; and if this be
sufficiently considerable, bending of the vertebral
column occurs, with posterior curvature. From this
cause, or from opening of the vertebral canal, pressure
is sometimes brought to bear upon the spinal cord
itself, with a resulting paraplegia. The esophagus
is sometimes compressed and dysphagia produced.
Attacks of pleuritis in the lower part of the left side
are a very frequent accompaniment. These usually
result in plastic effusion, but, at times, even pretty
considerable quantities of serum may be found.
Some years ago I found a hospital patient com-
plaining of stitching pain in the left side. Aery
moderate effusion was determined by physical ex-
amination. There had been slight pain in the back
for some time previously, but this had not been of
sufficient duration or intensity to lay stress upon.
The fluid continued to collect, and was removed by as-
piration, with relief. A few days afterward he died
suddenly from rupture of an aneurysm of the descend-
ing aorta into the same pleural cavity.
Wynter records cases of simulating aneurysm of
the descending arch associated with a ringing second
sound, tracheal tugging, paralysis of the left recurrent,
nerve, and downward displacement of the heart owing
to lengthening of the aorta. He believes these signs
are due to atheroma of the upper portion of the arch
and that they can be distinguished from aneurysms of
the arch only by x-ray examination.
Rupture of these aneurysms occurs most frequently
416
REFERENCE BANDBOOK OF THE MEDICAL SCIENCES
Aneurysm, Interna]
Into the left pleural cavity, sometimes into the right,
and occasionally into the esophagus. Cases are known
in which the sac opened into the spinal canal.
Diagnosis. The recognition of thoracic aneurysm
i t as easy in some cases as it is difficult in ol hers.
During the i >:i-t decade ii has become more generally
recognized that a not inconsiderable number of cases of
trysm arc entirely latent. An important method
in the recognition of such eases has been made by the
application of the x-rays. Cases otherwise obscure
ran be cleared up in this way, and when aneurysm is
falsely suspected an x-ray examination may disprove
its existence. Observations are' best carried out by
means of the fluorescent screen, when a distinct en-
largement lying in the course of the aorta is detected.
Pulsation is sometimes observed, and, its occurence
ngthens the view that an aneurysmal tumor is
ent. Williams states that the movements of the
diaphragm are often less on the left side, due prob-
to pressure on the left bronchus. Care must
.crcised not to mistake enlarged glands or other
intrathoracic tumor for aneurysm. Such an error is
likely to occur only when the growth lies in contact
with the aorta.
By this method of examination the diagnosis often
becomes apparent in obscure cases, and aneurysms are
limes found which are unrecognizable by other
methods of physical examination.
Superficial, strongly pulsating aneurysms are
readily observed, and not unfrequntly the throbbing
will have been noticed by the patient himself. On
the contrary, deep-seated dilatations may give no
appreciable physical signs, and in that case the
diagnosis may be obscure. Furthermore, if, in one of
these obscure cases, the aneurysm causes no symptoms
by its pressure, then the diagnosis becomes impossible.
Not a few aneurysms of the ascending arch, even of
considerable size, prove the cause of sudden death in
persons previously believed to have been in good health.
These, having caused no symptoms, had never been
looked for, but could undoubtedly have been detected
by physical examination. The combination which
gives the greatest certainty to the diagnosis of thoracic
aneurysm is the union of physical signs of tumor with
pulsation in the course of the aortic arch, together
with some, or best, several, of the pressure symptoms
enumerated. The difficulties in the diagnosis of
these cases arise from the great variability which is
met with in the manner in which these different in-
dications may be grouped together. Thus we meet
with cases in which some of the physical signs of
aneurysm are observed, and no pressure symptoms;
others, again, in which there are evident pressure
symptoms, with perhaps only a few of the signs of
aneurysm. In not a small number of cases the con-
ditions lead to the recognition of an intrathoracic
tumor, and the difficulty begins only when we
endeavor to differentiate between a solid tumor and
aneurysm. The resemblance between an an-
eurysm and a solid tumor placed between the chest
walU and the aorta maybe very close. In both there
may be dulness on percussion, pulsation, and a
recognizable bruit, and pressure symptoms of identical
character may also be present. The chief points of
distinction ari' the following: In the case of the neo-
plasm, the dulness is likely to be less clearly restricted
to the aortic region, the pulsation will not be at all so
forcible, and the systolic bruit will probably not be
followed by an accent uated second sound. Bronchial
respiration is commonly heard over a solid tumor,
while enfeeblement or silence is the rule in aneurysm.
Again, persons with aneurysm are not likely to suffer
severely in their general nutrition and appearance,
while the contrary holds good with reference to nearly
all forms of intrathoracic solid growth. Attention
to the following points may also assist the investigator
in doubtful eases. Aneurysm is many times more
frequent than solid tumor. It occurs much more
often in men than in women. It i- favored by a
in t.iry of syphilis, rheumatism, or -train.
Pulsating empyema is i lition, which some-
times simulates aneurysm. The chief physical signs
to be here met with will be dulness 1,11 percussion and
local pul ation, but no pic -lire symptoms will be
present. Examined closely, the dulness will be ob-
served to be less clearly localized in the aortic region
than is that of an aneurysm. Moreover, other sign
of arterial disease will be- wanting, and. on I he other
hand, there will be some evidences of disease in the
pleura or the lung, accompanied by a certain degree
of constitutional disturbance. These differences will
usually suffice to prevent error. Puncture with a
tine aspirator needle will, in any case, clear up the
diagnosis.
Violent throbbing pulsation of the aorta in eases
of severe aortic regurgitation often leads to a sus-
picion, or even to an erroneous diagnosis, of aneurysm.
The pulsation, however, ha- not the heaving charac-
ter of aneurysm, and there is an absence of pressure
J nipt ollis.
Prognosis. — It is usually a matter of considerable
difficulty to form a satisfactory opinion as to the
prospects of life of a person suffering from thoracic
aneurysm. Undoubtedly the disease generally tends
to prove fatal, and is actually the immediate en
of death in the majority of eases; and yet, in a certain
number, increase in the tumor is arrested and moder-
ate health is enjoyed for perhaps a period of several
years, even (hen the fatal event being brought about
by some affection entirely independent of the aneu-
rysm itself. It is often clearly impossible to estimate
at all accurately the size of a deep-seated tumor, or
the degree to which it may lie against important
adjacent organs; and hence ruptures in various
directions, which no skill could possibly foresee.
Those aneurysms which arise from the root of the
aorta are the most dangerous, as they tend most
frequently to rupture while yet small. Those of the
ascending arch — if they grow forward and to the
right — are calculated to permit of the longest tenure
of life. Those of the transverse arch and descending
thoracic aorta are probably, on the whole, more
favorable than the first and less so than the last;
the reason for this, of course, being their greater
proximity to numerous important structures, which
can hardly escape from injurious pressure. Our
opinion, therefore, of the probability of the pro-
longation of the patient's life must depend upon the
situation of the aneurysm, the fluidity or the contrary
of its contents, and the presence or absence of symp-
toms of compression, to a serious extent, of the sur-
rounding parts. If this be well marked upon the
trachea or esophagus, a fatal result may lie anticipated
before many weeks or months. Other conditions
to be considered are the following: Mode of life; if a
person with aneurysm is obliged to earn his living,
and especially if the occupation followed is at all
laborious, his chances of living will be far less than
those of his more favored fellow who is able to live at
ease and free from care. Rest is so important in
these eases that if this cannot be secured the disease
is almost sure to be progressive, and perhaps even to
advance rapidly, while, on the other hand, it seems
sometimes surprising how long the fatal end can be
averted, even in advanced cases, by the observance
of great precautions in this respect. This remark
will also necessarily apply to the cases of patients who,
from irritability of temper or other similar causes,
refuse to carry out this essential principle of their
treatment. The temperament of the patient is of
importance, for anger, excitement, and, indeed, any
violent reaction may be followed by the most serious
results. Indulgence in alcoholic liquors is sure to
interfere with the quiet action of the heart which is
so desirable; intemperance must, therefore, influence
strongly our prognosis.
Vol. I. — 27
417
Aneurysm, Internal
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Associated Conditions. — In estimating what is
likely to be the future of any given case of thoracic
aneurysm, it is important to study carefully any
pathological conditions which may be associated
with it— such, for example, as affections (especially
valvular) of the heart, of the lungs, of the larynx, of
the bronchi, etc. — and to assign to each its true
value as a factor in the problem. Finally, the general
condition with reference to nutrition, muscular
development, etc., must also take its place in
rendering the prognosis either more or less
favorable.
Treatment. — Aneurysm within the chest is capable
of the same spontaneous cure which occurs occasion-
ally elsewhere. Complete coagulation and hardening
of the contents, with arrest of all symptoms, is, how-
ever, extremely rare. Still it is always obviously a
duty to endeavor to place a patient who is the subject
of this formidable disease in as favorable a position as
possible for this process to occur. All treatment,
therefore, which is not merely palliative should be
directed toward insuring conditions likely to promote
firm coagulation within the sac.
In the large majority of cases of intrathoracic
aneurysm we are, from the nature of things, pre-
cluded from those methods of treatment which are
applied directly to the tumor itself or its immediate
neighborhood, and are frequently distinctly curative.
We are, on the contrary, compelled to treat these
cases by general measures and by such indirect
means — drugs — as experience has proved to be of
value. The objects in view may be briefly stated
to be to reduce the tension within the aneurysm, to
secure regularity of the heart's action without fre-
quency, to maintain the blood in good chemical con-
dition without undue bulk, and to favor thickening
of the sac's walls. To follow out these indications
it is necessary to secure the full direction of the case
for, perhaps, several months. If the physician,
therefore, is to meet with any success, it is absolutely
requisite that he should have the hearty cooperation
of the patient, who, if sufficiently intelligent, must be
made acquainted with the nature of the case and the
urgent need of his assistance, irksome though he may
find it to be.
The recumbent position, for a length of time, is
always to be recommended. The effects of this
measure alone, are often sufficiently striking. When
the person's circumstances permit, the restriction
to a lying posture should be absolute, and should be
persisted in for several months, unless the general
health appear to be suffering materially from the
close confinement, when, with due precautions,
sitting up and slow walking may be permitted. If,
on the other hand, circumstances prevent absolute
rest from being carried out, then, at any rate, very
stringent rules must be insisted upon, governing the
patient's entire mode of life, with the view of insuring
the least possible muscular exertion. This is a point
on which too much stress cannot be laid. These
patients live constantly on the edge of a precipice,
yet, when immediate suffering is relieved, this fact
is too often lost sight of, with disastrous results. A
patient whom I treated during a year not long ago,
for an aneurysm of the ascending arch, was so far
benefited that he took a situation as a messenger.
In spite of all warnings to the contrary, he soon
undertook to handle heavy baskets and other pack-
ages. One day, shortly after, he experienced sudden
pain in the chest, followed by the extraordinarily
rapid development of an external tumor. This
quickly attained the size of a child's head, and
proved fatal, with great suffering. Hardly less
important than physical rest is mental quietude.
Habitual worries of all kinds should be as much as
possible excluded, while actual excitement is in every
respect highly dangerous. A fit of anger or other
violent emotion may prove fatal, either by actually
causing rupture of the sac or (as in a recent case of
my own) from syncope.
The diet is a matter of importance. A very old
treatment of aortic aneurysm is that of Valsalva, in
which repeated blood-lettings were practised, . to-
gether with a gradual restriction of the food until
the amount of this was brought within the lowest
possible limits short of actual starvation. The
fallacy of this proceeding has, however, been long
ago demonstrated. Blood-letting has but little, or
but a temporary, effect upon the blood pressure;
and the withdrawal of food causes anemia and weak-
ness, with irritability of the heart and impaired
nutrition of the arterial walls, which conditions
indirectly aggravate the disorder. The result of
experience shows that the formation of a coagulum
which is likely to be of service in the process, will
proceed better if the patient be not too much reduced,
Tufnell, of Dublin, is the only comparatively recent
writer who has advocated the starvation plan.
Conformably with his recommendation, the system
has been extensively tried, but few are found who
can report results calculated to lend support to its
efficacy. The quantity of fluid allowed should not
exceed forty or fifty ounces daily; it is difficult to
get patients to submit to smaller quantities for a
prolonged period of time. If the patient be plethoric
and show evidences of congestive tendencies, then
our treatment may well be begun by the adoption of
depletory measures for a time — a low diet with laxa-
tives or saline purgatives.
As regards medicines, many have been tried, but
few have proved useful. The most valuable drug is
undoubtedly iodide of potassium. The good effects
of the iodide were described by Chuckerbutty in
1862, and by Roberts in 1S63, and they were em-
phasized and enlarged upon by George Balfour a
few years later. Since that time it has been exten-
sively employed, and has«ontinued to grow in favor.
The two former writers considered that it acted by
inducing increased coagulability of the blood, but
this view is not shared by Balfour. He considers
that the iodide has "a peculiar action on the fibrous
tissue, whereby the walls of the sac are thickened and
contracted, while if coagulation should take place
within the sac, it plays but a very secondary and unim-
portant part, depending for its occurrence solely on
the remora of the blood, and is in no respect due to the
iodide of potassium." This corresponds entirely with
the results of my own observations, for in one case, in
which the relief to pain and the general improvement
had been very marked for a long time under this
treatment, the autopsy subsequently showed that not
a particle of fibrin had been deposited on the walls of
the sac. The symptoms which specially indicate the
use of the drug are pain and troublesome cough. The
special pains of thoracic aneurysm are generally very
rapidly alla3*ed, and are often for a great length of
time held in abeyance by this agent; and the same
may be stated with reference to tin? troublesome
attacks of irritating cough which the tumor may
excite from time to time. Independently, however,
of its employment for the relief of these urgent symp-
toms, it is to be administered steadily for such a I
as may be thought necessary to influence, as al"
the disease itself. The dose usually given varies from
gr. x. to gr. xxx. thrice daily. Balfour, who formerly
inclined to the larger dose, thinks now that fully as
good effects can be obtained from smaller ones. His
rule is to employ such a quantity as will lower the
blood pressure without increasing the frequency of
the cardiac contractions. Beginning with ten-grain
doses, ascertain the pulse rate (the patient h<
recumbent), and increase to fifteen; if no increase in
the pulse be observed, this is to be continued; but if
the pulse gets quicker,- then return to ten. It is rare
that more than fifteen grains can be borne within the
limits of this test. The treatment must be persevered
4 IS
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Aneurysm, Internal
in, mi the least, for several months, and, to give it a
f:iir trial, probably for a whole year, or even longer.
If troublesome erupt inns are produced by the potash,
an intermission must be allowed till these are recovered
from. II is also well to remember that some persons
who are thoroughly intolerant of iodide of potassium
, J,, takciodide of odium without any outward effects.
Balfour speaks truly when he says the results (from
iodide treatment) "are extremely encouraging; and
when we reflect upon the entire absence of any risk
to tlic patient from the treatment, and the almost
certainty of relief to his sufferings and prolongation of
his life being at least attained, I think I am warranted
in saying that no treatment for internal aneurysm
hitherto devised holds out anything like an equal
prospect of relief, if not of cure, with that by the
i if potassium."
Tlic hypodermic injection of a one-per-cent. solu-
tion of gelatin in normal saline solution has been
gly recommended by Lancereaux, with the view
of causing coagulation in the sue. From 50 to 100
o.c. may be injected beneath the skin of the buttock,
or thrown deeply into the muscles. There is some-
times considerable local pain and even general febrile
reaction after this procedure. Although successful
have been reported, the method is by no means
free from danger. Serious and even fatal results
have followed the injections, owing to the detach-
ment of large emboli. This method has not stood the
of experience and is now seldom used.
Christopher Heath and a few others have sug-
gested and practised ligature of one or more of the
great branches of the aortic arch, the object, of
course, being to retard still further the blood current
and thus promote coagulation. Some support is
given to this procedure from the benefit that has been
observed in certain cases of aortic aneurysm in which
the carotid and subclavian of the right side had been
ligatured, under the impression that the disease was
confined to the innominate artery. At most it would
be applicable only to cases in which the tumor was
sacculated and either involved the root or was situ-
ated close to the origin of some of the great vessels.
Evidence of extensive atheromatous disease would
preclude any prospect of advantage from this sur-
gical procedure.
The method of all others which seems to hold out
the greatest prospect of success, when it is decided to
penetrate the sac, is that first suggested by Moore,
and subsequently modified by Corradi. It consists
in the introduction of ten or more feet of coiled gold
or silver wire into the sac through a hollow needle,
insulated by being coated with French lacquer, com-
bined with the passage of a galvanic current of fifty
to seventy-five milliamperes, the anode being con-
nected with the wire. It is applicable only in cases
of sacculated aneurysms. In the thorax the .r-ray
is an indispensable aid, especially the fluoroscope, in
revealing the pulsating sac; a local anesthetic is used
to introduce the needle through the skin. In one case
Finnic removed the greater portion of the sternum
and three adjacent ribs to gain better access to the sac.
In abdominal aneurysm an incision is required through
the abdominal wall in order to apply this method
of treatment. The current should pass for at least
an hour and Finnie in his later cases has continued it
for two hours.
In favorable cases decided relief to pain has
been obtained with lessening of pulsation; and in a
considerable number of reported cases marked
improvement has been noted. From the nature
of the disease cure can seldom be expected, and
has been reported in but few instances.
Certain risks must be faced in undertaking an opera-
tion of this character. Embolism has occurred and
also rupture of a subsidiary sac. Sloughing in the
course of the wire or in the sac itself, with subsequent
hemorrhage has also been observed.
Although the special treatment of aneurj m in the
majority of cases con i I of prolonged rest and
the administration of iodide of potassium, a al
detailed, (here are be ide the e certain therapeutic
measures al our command for the relief of individual
symptoms.
Excited cardiac action and palpitation are be I
relieved by the judicious use of morphine and the
employment of a bladder of ice over the front oi the
che t.
The pain, it has been already stated, is generally
best treated by the iodide of potassium. If, how
it be very severe, ii may be necessary to use hypo-
dermic injections of morphine until the iodide shall
have had time to act. Moreover, we do meet with
ran' cases in which the effect of the iodide ultimately
bee s lost, and our only resort is the frequent use
of morphine to make life bearable. ( Ine very marked
ease of this kind came under my notice in the person
of a hospital patient. His aneurysm was as large as
a cricket ball, and almost as solid. Neuralgic pains
were complained of persistently, were relieved for
a considerable time by the iodide treatment, but, for
more than a year previous to his death, we were
obliged to administer daily hypodermics of mor-
phine in considerable quantity. Pain of well-defined
neuralgic character (especially along the intercostal
nerve) is decidedly benefited by the application of
small blisters over the most tender parts.
Dyspnea, if due to accompanying catarrh, must
be treated with reference to the latter disorder. But
if, as is most frequently the case, it is the result of
mechanical pressure and irritation of nerves, recourse
must be had to sedatives and narcotics, especially
morphine and hydrocyanic acid. Alcohol in toler-
ably full doses is also of considerable assistance.
If a projecting tumor form, care must lie taken to
protect it from injury or friction by some arrangement
of pads or a shield of some smooth metallic substance
lined with cloth.
When rupture has actually taken place, we can
probably do nothing; but if any preliminary bleeding
should occur, we may endeavor to prevent this going
on to rapid hemorrhage by the use of ice externally
and the administration of astringents, while the most
perfect quietude is enjoined.
Abdominal Aneurysm. — Symptomatology. — Aneu-
rysm of the abdominal aorta is occasionally latent,
as in two of Osier's series of eighteen cases. In a few
instances, again, aneurysmal tumors may reach a
considerable size without the distressing symptoms
which usually accompany the malady.
The earliest, the most persistent, and the most
distressing symptom is abdominal pain. As Beatty
long ago pointed out, the pain has a double character,
being constantly present as a dull aching sensation
in the abdomen and back, and subject to paroxysms
of extreme violence which even large doses of mor-
phine may only partly allay. The site of pain in
these crises is situated in the abdomen and back,
and is due to pressure on the lumbar nerves. These
paroxysms may also radiate more widely, down the
thighs or to the testicles; they may simulate renal,
hepatic, or intestinal colic and have even been mis-
taken for the abdominal crises of tabes. The pain
may be increased by the taking of food, as in Beatty's
case; Hoyle records cases in which it was increased
by the respiratory movements.
Other symptoms are due to pressure on surround-
ing structures. Vomiting is present in many in-
stances, and pressure on the duodenum may induce
partial obstruction with dilatation of the stomach,
as in a case recorded by Osier. Dilatation of the
esophagus from compression of its lower end has
also been noted by the same observer.
When the tumor is in the proximity of the bile
ducts, jaundice may result and enlargement of the
419
Aneurysm, Internal
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
liver may follow pressure on the hepatic vein-;.
Ascites is an extremely rare manifestation of aneu-
rysm, and edema of the extremities and trunk is of
little diagnostic import. Fever is usually absent
and its presence denotes a complication. The nutri-
tion of the patient often fails to some extent, but in
some cases extreme emaciation is a noticeable feature
and may be attributed to loss of rest, to gastric dis-
turbance and possibly in some instances, as in
Pepper's case, to occlusion of the thoracic duct.
Aneurysms of the various visceral arteries are
usually -mall in size and are seldom recognized
during life or until fatal rupture lias occurred. They
are frequently of mycotic origin, or follow an acute
infection. They usually run an acute course and
occur in younger individuals than the more common
form of the disease.
The branches of the celiac axis, the superior mesen-
teric and renal arteries are the vessels most commonly
involved.
Dean and Falconer refer to fifty instances of aneu-
rysm of the hepatic artery of which seventy-three
per cent, followed acute infection. In their ca
jaundice developed twenty days after pneumonia,
and hematemesis and melena resulted from rupture
into the dilated bile duct. In a case recorded by
Schultz, aneurysm developed as a result of erosion of
the outer coats of the vessel from gallstones.
The superior mesenteric is more commonly affected
than other vessels. Aneurysms of the renal artery
are very unusual and sometimes lead to hematuria.
In a case of Keen's an abdominal tumor was removed
with the kidney and subsequent dissection proved
the mass to be an aneurysm of the renal artery.
By far the most common termination of abdominal
aneurysm is rupture. In 233 cases collected by Nixon
this occurred in 152 instances; of these there were
sixty-five retroperitoneal, forty-five intraperitoneal,
seven pleural, one esophageal, and four pulmonary.
Melena and hematemesis indicate rupture into the
intestines or stomach. Elbe has reported a case of
rupture to the vena cava and states that there are
only four recorded cases (Deutsche med. Woch., 1910).
Rupture into the peritoneum is usually rapidly fatal;
when retroperitoneal the termination is more gradual
and the symptoms may be those of acute peritonits.
Osier refers to four cases operated on for appendicitis.
The recognition of aneurysm rests on the discovery
of a pulsating expansile tumor. If large it is visible,
conveying a distinct impulse to the abdominal wall.
Careful inspection of the lumbar region in a good
light sometimes reveals pulsation of an aneurysm
not seen in front.
Pulsation in the epigastrium or along the front of
the normal aorta is frequently found, particularly
in neurotic individuals, but in aneurysm it has an
expansile character, pulsating not only from before
back but from side to side and separating the observ-
ers hands when laid on each side of the tumor. A
thrill is occasionally felt. The consistence of the
tumor varies with the amount of fibrin deposited in
the sac. When the latter has thin walls it is soft and
fluctuating and can sometimes be emptied by pres-
sure. With a large deposit of fibrin the tumor has
a more solid character and pulsation may even cease.
When connected with the aorta aneurysms are
commonly fixed, they do not alter with change of
posture, and he behind the alimentary tract. In the
case of large tumors these may however come for-
ward and give rise to a dull note on percussion. The
surface of t he tumor is smooth and only exceptionally
lobulated.
A bellows murmur is heard in a considerable number
of cases and in suspected cases the stethoscope should
be carefully used in the lumbar region as well as over
the abdomen.
Diagnosis. — With a history of severe and persist-
ent abdominal pain aneurysm is one of the condi-
tions which should be considered, and evidence of
syphilis increases the probability of such a condi-
tion being present.
The difficulty of recognition is shown by Bryant's
collection of fifty-four cases from Guy's Hospital, in
which only one-third were recognized during life. l"n
fortunately the .r-rays render little or no assistance in
the diagnosis of abdominal aneurysm owing to the
impermeable character of the abdominal viscera.
Treatment. — See the section on Thoracic Aneurysm.
Cerebral Aneurysms. — Miliary aneurysms, de-
scribed by Carcot and Bouchard, are visible to
naked eye and vary in size from two-tenths to one
millimeter. They are most readily seen in the i
volutions and occur in order of frequency in the
optic thalami, pons, convolutions, corpora striata,
cerebellum, medulla, middle peduncles, and centrum
ovale. Their number is very variable, from two to
three to as many as one hundred. They derive their
importance from the fact that they are sometimes the
source of cerebral hemorrhage, particularly in aged in-
dividuals. They result from degenerative changes in
the minute \ r essels and are frequently accompanied by
atheroma of the larger cerebral arteries.
Aneurysm of the larger arteries is a rare condition,
occurring nineteen times in 9,000 autopsies collected
from Guy's Hospital by Pitt, and seven times in 501
cases of aneurysm according to Crisp's figures. 'I
seldom attain a size larger than a walnut and fre-
quently lead to fatal rupture when no larger than a
pea. The middle cerebrals and the basilar are more
often affected than the other vessels, then the internal
carotids. The other cerebral arteries, the vertebrals
and the communicating arteries occasionally suf-
fer. Beadles (Brain, Vol. xxx.) has collected
cases and classifies them symptomatically in four
groups:
1. Those in which rupture and apoplexy have been
the first signs of cerebral disease.
2. Those in which fatal apoplexy has been preceded
by symptoms suggesting cerebral tumor or other
cerebral lesion.
3. Those in which there have been symptoms of
cerebral tumor only.
4. Those discovered accidently after death or
latent during life.
In nearly half the cases (46.3 per cent.) apoplexy
was the first symptom, and in only a little over a
third of the cases | :;7.1 1 per cent.) were signs of tumor
or brain lesion present, and even in these the symp-
toms were by no means always distinctive of organic
disease.
In thin-walled sacs early rupture is apt to occur, and
symptoms from pressure on the nerves at the base
or on the cerebral substance are often absent. Where
the sac has a thicker and harder wall pressure symp-
toms appear more frequently. These cases may
last for years and death often results from pressure
on the medulla or other portions of the brain.
In cases where the symptoms of tumor are pres-
ent, headache, vomiting, recurring convulsions, and
optic neuritis, sometimes with retinal hemorrhaj
may occur. Owing to the contiguity of the vessels
and cranial nerves, one or more of these may suffer
from pressure. Symptoms due to pressure on the
pons and medulla result most frequently from dis-
ease of the basilar artery with which these structures
are in close contact.
A murmur, according to Beadles, is seldom hi
and a diagnosis based upon it has has been proved
ci hi oct in only two instances by postmortem examina-
tion. This fact is not surprising when the small si/e
and deep position of these aneurysms are remembered
So many other conditions may produce a cranial
murmur that no significance should be attached to
this sign.
In these cases however blood extravasation is usu-
420
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Angina Abdominis
ally in the tumor or brain substance, and is less
likely to reach the surface.
(I,,- diagnosis of cerebral aneurysm is seldom if
over made with certainty. Wichern (2><
Ztitschrift fiir S < rv< nln ilkitttdr. Kill') puints out thai
rigidity of the nock is frequently present with the
apoplectic attacks, signifying a surface hemorrha
in such instances lumbar puncture would reveal the
presence of blood, and this combination of signs should
suggest aneurysm as the probable source of hemor-
;e. The occurrence of apoplexy in an individual
who has suffered from signs of tumor might also
-t such an explanation, and the finding of bl 1
in a lumbar puncture would be further evidenci
in its favor. On the other hand cerebral growths are
occasionally attended by sudden apoplectic attack
usually due to hemorrhage. In these cases howevei
the extravasation is usually in the tumor or brain
tance and blood is therefore not likely to be pres-
ent in the spinal fluid. F. G. Finley.
Angelica. — Angelica L. (fam. Umbelliferce) is a
genus the limits and dimensions of which are greatly
in dispute among botanists, the various sub-genera of
one author being regarded as so many distinct genera
by another. As recognized by Messrs. Engler and
Prantl, whom we follow, it contains about twenty-
live species, most of them natives of the cool tem-
perate regions of the northern hemisphere. The
plants abound in the aromatic principles of the
family. A number of them have been employed in
domestic practice, and two, under the names "Euro-
pean'' and "American" angelica, have been very
extensively used in medicine.
pean Angelica is the rhizome and roots of
lica archangelica L., a biennial, four to six feet
high, with a stout, hollow, purple-green, fluted stem,
large decompound leaves with clasping petioles, and
large umbels of white flowers. It is a native of far
Northern Europe and Asia, and is very extensively
Cultivated, our commercial supplies coming mostly
from cultivated plants of Germany and France.
It is one of the few vegetables whose use began in
the extreme north of Europe and extended south-
ward. It was an article of food in Norway and
Iceland many years ago, when its spicy taste made it
a grateful addition to the monotonous diet of the
North. Later, in the fifteenth and sixteenth centuries,
it was generally cultivated throughout Central
Europe. .Since then, the use of angelica has been
gradually diminishing, milder-flavored vegetables
taking its place, and it is only grown at present to fill
a very moderate demand in domestic and veterinary
medicine, confectionery, and liqueurs.
It is important to note the extensive use of the
"candied" stems (Angelica glare) as a confection.
since important cases of poisoning sometimes result
from the ignorant use of certain toxic plants which
bear a close resemblance to this.
The "root" consists of a large short rhizome, ter-
minated above by a hollow stem, and often worm-
eaten. Below, it divides into numerous thick,
fleshy roots, four millimeters (one-eighth of an inch) in
thickness, and twenty or thirty centimeters in length,
of a blackish-brown color, much wrinkled longitudin-
ally, and tubereulated. They are rather soft and pli-
able, brownish-white within, and in the dried speci-
mens He in a parallel tress or bunch. The odor is
rather pleasant: the taste at first sweetish, later bitter
and musky. Radially arranged oil-ducts and resin
cells are to be seen under the microscope on section,
chiefly in the cortical portion.
The constituents of angelica are, first, an essential
<~>il, containing phellandrene, and probably pinene
and evmene, of which it yields from eight-tenths to
one per cent.; this has the odor of the plant and the
usual carminative qualities of the oils of the order.
Second, six to ten per cent, of resin. Third, angelic
acid, one-third of one per cent., discovered bj Buchni
in 1843, ami since found in a number of other plants,
as well as made by synthesis; an odorous crystalline
volatile acid. Fourth, a very small amount ol va-
lerianic acid, together with the crystalline angelii
an amaroid, and a little ea< h ol tarch, tannin, and
sugar.
Its properties are aromatic, stimulant, carmina-
tive, and flavoring, as usual in the family. The dose
is from 0.5 to 2 grains (gr. viij.-xxx.).
A ml: lica oil from this source is an article of corn-
ier
American Angelica is the root of Angelica airn-
purpurea L., a plant of very similar habit to the last,
growing in Northeastern North America The tool
;i'"« in the same manner from a similar rhizome, but
are marketed detached therefrom. They are some-
what larger than those of the European, and arc of a
light gray-brown color. The composition and prop-
erties are practically the same, though the root and
the oil have a perceptibly different odor and taste.
II. II. Rusby.
Angina Abdominis. — This term was apparently
first used by Baccelli of Rome, according to Minella, '
who reported a case of this condition. The latter
observer defines angina abdominis as a condition in
which there occur paroxysms of severe abdominal
pain, resulting from aneurysm or arteriosclerosis of
the vessels of the celiac plexus. In Minella's ease at
autopsy there was demonstrated an aneurysm of the
celiac axis. The pain may be associated with the
symptoms of angina pectoris, in which case the diag-
nosis is not difficult. In other instances the pain is
confined to the abdomen, occurs usually in elderly
persons affected with arteriosclerosis, and is accom-
panied by the feeling of impending dissolution.
The subject of angina abdominis is discussed at
length by J. Pal in his article " Ueber Angina Pectoris
und Abdominis" 2 and in his book entitled "Gefass-
krisen." 3 According to this author anginal attacks
belong to the vascular crises. There are two types of
angina: the pectoral and the abdominal. The latter
is comparatively rare, but has been described by
many clinicians, including Huchard,' Leydcn,
Jaworski, Neusser, 5 and Pauti and Kaufmann. The
vascular crises also include the abdominal crises of
tabes and of lead poisoning. In all of these cases the
pain is the result of the contraction of the blood-
vessels of the abdominal viscera. In addition to the
pain there is an inhibition of peristalsis. But the
pain controls the clinical picture. Huchard also
refers to the similarity of the attacks of angina
abdominis to the gastric crises of tabes. In certain
cases it is difficult to differentiate between the two
conditions. In both of these the pain is severe and is
localized in the epigastrium, but it may radiate
widely from this region. On the other hand, Pauli
and Kaufmann believe that the pain is localized in
the visceral blood-vessels, and is the result of lesions
of the inner lining of the latter. Their conception
agrees with Nothnagel's views regarding vascular
colic. Pal states that one is accustomed to localize
abdominal pain in some definite organ. As a rule
this localization is deceptive, for the objective locali-
zation of pain is possible only if this symptom is
accompanied by manifest lesions of the suspected
organ. This difficulty is further complicated by the
fact that the nerves of the abdominal viscera are not
particularly sensitive, for gastric and typhoid ulcers
may be present without giving rise to the slightest pain.
Within recent years there have been describe. 1
cases of paroxysmal abdominal pain, which has
been attributed to arteriosclerotic changes in the
visceral blood-vessels, which changes in turn give rise
to intermittent obstruction and ischemia. These
421
Angina Abdominis
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
cases have been reported by Markwald, Schnitz'ler, 6
Ortner, 7 and others. To this group belong the cases
described by Ortner as the intestinal type of arter-
iosclerosis, under the name "dyspraxia intermittens
angiosclerotica intestinalis." According to Pal, the
pain of angina abdominis is not the result of ischemia.
He believes rather that the peripheral vasoconstriction
is accompanied by a distention of the proximal
arterial vessels. In this view Pal agrees with Colin,
who attributes the pain to increased tension in the
mesenteric vessels. That this theory is a plausible
one is shown by the fact that the administration of
drugs, such as the nitrites and nitroglycerin, which
dilate the blood-vessels in other parts of the body,
removes the tension in the visceral blood-vessels and
relieves the pain. In all of Pal's cases there was a
generally increased arterial tension. In most of the
cases there was an increased and more widely diffused
pulsation in the region of the abdominal aorta.
An accompanying phenomenon of angina abdom-
inis is constipation, which also occurs in the visceral
crises of tabes and plumbism. In some cases tnere is
a retraction of the abdominal wall, in others there is
meteorism. There may also be a segmental dis-
turbance of sensibility in the regions supplied by the
lower dorsal and upper lumbar roots. The retracted
abdomen of lead and tabetic colic is not as characteris-
tic in angina abdominis, in which the condition is
possibly masked by a hyperemic liver. Distent inn
when it occurs is caused by an intestinal atony due to
vasoconstriction, and may be compared to the dis-
tention occurring in renal and biliary colic. Vomit-
ing sometimes occurs as a secondary manifestation.
Pal alludes to the fact that the vasoconstriction may
affect only certain vessels of the abdomen. Angina
abdominis must also be differentiated from neuralgia
of the abdominal sympathetic. In this condition
there is no evidence of increased arterial tension.
Neuralgia of the abdominal sympathetic is probably
identical with the "syndrome solaire aigu d'excita-
tion" of Jaboulay.
Pal s in his paper entitled "Zur Kenntniss der
abdominellen Gefasskrisen der Tabetiker und ihrer
Beziehung zur 'Aortite Abdominale' " states that
angina abdominis may occur coincidently or al-
ternately with angina pectoris. Many of Pal's cases
suffered from tabes. This observer recognizes in the
latter disease two varieties of gastric crises. In one
of these the attack is purely gastric; there is vomiting
with or without pain, and the blocd pressure does not
rise to any marked extent during the attack. In the
second variety of tabetic crises there is marked
abdominal pain associated with high arterial tension.
In these cases the pain comes on as the pressure rises
and is relieved by amyl nitrite or the other nitrites.
In his article "On Abdominal Pain" Sir Lauder
Brunton 9 referred to an observation made by Dresch-
feld of Manchester in a case presenting paroxysmal
abdominal pain. At autopsy the only abnormal
condition found was an atheromatous state of the
intestinal vessels. In this article Brunton described
a condition of paroxysmal abdominal pain occurring
in individuals who are apparently otherwise perfectly
healthy, whose digestion is good, and whose bowels
are regular. Brunton attributed these attacks to
irregular spasmodic contractions of the abdominal
vessels analogous to the peripheral contraction and
proximal dilatation of the temporal artery occurring
in migraine, which latter condition Brunton had
observed in his own case. For the abdominal pain,
just as for migraine, he advised the use of salicylate
of sodium and bromide of potassium together with
carminatives and friction of the abdomen during the
attack.
Sir Lauder Brunton and W. E. Williams 10 report
the case of a man aged sixty-eight years who had
been suffering from diabetes for twenty-five years.
For the previous eighteen months he had been
422
suffering from abdominal pains that had been at-
tributed to flatulence, and that had been accompanied
by marked loss of weight and drowsiness. The
striking feature in this case was the severe spasmodic
abdominal pain which came on about twice daily
mostly after the exercise of walking or of playing
billiards. An unmarried sister aged sixty-four
years had also suffered from similar pains for the past
seven years. The pain resembled that of angina
pectoris but it differed in its localization, being
most severe in the umbilical region. It gradually
increased in severity and extent so that it spread
all over the front and back of the chest and was fol-
lowed by a profuse perspiration that broke out all
over the body. The attacks were controlled by the
administration of nitroglycerin.
An interesting case of angina abdominis occurring
in a patient exhibiting pronounced symptoms of
cardiac insufficiency, is reported by W. K. Hunter."
The case was that of a man aged futy-six years who
was under observation in the ( rlasgi iw Royal Infirmary
for one month previous to his death. The attacks
of epigastric pain began eighteen. months before he
was admitted to the hospital. The pain at first was
dull and aching, usually began about one hour after
meals, and was relieved by the taking of food. It was
frequently associated with flatulence. Shortly before
the patient was admitted to the hospital the pain had
altered its characters, being now sharp and shooting.
and coming on in a series of frequent paroxysms
which had no relationship to the taking of food. There
were marked loss of weight and slight jaundice, but
there was no history of alcoholism or of syphilis. His
previous health had been good. On examination,
the patient was lying in the semi-recumbent position,
very restless, with a good deal of dyspnea, and
with occasionally a C'heyne-Stokes type of respiration.
The pain in the epigastrium was more or less constant,
with frequent and severe exacerbations, each paroxysm
lasting about one minute. With each paroxysm the
breathing was quickened and the face became cy-
anosed. There was pronounced cardiac arrhythmia
and the heart sounds were indistinct and of poor
quality. The radial arteries were atheromatous.
There were signs of pulmonary hypostasis, the liver
was enlarged, the feet and legs were edematous, and
the urine contained a small amount of albumin and
easts. During the month the patient was under
observation the paroxysms of pain occurred nearly
every day at intervals of fifteen to twenty minutes,
and would last about one minute. This would go on
for an hour or an hour and a half at a time. At one
time it was thought that the patient was suffering
from hepatic colic. The pains seemed to be too
frequent and to have occurred over too long a period
of time to be due to gall stones. The stools moreover
showed no evidence of the latter, and the jaundice
lessened in intensity. The appetite was poor and
the patient frequently complained of nausea. The
signs of myocardial failure became more marked.
The blood pressure was unaffected by the pain. '1 he
systolic blood pressure ranged from 150 to 155
millimeters of mercury, except for a day or two just
before death when it fell to 115 mil.imeters. The
pain ultimately became so severe and the patient so
noisy and restless that it was necessary to keep him
under the influence of morphine. He died with all
the signs of heart failure. At autopsy the heart was
found to be hypertrophied and dilated, and the seat of
myocardial "degeneration which was apparently
due to the patchy sclerosis and narrowing of the
coronary arteries. The aorta was the seat of wide-
spaced patchy atheroma which also extended into
the larger vessels. The lungs wire intensely congested
and some pneumonic areas were present. In the
tight lung there were a number of large infarctions,
The liver was considerably enlarged with a certain
amount of old perihepatitis. The gall bladder,
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Angina Abdominis
bile ducts, and pancreas were normal. The spleen,
kidneys, ami stomach uVre congested, and in the Last-
named organ there was a considerable number of
small hemorrhagic ulcers.
Hunter believes that the above case presented a
up of symptoms and postmortem findings that is
frequently mei with in angina pectoris, and that the
0C8 e corresponds very closely in its clinical and pal h-
llogical aspects to the cases described by lliiehard
under the phrase "angine a forme pseudo-gastral-
giqiic." The slight amount of perihepatitis would
not cause the pain and the possible role of chole-
lithiasis was ruled out. The hemorrhages into the
gastric mucous membrane were regarded as venous in
origin, and a phase of the marked passive congestion
of the viscera. It was very doubtful whether these
hemorrhages could cause the pain and the author
had not seen any ease of gastric ulcer with pain of such
great severity and of as Ions duration as in the case
reported, in which the pain had the characters of the
pain in true angina pectoris. The pain had no
relationship to the taking of food. It is pointed out
that A. F. Hertz has shown that gastric pain even
when associated with ulceration is not due to irrita-
tion of the sensory fibers in the mucous membrane,
1ml is to be attributed to a sudden tension of the
gastric muscle fibers, such as is met with in very
e peristalsis. Hunter suggests that if the
origin of the pain in angina abdominis is to be sought
tor in the stomach itself, one must regard this pain as
being due to spasmodic contraction in the muscle
of the stomach wall. Indeed, quoting C. F.
Hoover, 12 lie states that at the present time there is a
tendency to attribute angina abdominis to some
fault in the arterial supply of the stomach wall, and
to discard the older view that it is a referred pain
originating in the heart muscle or in the ring of the
aorta. An analogy is pointed out between the pain of
angina abdominis and that of intermittent claudica-
tion, in both of which conditions, as in the case re-
ported by Brunton and Williams, the pain is induced
by a muscular effort of some sort. But in Hunter's
case the pain came on independently of muscular
exercise, without rise of blood pressure and with no
definite relationship to the taking of food. This
last fact would seem to rule out the possible causative
factor of increased peristalsis in the production of the
pain. Hunter agrees with Pal in the view that
ischemia of one or more of the abdominal viscera is not
a satisfactory explanation of the causation of angina
abdominis. There is greater plausibility in Sir
Clifford Allbutt's contention that in most cases the
condition is caused by a painful distention of an
aorta which is the seat of an inflammatory lesion.
H. W. Verdon 13 advances the theory that the
anginal habit, whether of the abdominal or thoracic
type, results from a state of increased irritability of
certain medullary and spinal centers, and the parox-
ysm is excited by impressions reaching these centers
from the muscular coat of the esophagus and stomach,
when this muscular coat is in a state of hypertonus or
tetany. This theory is based upon the author's
observation of four cases of angina abdominis. In all
of these cases there was pain in the epigastric region,
which pain was associated with hyperesthesia. In
three of the cases the seat of the hyperesthesia was
the rectus muscle, and in one case the skin alone
over this muscle was hyperesthetic. In two of the
oases pain appeared simultaneously in the epigas-
trium and in the arm. In all of these cases the dis-
tribution of the pain together with the hyperesthesia
can be explained on the basis that the pain is reflex
or referred, according to the views advanced by
Mackenzie, Head, and others. According to Verdon,
fullness of the stomach whether occasioned by an
excess of solids, fluids, or gases, seems to have no
effect by itself in exciting a seizure, although it
heightens the tendency to an attack. The attack is |
usually excited by the act of walking soon after a
meal, which muscular effort apparently induce- hy-
pe] tonus of the gastric muscle.
To recapitulate, the various theories that have
been advanced to explain the causation of angina
abdominis are as follows: aneurysm or arteriosclero i
of the vessels of the celiac plexus; contraction of the
peripheral blood-vessels ol the abdominal viscera
with distention of the proximal vessels; le ion ol the
inner lining of the visceral blood-vessels; ischemia
due to arteriosclerosis of the bl I ve els <,f the
abdomen; painful distention of the aorta which is the
seat of an inflammatory lesion; and a state of hyper-
tonus of the stomach induced by distention and
bodily movements.
The symptoms of angina abdominis are pain in the
epigastrium, which may be associated with pain in
other parts of the body; hyperesthesia oxer the region
of the rectus muscle; a feeling of intense anxiety or of
impending death, as in angina pectoris; increased
arterial tension; and constipation.
In the differential diagnosis the main conditions
to be ruled out are angina pecti ris, the gastric crises
of tabes, and lead colic. E. von Neusser 5 states that
violent gastralgia or intestinal colic may be the only
manifestation of angina pectoris. Other conditions
to be considered are nervous gast ralgia; ulcer or cancer
of the stomach; pyloric stenosis; duodenal ulcer;
malignant disease of the intestines; ulceration, chiefly
tuberculous, of the small intestine; intestinal stenosis;
constipation; appendicitis; Dietl's crises; renal colic;
tabes mesenterica; diseases of the liver, gall bladder,
and pancreas; aneurysm of the aorta; neuralgia of the I
abdominal sympathetic; and caries of the vertebral /
column. Many of the points in the differential dia'g=^
nosis will readily suggest themselves; others have been
dwelt upon in the preceding lines.
The treatment which is practically the same as
that for angina pectoris consists in reducing arterial
hypertension by means of amyl nitrite, nitroglycerin,
or any other of the nitrites. The hygienic and dietetic
measures which are suitable for cases of arteriosclero-
sis should be enforced during the intervals between the
attacks. Jacquet 14 has obtained good results with
the combined administration of iodide of potassium
and nitrite of sodium, as recommended by Lauder
Brunton. The latter has also advised the use of
salicylate of sodium and bromide of potassium, along
with carminatives. During the attack gentle massage
of the abdomen may be employed. In the very se-
vere attacks which cannot be controlled by either
measures the hypodermic use of morphine may be I
necessary. Alexander Spingabn. —
References.
1. Minella: Gazzetta degli Ospedale et delle Cliniche, 1902,
No. 120.
2. Pal, J.: Wiener medizinische Wochenschrift, April 2, 1904,
page 570.
3. Pal, J. Gefasskrisen, Leipzig, 1905.
4. Huehard: Maladies du Cceur et de l'Aorte, Paris, 1S99,
vol. ii., page 19; also Formes Cliniques de 1'Arterio-sclerose, Paris,
1909.
5. von Neusser E.: Clinical Treatises on the Symptomatology
and Diagnosis of Disorders of the Respiration and Circulation,
English Translation, Part III, Angina Pectoris, New York, 1909.
6. Schnitzler: Zur Symptomatologie der Darniarterienver-
schhiss, Wiener medizinische Wochenschrift, 1901.
7. Ortner: Zur Klinik der Angiosclerose der Darmarlerien
(Dyspragia intermittens angiosclerotica intestinalis), Sammlung
klinischer Vortriige, n. f., Innere Medizin, No. 347.
8. Pal: Medizinische Klinik, 1908, page 1790.
9. Brunton, L.: International Clinics, 8lh Series, London,
1S99, vol. iii., page 111.
10. Brunton, L, and Williams, W. E.: Lancet, April 6, 1912
11. Hunter, W. K.: Lancet, July 6, 1912.
12. Hoover, C. F.: Osier and McRae's System of Medicine
vol. iv., p. 288.
13. Verdon, H. W.: Lancet, June S, 1912.
14. Januet, A.: Zur Symptomatologie der abdominalen
Arteriosklerose, Correspond. -Blatt fur Sehweize Aerzte, 1906.
423
Angina Ludovici
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Angina Ludovici. — Various names have been
applied to this affection. Among them may be men-
tioned the following: acute phlegmonous pharyn-
gitis, erysipelas of the pharynx, diffuse cervical
abscess or phlegmon, submaxillary bubo, infectious
submaxillary angina, sublingual abscess or phlegmon,
subhyoid phlegmon, gangrenous induration of the
neck, cynanche cellularis maligna, cynanche sub-
lingualis rheumatica. As will be seen, these terms
are not definite. In late years phlegmonous inflam-
mations of the various regions of the neck and throat
have been differentiated and given each its own
descriptive name. Thus in a thesis by Broeckaert,
of Ghent (Paris, 1909), the author refers to no less
than fifteen different anatomical spaces, each one of
which may become infected. While early writers
asserted a specific individuality for this disease, later
authorities regard it as a septic sore throat with a
peculiar localization, not differing etiologically from
phlegmonous pharyngitis, erysipelas of the pharynx,
or acute edema of the larynx, all of which seem to
represent merely different degrees of virulence of the
same infecting agents.
The question of primary development and localiza-
tion depends probably upon the seat of original
infection, and it is difficult to establish definitely a
line of demarcation between the purely local and the
less complicated, as distinguished from the edematous
and purulent forms. The application, clinically,
of general bacteriological principles to this group of
septic inflammations harmonizes to a certain extent
former conflicting views.
Angina Ludovici is a diffuse phlegmonous inflam-
mation of the floor of the mouth and of the inter-
muscular subcutaneous tissue of the submaxillary
and sublingual regions. It may end in resolution,
abscess, or gangrene.
Gerster defines it as a phlegmonous destruction of
the submaxillary gland characterized by alarming
and extensive dense edema, caused by the unyielding
character of the fascial envelope of the gland, which
edema is most manifest about the latter vicinity,
namely, the floor of the mouth.
Its possible epidemic character can be explained
by the simultaneous exposure of various patients to
the same septic influence. As a sequel to or com-
plication of infectious maladies, it has been observed
more often in typhus fever.
As yet no special pathogenic germ of the disease
has been found, and where examinations have been
made only the ordinary bacilli of suppuration have
been present. Of these the streptococcus is most
frequently found. The staphylococcus is also often
in evidence. It is only in respect to the site of the
disease that it may claim special consideration. The
location in which the pus originates is a triangular
pyramidal space with the following boundaries: The
apex (below) corresponds to the point where the
mylohyoid muscle borders the genioglossus. The
base (above) stretches along under the tongue. The
external wall (oblique) is made up of the internal
face of the inferior maxilla and the mylohyoid muscle;
the internal wall (vertical) by the genioglossus and
the hyoglossus. The mucous membrane of the floor
of the mouth and the glandules sublinguales close its
cavity on top. It is through this channel, however,
that the infection gains entrance, so that the affection
of the submaxillary gland is in many, if not all,
instances secondary.
The symptoms are constitutional and local. The
former are in general those of pus formation, but it
is important to bear in mind that the pathological
process may also give a distinctly asthenic type of
symptoms, with an overwhelming prostration and
low temperature.
The local symptoms, in addition to the prominent
swelling of the neck, present the following diagnostic
points: first, and most diagnostic of all, there is a
424
peculiarly hard and wooden-like induration of the
affected region, sharply define'd from the surrounding
normal tissue; second, the thrusting forward and
upward of the tongue toward the palatal vault by
the accumulating inflammatory products; third,
severe dyspnea, with the possibility of laryngeal
edema; fourth, the sensation of pressure as from a
hard pad or button-like swelling at the inner aspect
of the dental arcade. With all of these there are
associated the ordinary features of a phlegmon.
Swallowing is painful, if not impossible, on account of
the muscular infiltration, and the patient may not be
able to open the mouth.
The prognosis is always grave and the rate of
mortality high, one series of cases reporting over
fifty per cent, of deaths. Death most frequently
results from sepsis, or from suffocation due to laryn-
geal edema.
Diagnosis. — The condition must be differentiate ,1
from osteomyelitis of the lower jaw, simple adeno-
phlegmon of the submaxillary gland, and the rare
disease known as Fleiscliman's hygroma. In the
first there is no limited focus of inflammation.
The entire bone is affected, the inflammatory process
is more generalized, and the subhyoid region is rarely
involved. In the second, adenophlegmon, the in-
flammation is superficial, the gland and its capsule
are easily accessible, there is no wooden-like hardness,
superficial ineison gives exit to pus, and the process
is localized at the outset behind the internal face of
the maxilla. In the third the diagnostic points are
suddenness of onset, location in the median line, and
lack of either constitutional or local evidences of
inflammation. In Angina Ludovici the diagnosis may
be made from the symptoms described above. To
these must be added two signs of great importance:
fust, pain on pressure over the focus of the inflam-
mation; and second, the withdrawal by aspiration
from the focal region of a bloody fluid. These
signs call for immediate operation, never by limited
incision, but always by careful and thorough
dissection.
The treatment must be based upon three principles:
First, early and free incision; second, careful sub-
sequent antisepsis; and third, constitutional support.
The condition is one of sepsis. The cause must he
removed, and the effects already produced must be
vigorously counteracted.
Gerster demonstrates that the object of the incision
is not so much to evacuate pus as to relieve tension.
He supports the modern view that the submaxillary
gland is the focus of the disease, and attaches much
importance to the fact that pressure over the edema-
tous area rarely causes pain except directly over the
gland. If such evidences appear, delay in operating
is not justifiable.
The operation must be done under general anes-
thesia, for deej) tissues must be explored in close
proximity to important vessels and nerves.
Fluctuation may be delayed because of the pus
being confined within a fibrous capsule. Early
incision may evacuate nothing more than an ichorous
discharge, while pus may form later, but tension i-
thus relieved and the consequent dangers of suffoca-
tion are much lessened.
Deep lateral incision over the submaxillary gland,
operation through the mouth, and even external
incision in the median line are all to be condemned.
The most satisfactory method is that suggested by
Gerster, namely, to lay bare the entire submaxillary
region by a careful dissection before making the
incision for evacuating the abscess.
To be effective the incision must penetrate the
mylohyoid muscle.
Following incision irrigation with bichloride (1 to
1,000) or boric acid (1 to 100) must be carefullj
carried out, and stimulants and tonics administered
according to indication. The application of cold to
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Angina Pectoris
the neck, if of any value at all, can be of service only
in the very earliest stages.
Hydrogen peroxide may assist in the separation of
the slougns.
The value of vaccines and serums in tins condition
lias not yet been demonstrated, although in other
somewhat analogous infections due to the strepto-
coccus, hopeful results arc being obtained. (Ball,
(, June 8, 1!)12.)
Prophylaxis. — To guard against the occurrence
of Angina Ludovici, the mouth, pharynx, and nose
should be kept carefully cleansed in all eases of dis-
ease, such as typhus fever, in which infection of the
sublingual region may take place. Recently some
forms of grippe have shown a tendency to generate
ical phi union. Here again and in all allied
litions of the mouth and throat proper aseptic
precautions may avert many possibilities of danger.
D. Bkyson Delavan.
Angina Pectoris. — Angina pectoris is a convenient
name for a group of .symptoms in which the pre-
dominating feature is pain of varying degrees of
intensity over the precordial region, occurring in
paroxysmal attacks, occasionally prolonged to be-
come chronic, and in rare instances associated with
the subjective symptoms of impending death.
The pain may originate in distant organs or in the
precordial region itself, and from this point radiate
in various directions, usually to the left shoulder and
arm, sometimes to the right: occasionally to both
.shoulders and arms.
There are two main divisions of angina pectoris, the
true and the false. In the true form, or angina
vera, there is an anatomical basis in the heart itself;
the false form, or pseudoangina, is a neuralgia of the
heart .
In the true form, affections of the coronary system
are noteworthy among the pathological findings,
while other degenerative changes, in either the
aorta or its branches, in the endocardium, or in the
walls of the heart, may be more nearly related to the
cause of the attacks.
Although the name angina pectoris does not de-
scribe the essence of the disease, it is likely to be re-
tained, because, theoretically at least, it covers a
perfectly recognizable group of cases, that may, in
the majority of instances, be relieved and usually
cured by appropriate management. For though
true angina is a dangerous disease, with a very un-
favorable prognosis, it is extremely rare. False
angina, on the contrary, is very common, if we in-
clude under the name all the minor forms; and it is
amenable to treatment. The etiology of the two
forms is different also, though unfortunately they
cannot always be differentiated, and occasionally
may be combined. At no time, however, does the
angina kill. If death occurs, it must be attributed
to an underlying organic disease.
True angina pectoris came to be generally known
in France and England as early as 1768, though it had
been described some years earlier by Morgagni, as to
both its clinical and pathological features. In the
year above mentioned, Heberden was the first to
differentiate it from cardiac asthma, a distinction that
is not always maintained at the present day. In 1772
.leaner and in 178S Parry noted the coincidence
between sclerosis of the coronary arteries and angina
pectoris. Angina pectoris motoria was described by
Landois in 1866. He held it to be an exaggerated
vasomotor disturbance causing increased arterial
pressure, or vasomotor paresis, and to be found in
chlorotic and anemic girls in emotional or cerebrospinal
crises. Niemeyer held the same view, and Nothna-
gel recognized this form also, having seen it in cases
of exposure to cold. Bamberger held analogous
ideas. This is a variety of the false form. Angina
sine dolore is the m given to an attack where
there is a feeling of constriction of the chest without
pain.
Another division of angina pectoris has been into
the smrf and mild forms. Hui this classification is
in. i satisfactory, because it misleads as to results.
A severe at lack may be of the pseudo form, or a mild
uiie of the true variety. i have seen a ease of the
former where the pain was intensely excruciating, and
in other instances attacks of the true form that were
comparatively mild.
In ls7:'., the distinction between true and false
angina was emphasized by Walshe. This distinction
is essential, because on the differential diagnosis
hang the prognosis and the treatment.
Statements \ ary as 1" the frequency of true angina.
In England it is not regarded as an unusual disea I -
However, in a series of 823 cases of my own, fairly
complete as to clinical histories and autopsical findings,
and covering an experience of ten years in one hospital
and fifteen in another, I did not find mention of a
single case of true angina pectoris. And in a series
of 2,31 » i medical eases treated by one of my colleagues
at the Post-Graduate Hospital, there was not a single
ease of true angina recorded. Another of my
colleagues, who had an even larger experience in the
outdoor medical department of Bellevue Hospital,
did not remember having seen during the years of
his service a case of true angina. In this vicinity at
lea-i, therefore, true angina is a rare disease.
There has been a tendency to attribute true angina
to coronary disease with sclerosis, with or without
embolism or thrombosis. Gautier and Huchard in
a series of seventy cases found coronary disease in
thirty-eight, or about fifty-three per cent. In a
later series Huchard found coronary disease in 128
out of 145 cases, or eighty-eight per cent., but evi-
dently the myocardium was not subjected to a close
examination. Coronary disease without angina is
common. Indeed, coronary disease between the
ages of fifty and sixty is the rule. And yet as I have
said it may exist without any symptoms of angina.
In fact, I should be quite willing, from own experience,
to say that I have seen hundreds of cases of coronary
disease at autopsies where clinically there had been
no symptoms of true angina, and I believe that the
best of our modern pathologists will subscribe to this
view. In fact, Romberg in his recent work admits
that angina is frequently absent in coronary disease,
though he maintains that there is usually a localized
contraction of the arteries round about the points of
their origin. Embolism or thrombosis he believes
may cause attacks, and this view is well sustained by
evidence.
Etiology. — In order to realize the diversity of opin-
ion as to the etiology of angina pectoris, a brief review
is necessary. In 1768 Heberden broached the idea
that the pain was due to the contraction of the heart,
which being a hollow organ suffered from pains some-
what analogous to those of other hollow organs, such
as the intestines and uterus. This theory is now main-
tained by Mackenzie in a modified form. But accord-
ing to this theory there should be violent alterations
in the rhythm of the pulse, which I have not found.
There is undoubtedly some hypertension, however, in
the early part of attacks. However, Parry, Stokes,
and Traube claimed that the pain was due to cardiac
paralysis, Traube holding that there was acute
dilatation which caused laceration of the cardiac
nerves. Of course, there is no doubt that if death
impends in true angina there is cardiac paralysis.
Some have held that the attacks are manifestations of
lithemia, and I am inclined to believe that in lithemie
cases there can be a fibrosis of the heart inn cle that
may have to do with the pain. Laennec and Lartigue
referred the pain to the pneumogastrie, while Lancer-
eaux, Peter, and Bazy laid it to infiltration of the
425
Angina Pectoris
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
cardiac plexus. But as a matter of fact infiltration
of this plexus by the new growths does not always
produce pain, and if this latter view were correct the
pain should be continuous, not spasmodic.
Friedreich thought it a functional affair, a neurosis.
Trousseau compared angina to the nerve explosions
of epilepsy; Bouillaud ascribed the pain to phrenic
and intercostal irritation; while Piorry called it a
brachiothoracic neuralgia. Allan Burns referred it
to the distention of the cardiac vessels, and Lauder
Brunton similarly ascribed it to the overdistention of
the coronary vessels. This latter theory might apply
in pseudoangina, but could not in cases of stiffness
of the coronaries, which characterizes the progressive
stages of the disease. Nothnagel advanced a theory
that the pain was due to spasm of the vasomotor nerves
of the heart. Josueand Allbutt have held that the pain
is located in the aortic ring. Romberg in his latest
edition was inclined to think with Charcot and Erb
that angina is related etiologically to the diminish,! I
supply of blood occasioned by the narrowed lumen of
the degenerated coronary vessels. According to his
theory, while under ordinary circumstances there is
a sufficient blood-supply to the heart to admit of its
functions being satisfactorily performed, under the
operation of certain physical and psychic influences
the relation between the blood-supply and the heart
muscle may be disordered sufficiently to cause pain.
In this connection, it is important to know that the
coronaries terminate in comparatively large trunks
from which capillaries are given off, and that these
unite to form reservoirs between the muscle fibers,
while the capillaries freely anastomose, so that inter-
ference with the circulation within a cardiac artery
means interference with a large amount of capillary
tissue. As a result of this anatomical peculiarity of
the capillary system, its contractions might cause
sensations of pain quite unlike those of any other
organ in the body.
It will be noted that in the summary of veiws given
above as to the cause of the attacks, little distinction
was made between the true and the false forms. In-
deed, although for excellent practical reasons we may
recognize tin- two, it may well be that in all cases the
cause of the pain is neuralgic. In one of my patient -
who had false angina (where the treatment was even-
tually so successful that she has now for about ten years
been enjoying life, with only an occasional intimation
that she has a heart, the apex was brought in by
treatment one and five-eighth inches, and was con-
tracted as well), I believe the pain was located in the
nerves of the heart walls, and arose from dilatation.
It may arise also from compression, as from a dis-
tended stomach, a very common occurrence in people
who are comparatively well. Recent physiological
studies have shown us that there may be irregular
contraction of the walls of the heart at times, i.e. local
spasms. Besides, in fibrosis of the heart walls, which
seems to be sometimes a feature of the lithemic heart,
there must be unequal contraction of the muscles.
Any ime of these conditions may cause unequal ten-
sion of the walls. This theory I proposed some years
ago. The pain may originate either from disease of
the heart or great vessels, or from a remote locality.
But how are we to explain on the ground of the
unequal tension theory the fact that coronary disease
is an important factor in the causation of angina?
The answer is that coronary disease may be a cause
of degeneration of the heart because it diminishes
the supply of blood, the result being that weak spots
are developed in the cardiac walls in areas where the
nourishment is imperfect. Again, fibrosis eventually
takes the place of infarcts. The heart muscle cannot
therefore contract evenly, and the uneven contraction
causes the pain. Charcot held the view that it was
due to local spasm, similar to the local spasms of the
intestine in influenza, the fibrillary contractions of
facial muscles in cerebral disease, or the spasm of the
muscles of the extremity in the "intermittent claudi-
cation" of Bouley, the veterinarian, who first saw it in
horses. After a number of these attacks, there is left
in the cord a susceptible area, which is prone to
originate successive attacks.
Among the lesions that have been described, it is
noticeable that coronary diseases have a rather
large place, while atheroma of the large vessels,
aortic endocarditis, pericarditis, and myocardial
disease have been subordinated. However, there has
been a tendency of late to look upon the myocardium
as the chief tissue implicated. High pressure is re-
garded as one of the determining causes of an attack,
but it may be the result as well. In the later stage- of
an attack, a normal or subnormal pressure i
occur. The exciting causes may be disturbance of
the function of any organ or system. I have known in
a single instance that one at tack was excited by conges-
tion of the kidneys, a second by obstinate constipation,
and a third by overloading of the stomach with in-
digestible food. Unusual muscular activity may also
be a cause, while in the false variety emotional causes.
a sudden impression on the sensitory nerves, walking
in the face of a sharp wind, or toxic causes such as the
use of tobacco, tea, or coffee, may bring on an attack.
While the incitement to an attack of angina vera may
be from the heart itself, as in a sudden attack of
cardiac embolism, or from without, usually from an
abdominal organ; in the false form the seizure origi-
nates from a point without the heart.
True angina is more frequent in males. Pye-
Smith found the proportion seven to one; Huchard
about five to one. On the other hand, the pseudo
cases are much more common in women. Huchard
found the proportion three to one in favor of women,
and the proportion is undoubtedly much higher in
this country. True angina rarely occurs before forty
years of age: in Forbes' eighty r -four cases, seventy-
two were over fifty, or eighty-six per cent.
Symptoms. — In an attack of true angina, the pain
is referred to the sternum about its middle. From
this point it may radiate to the left shoulder and arm,
to the right, or, occasionally, down both shoulders
and arms.
In a well-marked case the face will be pallid, and the
forehead covered with sweat, while the rate of respira-
tion, in uncomplicated case-, may either be incrr
or remain unchanged. This condition of the respira-
tion contrasts sharply with the increased rate of the
cardiac asthma in valvular and myocardial disease.
Toward the end of an attack, or after successive
attacks, a somewhat increased rate of respiration may
be expected. If the patient gets relief promptly,
the respiration should fall to the normal. Inasmuch,
however, as the increased action of the weak heart
is likely to produce more or less stagnation of blood
in the pulmonary cavities, there will be in such a
case a proportionate increase in the respiratory rate.
While the heart's rate may be increased or unaffecti d,
in mild cases it is apt not to be changed. _ There is,
how-ever, usually some degree of arrhythmia. Blood
pressure is usually increased, and Mackenzie reports
that he has found it as high as 200. As the attack
passes off, there is a sense of weakness proportionate
to the severity of the seizure. During the attack
there may be great belching of wind, while the urine
voided is apt to be of a very low specific gravity.
In a case where the neurotic element is well marked,
these two latter signs may be pronounced.
The pain is a distinctive feature of true at
It is the pain of an intense neuralgia, so excruciating
that tin- patient feels that he must keep absolutely
still until it has passed. In my experience the
" sense of impending death" has not been a prominent
feature, but on several occasions the patients have
expressed themselves as feeling that the chest was
lieing compressed, as if in a vise. In one instance the
426
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Angina Pectoris
patient said she felt as if ":i house wen- resting mi her
chest." But then' are degrees in the amount of pain
felt. Tin' attack is visually brief c especially
after the first attack, for then the patient's experience
ha< taught him or her how to manage the seizure.
But while it is usually of only a few 9 mis' or
minutes' duration, it may last several hours, and in
One of my eases an intense angina continued for
eral days. This constituted what is called the
*is anginosus.
The immediate cause of an attack may vary, as
has already I n mentioned. In one of my pseudo
sit was produced by sexual intercourse, in a not her
by the smell of fresh paint, and in a third by pro-
longed conversation. A common cause is undue
hurry, or walking in the face of a sharp wind.
Death in true angina has been ascribed to defective
tabolism. This may be a contributing cause, for
if the disease is associated with uremia the muscular
e "f the organ may be paralyzed by the toxemia.
\\ e may safely assume t hat actually death is due to the
disease of the heart walls resulting from exhaustion or
defective innervation. The heart comes to a standstill
simply because it is worn out.
Diagnosis. — All of the circumstances of a case must
be carefully considered in making a differential diag-
nosis, and it will not always be easy, because the
nature and gravity of the underlying disease may
not at first be readily determined. If in the male
sex, after fifty years of age, and in association with
general arteriosclerosis and some form of heart dis-
ease, particularly of the aortic valve, or pronounced
evidences of the lithemic diathesis, the diagnosis of
true angina may be made with a considerable degree
of confidence. On the other hand, in young people,
especially women, and those of neurotic history and
lowered vitality, in the absence of arteriosclerosis or
any form of heart disease, the diagnosis of pseudo-
angina may be made with an equal degree of confi-
dence. Then, too, in the false angina from poisoning
by tobacco, tea, or coffee there is a history of indul-
gence in these luxuries, with their associated cardiac
and neurotic symptoms that cease when the cause is
removed. As regards the differential diagnosis from
cardiac asthma, in the latter there is actual dyspnea,
while in uncomplicated cases of pseudoangina there
is never any actual dyspnea, for the patient can
draw a long breath if he makes the attempt. In
cardiac asthma there is engorgement of internal
organs, and externally there are physical signs of
venous congestion.
Treatment. — Nitroglycerin, given by the mouth
in doses of at least T J to^j grain, is indicated.
I do not hesitate to give Jj every two minutes for
ten minutes to abort an attack. If the patient can
swallow, the desired effect is produced more quickly
by oral administration than by hypodermics. A
few drops of the nitrite of amyl given on a handker-
chief may relieve mild attacks, and the delicate glass
capsules containing three or five minims of the drug,
which can be crushed in the handkerchief, are con-
venient for administering it. But the nitrite of
amyl alone is not always effective. I give it inter-
nally also, as in the following prescription:
. Glonoin grain 1J3
Amyl nitrite grain i
Menthol grain 53
Oleoresin of capsicum grain iha
Place in air-tight gelatin capsules.
S. One at a dose.
When properly made, these capsules are effective
in mild attacks. Unfortunately the ingredients are
not -table.
In cases where these remedies are not at hand,
morphine should be used, followed up, without wait-
ing for its action, by inhalation of chloroform or
ether. The patient may pour a few teaspoonfuls
of ether into a, saucer and inhale the fumes. Bal-
four's plan i- to put a sponge "il.ed m chloroform in-
to a. wide-mouthed bottle, and allow the patient to
inhale the fumes until relief is obtained. Heat ap-
plied to the chest by a hot-water bottle or bag, replaced
by mustard leaves or poultices, will often give
relief.
If there is any sign of heart failure, brandy, whiskey,
or ammonium carbonate is indicated, the latter being
almost universally applicable. Digitalis] too low in
its action to be useful during an attack, but is valu-
able afterward. The aromatic spirit of am nia is
often of great assistance, and also promotes the expul-
sion of gas. After the paroxysm has passed, aconite
will be found useful, in two minim doses, t.i.d., to
regulate the pulse. In rass where there' is arterio-
sclerosis, arsenic should be kept up for a while, and
then replaced by potassium, sodium, or strontium
iodide in doses of from five to ten grains, or even
more. In rheumatic or gouty cases, a prolonged
use of the iodides gives good results.
In the pseudo cases Hoffman's anodyne is indicated,
the valerianate of ammonium, the monobromate of
camphor in one or two grain doses, or asafetida in
doses of from three to ten grains. I sometimes give a
thirty grain powder containing equal parts of the
ammonium, potassium, and sodium bromides. Some
prefer the nitrites. They are used extensively in
England and France. The nitrite of sodium is
preferred, and the dose is from one to three grains,
given cautiously. In one of my cases I gave entire
relief by the use of the continuous current.
In true angina, as soon as the paroxysm has been
relieved the treatment should be that of heart failure,
or, in other words, enfeeblement of cardiac action
due to the strain on an exhausted heart. Nothing
equals the use of digitalin and strophanthin, which
should be given together with glonoin in doses of
one one-hundredth grain each, at first administered
every four hours, and later after the pulse has fallen
below the hundred mark, three times a day. This
trea tmentmay be kept up for weeks or months without
discomfort to the patient, provided the amounts of
the several drugs are increased or decreased according
to indications. Nothing but the very best makes of
digitalin and strophanthin should be used. The
tinctures and fluid extracts of digitalis and strophan-
tus should not be used.
Owing to the inflation of the stomach in these seiz-
ures, it may be desirable to pass the esophageal tube.
This has been practised successfully by Verdon in
several cases. It is called gastric deflation. In such
instances a sudden attack of vomiting may bring the
seizure to a close. Where an attack is associated
with constipation, an active cathartic will accom-
plish the same result.
Protracted rest in bed after a severe attack may
materially aid in warding off another seizure. Car-
bonated baths and resistant exercises are also effective.
The diet should at the same time be carefully regulated.
If uremia has superinduced the attack, a course
of milk diet, in which the patient may take as much as
two quarts per day, may relieve the uremia and
restore the patient to comparatively good health.
One must guard, however, against overloading the
stomach with milk, and remember that many persons
cannot digest much milk. Usually sufficient lime
water should be added to prevent curdling.
Coronary disease of itself is quite compatible with
a long life, so that we must look beyond it for the
cause of angina. And the evidence is increasing day
by day that it is disease of the myocardium that
determines angina vera. A single attack, as in
embolism or thrombosis of the coronary arteries, may
cause death. Also, if, after the age of fifty, anginal
seizures become more and more frequent in persons
with arteriosclerosis, fatty heart, disease of the great
427
Angina Pectoris
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
vessels, such as aortic aneurysm, advanced lithemia,
or uremia, the prognosis cannot be other than grave,
and the danger will be increased if there is a neurotic
element superadded to these conditions. But even
in these cases the expectation of life will be improved
provided the patient can avoid cold weather and
excitement, commits no excesses of any kind, and
lues a methodical life, free from hurry and -worry.
For any one of these exciting causes may bring on an
attack which may lead rapidly to a fatal issue. The
violence of the attacks is not always a measure of the
gravity of the disease. On the other hand, in pseudo-
angina, which is not only very frequent, but at one
time or another affects most of us in the course of a
long life, the prognosis is not grave. Under this
head I classify the reflex vasomotor angina of Landois,
which is associated with visceral and peripheral dis-
turbances without any gross heart lesions, and also
the so-called angina sine dolore, where the sensation
is constriction rather than pain. These cases are in
the class with hysterical seizures, hyperesthetic areas,
and peripheral neuralgias. All we have to do in these
instances is to control the neurotic symptoms, and
we control the angina. There is seldom much diffi-
culty in accomplishing this result by the use of such
remedies as have already been enumerated.
Thomas E. Sattekthwaite.
Angina Vincenti. — Synonyms: Plaut-Vince nt
angina, ulcerative angina and stomatitis, ulcero-
membranous angina and stomatitis, angina diphthe-
roides, angina exudativa ulcerosa, angina chanci-
forme, pharyngitis ulcerosa, pseudomembranous an-
gina, "spiroehatenbacillen Angina," gangrenous ton-
sillitis, "ulcerative sore-throat," "septic" and "pu-
trid sore-throat".
This is a peculiar form of tonsillitis or stomatitis
in which pseudomembranes are formed upon the
affected mucous surface, usually, but not always,
with the production of a characteristic ulcer, and
containing in the exudate the so-called fusiform
bacillus of Plant and Vincent, usually in association
with long spirilla. Vincent's name is not properly
applied to this condition, as it had been previously
described by a number of French and Russian observ-
ers (Bartliez and Sanne, Simonowsky, Nevejin,
Moure, and Mendel), and the association of fusiform
bacilli and spirilla in ulceromembranous angina had
been noted in 1893 by Rauchfus. In 1894 Plaut
described the organisms in five cases of ulcerative
angina as "Miller's spirochetal" and "Miller's bac-
illi," giving Miller the credit of having observed as
early as 1S83 the association with spirochetes of a
bacillus longer than the diphtheria bacillus and pointed
at the ends. He states that .Miller had found these
on the edge of inflamed gums, and in an abscess of the
finger-tip caused by a laceration by artificial teeth,
and also in an abscess of the submaxillary gland.
In 1896 Vincent described fusiform bacilli and
spirilla in cases of hospital gangrene, stating that,
similar organisms could be found in ulcerative angi-
nas. Bernheim in 1897 reported thirty cases of
stomatitis and angina in all of which fusiform bacilli
and spirilla were present; and he is apparently the
first to show the etiological identity of certain forms
of angina and stomatitis. In the next year Vincent
reported observations of fourteen cases of ulcero-
membranous angina characterized by the presence of
the same fusiform bacilli and spirilla; and it is due
to tins accurate and complete study that his name
has become associated with this form of angina and
with the fusiform bacillus, which is also known as
"Bernheim's bacillus" and the "Plaut- Vincent bac-
illus," ''bacillus fusiformis," " bacillus hastilis," "spin-
dle-shaped bacillus," etc.
Observations upon these organisms and their
association with ulceromembranous angina and va-
rious morbid conditions have accumulated rapidly
in recent years in German, French, American, and
English literature, thus showing their widespread
and frequent occurrence. They have been found in
hospital gangrene (Vincent, Matzenauer, et al.), in
noma (Matzenauer, Seiffert, Perthes, Rosenbergcr,
and many others), in fetid abscesses about the mouth
(Veszpremi, Silberschmidt, and others'), in fetid sub-
pectoral abscess, fetid pleurisy, mastoiditis, laryngitis,
bronchitis, bronchiectasis, abscesses of liver, lungs,
and spleen, phlegmon, cerebral abscess, appendicitis,
gangrenous ulcers of the penis, in syphilitic lesions
of mouth and throat, in nasal discharges, and in the
intestinal contents of a dog affected with dysentery.
In the great majority of these conditions the two organ-
isms are found together, but in some instances the
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Fig. 239. — Fusiform Bacilli and Spirilla in a Throat Smear fn.m
■a Case of Vincent's Angina. (From a Text-Book of Bacteriol
by Hiss and Zinsser; D. Appleton and Company, New York.)
bacilli alone are present. Other bacteria, particularly
cocci, are usually present also; although in some
cases the bacillus alone, or in connection with the
spirillum occurs in pure culture. Both organisms
also are found in the mouth of healthy individuals,
while similar spirilla without the associated bacilli
have been found upon the normal genitalia and in
the vaginal secretion. The presence of the organ-
isms in all of the conditions named has usually 1 een
determined by the microscopic examination of smears,
and occasionally of stained sections of tissues, i.f-
forts at cultivation have usually failed, but both
organisms have been grown in mixed cultures, and
the fusiform bacillus in pure culture by a number
of observers (Angelici, Gross, Niclot and Marotte,
Seitz, Silberschmidt, Veszpremi, Seiffert, Perthes,
Pruning, Netter, Veillon and Zuber, Ellermann,
and Weaver and Tunnicliff).
428
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
\n:-iii.i Vincent!
Character of the Organisms.— As obtained in
smear-preparations the reported descriptions of the
bacilli and spirilla correspond very closely. The
bacilli appear as long slender rods, pointed at the
ends and somewhat larger in the middle. They
vary greatly, sometimes the rods are thick with
uled i- m"ls, sometimes they are slightly bent or
may be S-shaped. They are six to twelve microns
long, but longer thread-like forms are occasionally
seen. They occur frequently in end-to-end pairs,
often forming re or less obtuse angles, but may be
nged in rows, or in clumps, or in radial ins groups.
Observers differ as to their inutility, the majority
describing them as no! motile. Graupner described
peritrichous flagella, and found that motility was
quickly lost. According to Ellerman the .short
curved forms are motile spirilla.
I he bacilli stain well with carbolfuchsin, Loeffler's
methylene blue, anilin-water gentian violet, and
polychrome methylene blue, but do not stain with
Gram's, although some writers state that prolonged
action of alcohol is necessary for complete decolori-
zation. Babes-Ernst granules are not present,
and there is no staining with Lugol's. Spores have
nut been demonstrated, although light-staining
as ("vacuoles") have been described. Pure cul-
tures of the bacillus have been obtained by Ellerman
(1904) and Weaver and Tunnicliff (1905), as a non-
motile, obligate anaerobe, growing best at 30°, but
nut at room temperature. Horse-serum agar, ascites
agar, dextrose-free broth, plain agar, ascites broth,
horse-serum give growths of the bacillus. The
cultures may have an offensive odor, but no gas is
formed.
The spirilla are long and delicate with three, six,
or eight turns. They stain lightly and uniformly,
and are quickly decolorized by Gram's method.
They are usually motile, but. may quickly lose their
motility, especially when exposed to cold. They
have been grown only in mixed cultures. Weaver
and Tunnicliff used human pleuritic exudate and
broth, and broth containing muscle-sugar. The
growth was always slight, and was not influenced
by the exclusion of oxygen.
Veillon and Zuber, and Ellermann also, with inocu-
lations of pure cultures of Bacillus J'usijorntis caused
small abscesses in rabbits and guinea-pigs. Weaver
and Tunnicliff produced abscesses in guinea-pigs by
intramuscular injection of mixed cultures.
Mixed cultures containing a growth of fusiform
bacilli and spirilla with cocci also produced abscesses
in guinea-pigs. Similar results were obtained with
bacilli and cocci without the spirilla.
Relation of the Organisms. — The majority of writers
believe the fusiform bacilli and spirilla to be different
varieties of bacteria acting in symbiosis, the virulence
of the bacilli being increased by the presence of the
spirilla. Numerous observers have noted that the
cases of angina in which the bacilli alone are found
are of a milder type than those in which both are
present. In cases of deep destruction of tissues the
spirilla are always present. Some writers (Seiffert,
Perthes, Sobel and Herrman, and Krahn) believe
that bacillus and spirillum are developmental stages
of one organism, but there is no positive proof of this.
Only a few writers (Bliihdorn) are inclined to regard
the spirillum as the etiological agent, basing this
view upon Rumpel's and Gerber's successful treat-
ment of the angina with salvarsan, this being taken
as evidence of the spirochetal nature of the infection.
That the fusiform bacillus is the essential etiological
agent in the conditions in which it is found remains
yet to be positively demonstrated. The strongest
evidence in favor of it is the demonstration in the
tissues from cases of noma and ulceromembranous
angina of filamentous organisms that resemble the
cultural forms of the fusiform bacillus. Ellermann
has demonstrated the presence of both fusiform
bacilli and spirilla in the zone separating necrotic
and living tissues in a case of gangrenous stomatitis.
He also found the fusiform bacilli alone in the tissues
ui the uvula from a case of ulceromembranous angina.
The must recent writers regard the organisms as
saprophytes under ordinary conditions, but like
the colon bacillus, becoming primarily or .secondarily
pathogenic under certain conditions.
Predisposing Causes. — Although the infection
with the fusiform bacillus may occur in apparently
normal individuals, the majority of observers agree
thai certain predisposing factors are usually present.
Tobacco, defective teeth, tartar, inflamed gums, oral
uncleanliness, alveolar abscesses, scurvy, syphilis,
mercurial stomatitis, trauma of the inucuus mem-
branes following tonsillotomy and other operations
in the mouth, and primary infections with other
organisms are regarded as predisposing factors.
The condition is often associated with or follows
the acute infectious diseases (scarlet fever, dipht heria,
measles, and whooping cough). An epidemic of
Vincent's angina, may follow one of diphtheria, espe-
cially in institutions and hospitals, and under such
conditions the bacillary angina is likely to run a more
severe and malignant course.
Contagion*. — Vincent's angina is regarded as
directly ami indirectly contagious within rather narrow
limits. The affection often involves definite, groups
of students living in close association. A similar
group-infection of nurses and hospital attendants has
been observed. Institutional epidemics occur. The
infection may be spread by the use of common eating
and drinking utensils, towels, dental instruments, etc.
Buhlig calls attention to the possibility of transmis-
sion through the purse-string tobacco bag, the strings
of which are often drawn tightly with the teeth.
As a rule close contact is necessary for the spread
of the infection.
Occurrence. — The report of cases from all parts
of the world show the wide distribution of the infec-
tion. While many observers regard the angina as
rare, it certainly is not an infrequent condition, and
the most recent writings upon this subject regard it
as of frequent occurrence. Rodella found the fusi-
form bacillus in one-third of 2,000 cases of pseudo-
membranous angina. Holm in 20.) cases of suspected
diphtheria examined in 1908 at the laboratory of the
Michigan State Board of Health found the fusiform
bacillus present in seventy-three cases (thirty-three
males, forty females). Of the seventy-three cases
twenty-eight had been diagnosed as diphtheria clinic-
ally but the diphtheria bacillus was found in only
one of the twenty-eight. In over three-fourths of
the cases of pseudodiphtheria the fusiform bacillus
and spirilla were found, usually in association with
staphylococci and streptococci, as shown by culti-
vation. Smears from these cases showed the bacillus
fusiformis as the most prominent organism. Bliih-
dorn examined the throats of 222 patients for fusi-
form bacilli and spirilla, and found one or both organ-
isms present in all but twenty-seven out of seventy-
six cases of diphtheria, in eleven cases out of forty-
two of scarlatina, in thirteen out of twenty-six eases
of staphylococcus or streptococcus sore throat, in
two out of four cases of ulcerative si atitis, in
twenty-one out of thirty-one cases of syphilitic sore
mouth or throat, and in all but eighteen of forty
healthy persons. In healthy persons the organism
is found close to the teeth, and it is probable that it is
responsible for certain ulcerative conditions of the
gums. Other writers confirm the frequent occurrence
of the organism. As to the angina males and females
are equally affected, although some writers give a
preponderance of cases in the male. It is common
in children and young adults, but also frequent in
middle life and in old people. It occurs more often
in the spring than in the autumn.
429
Anelna Vincent!
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Pathology. — The local lesions vary from a slight
exudative inflammation to an ulceromembranous, or
even gangrenous process. One tonsil, more frequently
the right (Koplik), is first involved, but after a few
days the process may spread to the other. Many
cases are unilateral. A gray, grayish, yellow, gray-
ish-yellow, greenish-yellow, creamy, or dirty brown
membrane appears upon the affected tonsil, varying
in size from a lentil to that of the entire tonsil. Be-
neath the membrane is formed the ulcer; from the
first the base of the ulcer appears as if covered with
membrane. The ulcer is rather chancroidal in type.
with worm-eaten base and sharp overhanging edges
which may be slightly elevated above the surface of
the tonsil. Depth of ulcer varies greatly, from one-
eighth to one-half inch or more. On removal of the
membrane the ulcer bleeds freely and a new mem-
brane may be formed. In the majority of cases the
membrane does not spread, as in diphtheria; but in
some cases it may spread rapidly and involve uvula,
palate, gums, pharynx, larynx, or trachea. Sloughing
of the uvula and soft plalate may occur. More rarely
the ulcer is very destructive, the process becoming
gangrenous or noma-like in character. The entire
tonsil may be destroyed, and the necrosis may extend
to healthy tissues. An ulcerative stomatitis is often
present, and ulcers may occur in the tongue, cheeks,
and gums. As a rule the ulcer heals slowly, and not
infrequently becomes subchronic or chronic in char-
acter. The submaxillary glands are often enlarged,
as are the lymph-nodes at the angle of the jaw.
Suppuration of these nodes is uncommon.
Complications and sequeke in the form of middle-
ear disease, mastoiditis, meningitis, cerebral abscess,
bronchitis, pneumonia, edema of the glottis, pleuritis,
empyema, pericarditis, arthritis, etc., may occur, but
are relatively rare. In all of these conditions the
pus has usually a characteristic stinking odor, similar
to that produced in mixed cultures of the fusiform
bacillus.
Microscopically the ulceromembranous lesions show
the picture of a necrotic inflammation. Fusiform
bacilli and spirilla are found in the zone between the
necrotic and living tissue.
Symptoms. — The symptoms var}"- greatly, just as
the local lesions differ in severity and extent. Many
cases are very mild, others very severe. The infec-
tion may occur without any symptoms. There are
no characteristic prodromal symptoms. A feeling
of dryness or discomfort in the mouth, followed by
dysphagia and lassitude, restlessness, insomnia, loss of
appetite, headache, coated tongue, constipation or
occasionally diarrhea, vomiting, pain in the stomach,
epistaxis, chills, and fever gradually develop
during one to five days, when the local condition is
discovered. The fever is usually slight, rarely higher
than 103°. A marked fetor of the breath is often
present, especially when there is an accompanying
stomatitis. Some cases show a pallor of a distinctly
septic type. The average case gives only the ordinary
history of sore throat with ulceration.
The cases with stomatitis may show bleeding from
the gums, and the teeth may become loose. Earache
and nasal discharge are not infrequent. In the severe
eases the symptoms may be very violent; there is
great pain and difficulty in talking and swallowing,
the breath is very fetid, the cervical lymph-nodes are
enlarged and tender, there may be marked gastro-
enteritis, high fever, and extreme prostration. The
picture of noma may develop, or the symptoms re-
semble closely those of a malignant diphtheria. In
these cases albuminuria is common; purpuric and
polymorphous eruptions, and tender edematous
patches may appear in the skin. Appendicitis,
empyema, pseudorheumatism, arthritis, gastroen-
teritis, endocarditis, pneumonia, or peritonitis may
develop as a complication in the severe cases.
430
Some writers attempt to recognize several forms of
Vincent's angina. As the differences are wholly
those of extent and degree, it seems inadvisable to
class these varieties as distinct types. Every pos-
sible stage exists between them. The ulcerative
stage is only the later stage of the membranous.
While the constitutional symptoms may be slight or
absent, the local condition may be more marked
than in diphtheria. The more severe cases are likely
to occur in weakly children following other acute
infections.
A subacute or chronic course of the infection is not
infrequent. Such cases may run three weeks to
three months or longer without healing of the lesions.
These cases are especially dangerous in transmitting
infection to others.
Prognosis. — Usually good. The complications
of the severe form are relatively infrequent, but ex-
tension to the larynx and trachea is very dangerous.
Noma and other of the serious complications may
result fatally. The occurrence of chronic cases must
be borne in mind, however, so that a time-limit for
the disease cannot always be safely made.
Diagnosis. — The only positive test is that of the
culture tube. Smears from the base of the ulcer
will reveal the presence of the fusiform bacillus
either alone or in association with the spirilla or other
organisms. Cultivation is necessary to exclude
diphtheria and other infections. Many cases of
suspected diphtheria are undoubtedly cases of Vin-
cent's angina; but before assuming that any ulcero-
membranous process of the tonsils or mouth is
Vincent's angina, diphtheria must be excluded by
cultivation, as the clinical picture and stained prep-
arations are in themselves not conclusive. Chan-
croid and syphilis must also be excluded by the
history, other symptoms, Wassermann's reaction,
demonstration of Spirochete pallida and chancroid
organism.
Treatment. — Local applications of tincture of
iodine or methylene-blue powder have been used
with good results. The base of the ulcer may be
touched with Lugol's solution, or a ten per cent,
solution of silver nitrate. A thirty-grain solution
to one ounce of zinc sulphate is also recommended.
Weaver and Tunnicliff advise the use of hydrogen
peroxide. Mouth washes, such as Seder's solution
and potassium chlorate, are also used. Orthoform
in powder or tablet form is advised for relief from the
pain. Rumpel and Gerber obtained prompt healing
of the ulcer after the administration of salvarsan
with no other treatment and in cases where syphilis
was excluded. Yates used North's lactic acid' prep-
aration in a chronic case of mastoiditis due to the
fusiform bacillus and obtained prompt healing with
disappearance of the organisms. Internal medica-
tion is regarded by most writers as unnecessary,
although some advise the administration to children
of the tincture of chloride of iron in doses of three to
five minims, combined with glycerin ami water, every
three hours. Complications should receive appro-
priate treatment as they arise. A. S. Warthin.
Angioblast. — (From the Greek aj-fetov, a vessel,
and /iXacrris, a sprout.) The word A ngioblast was
proposed by His in 1900 to designate the embryonic
l issue that gives rise to the blood-vessels and the
blood. For a discussion of the origin and fate of this
tissue see article Blocrd-vascular system, origin of.
It. P. B.
Angiokeratoma. — Synonyms: Kerato-angioma : Tel-
angiectatic Wart; Mibelli's Disease.
Definition. — An unusual chronic skin disease,
chiefly met with on the hands and feet of those sub-
REFERENCE HANDBOOK OF THE MEDICAL SCI] \<
Angiokeratoma
jecl to chilblains. II consists of
single and grouped papular and
nodular lesions of a reddish or
purplish color, made up of epi-
dermic hypertrophy covering dila-
tation 01 ill" capillary vessels in
the papilla?.
History. Mibelli ga\ e the first
anatomical description of I In- con-
dition met with in the affection
proposed the name "angio-
keratoma" for the disease. The
lesions n hich formed i he basis of
his observations occurred on the
il hi face of the fingers of a
year-old girl, and had
existed for several years. They
preceded by chilblains.
Before Mibelli's careful investi-
gations, cases of the same affection
hail been noted by other writers
under various names; the true
nature of the lesions had not,
however, been determined.
We are indebted to Pringle for
a most accurate and painstaking
description of the clinical appear-
and morbid anatomy of the
affection, as well as for an analysis
of most of the cases which had
been met with up to the time of
his publication.
Pringle reported two cases affect-
ing girls with chilblains, and his
histological findings agree in all
essential points with those of
iMibclli. Since the publication of
these cases a number of others
have been reported, among them
Zeisler's, which presented, in ad-
d^ 10 " 2J?.'T Se °? 0n throu e h Sm all Blood Cavity Completely Enclosed by Hypertrophied
Kete. thickened epithelium at right of section. Spencer, one inch; ocular, one and onc-
iiuarter inches.
dition to characteristic lesions on
the hands and feet, nevus-like
patches and pedunculated vascu-
lar tumors on the forearms, over
the patellae, the legs, thighs, and
auricles.
In the case reported by myself,
the skin of the scrotum was the
seat of a number of small, spheri-
cal-shaped, dark purple tumors.
They were arranged in a linear
manner as if following the super-
ficial vascular supply of the parts.
The small growths, from the size
of a pin's head to several times
that size, were distinctly elevated
above the surface of the scrotum,
seeming to rest on it rather than
to be embedded in the skin. Some
of them were covered by a slightly
thickened horny layer under which
minute dark red points could be
seen, giving the tumors a wart-
like appearance. In this patient
the hands and feet were not in-
volved, and the usual etiological
factor, chilblains, could not, of
course, be invoked to explain the
development of the lesions. I
have also, through the kindness
of Dr. Leviseur, seen a similar
case in which the small tumors
were seated on the vulva of a
young girl. The diagnosis, in this
case, was confirmed by the micro-
scope.
Anderson has reported a case in
which the eruption began over the
431
w " 41 ' — LarEe Tumor Showing Cavernous Spaces Divided by Fibrous Septa. Organized
blood clots on the left of section. Spencer, one inch ; ocular, one and one-quarter inches.
Angiokeratoma
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
knees at the age of eleven years, gradually spreading
to the trunk and upper extremities, and finally involv-
ing almost the entire surface of the body with the
exception of the hands and feet.
Symptomatology. — A history of recurring attacks
of chilblains precedes the development of the affec-
tion on the hands and feet. After a variable time,
usually reckoned by years, minute telangiectases
appear over the dorsal surfaces of the phalanges of
the fingers and toes, which eventually cannot be
made to disappear by pressure. The points of vas-
cular dilatation become grouped, and over them the
epidermis undergoes thickening, giving rise to hemis-
pherical lesions from the size of a pin's head to that
Fig. 242. — Cavernous Space Filled with Blood Corpuscles and Divided by Fibrous Septa.
Hypertrophy of stratum comeum and rete Malpighii. Spencer, one-half inch; projection
ocular, 2 Zeiss.
of a spilt pea, or larger, having a rough warty surface
and a dark purple or lead color.
The minute vascular points beneath the thickened
epithelium can be detected by making pressure on
the growths.
In some cases lesions in all stages of development
from minute pink points to the commingled warty
growths can be detected. The palms and soles may
be involved. On parts of the body where the stra-
tum corneum is thinner than on the hands and feet
its hypertrophy is less marked than in the latter
localities and may not be perceptibly thickened. It
is usually bilateral, though not strictly symmetrical.
The affection may persist indefinitely, become sta-
tionary, or disappear.
Patohology and Morbid Anatomy. — The primary
change is undoubtedly in the capillary vessels of the
papillae, which, subjected to repeated congestions,
become permanently dilated, leading to the for-
mation of cavernous spaces, and by pressure alter
the normal conformation of the parts. On the
hands and feet the stratum corneum covering the
lesions is greatly thickened; this change is not so
pronounced, however, when the affection is met with
in other regions. The characteristic pathological
changes are shown in the accompanying photomi-
crographs made from sections of tumors removed
from the scrotum.
In Fig. 240 a small cavity filled with red and
white blood corpuscles is shown completely surrounded
by the hypertrophied rete layer.
On the right of Fig. 241 a large cavernous space
is seen to be filled with blood corpuscles, which have
by pressure caused a marked atrophy of the epidermis.
On the left of this section the circulation has been
obliterated, as the lacuna? are occupied by concen-
tric layers of fibrin containing blood corpuscles and
pigment.
Fig. 242 represents a more en-
larged view of the cavernous
spaces with their divided septa.
The stratum corneum is also
shown to be considerably thick-
ened.
An examination of the sections
shows that the lesions consist of
lacunar spaces filled with blood
occupying the papillary portion
of the derma, some of which are
enclosed in the rete Malpighii.
These cavernous spaces are evi-
dently the essential feature of the
disease and the primary patholog-
ical condition.
Etiology. — The disease, when it
occurs on the hands and feet, as
it most frequently does, is an
affection of early life, and caused
by repeated attacks of chilblains
Some cases have been associated
with tuberculous affections of the
lungs, glands, and other regions.
An attempt has been made by
Leredde to show that it is caused
by the toxins of the tubercle
bacilli. It is hardly to be hoped
that the von Pirquet reaction will
decide this point.
Scheuer, one of the most recent
systematic writers on this affec-
tion (1909), like many of his pre-
decessors, regards it as due to an
initial congenital weakness of the
capillaries aggravated in most
cases by frost-bite. The subse-
quent thickening of the epidermis
is conservative as it protects the
fragile vessels and thereby pre-
vents hemorrhages.
In my case, in which the skin of the scrotum was
affected, the tendency to dilatation of the blood-
vessels as manifested by a double varicocele, and the
degenerative state of the vessels and surrounding
connective tissue incident to old age, 'were probably
the most potent causes in bringing about the
condition.
Diagnosis. — A well-developed case of the disease
could hardly be mistaken for any other affection.
The color of the lesion and the presence of the vas-
cular points should differentiate it from tuberculous
or ordinary warts.
Treatment. — The tumors may be removed bj
excision or by (he application of the Paquelin or
galvanocautery. with the production of slight scarring.
Less deformity results from electrolysis.
John A. Fohdtce.
Literature.
Mibelli: Giornale Italiano delle Mai. Ven. e della Pellc. fasc iii .
September, 1SS9. Internat. Atlas of Rare Skin Diseases, No. ii.,
1889.
Dubreuilh: Ann. de la polyclinique de Bordeaux, tomei., fascio
i., January, 1S89, p. 50.
432
REFERENCE HANDBOOK 01 THE MEDICAL SCIENCES
Angioma
Pringle: British Journal of Dermatology, vol. iii., 1891, p, 237,
Zeislor: Trans. American Dermatol. Association, 9even
I Motting, I s ' 1 ;
Fordyce: Journ. Cutan. and Genito-Urin. Dis., vol. \i\.. LS96,
p. 81
Vndorson: British Journal ol Dermatology, vol x., 1898, p. 113.
\i.n. do Derm., 1S98, vol i\ . i> 10
Arch i Derm, u, Syph., L909, xoviii,, p. 251,
Angioma. — (iyytiov, a vessel.) The angioma, a
neoplasm representative of the connective-tissue or
histoid type of tumors, is a new growth composed
eal pari of blood-vessels or of lymph vessels.
on.- According to the character of the
sels entering into the structure of the tumor.
angiomata are classified into — 1. Hemangiomata;
_'. Lymphangiomata.
Hemangioma. — The hemangioma is a tumor the
atial structural components of which are newly
formed blood-vessels which are formed from the
preexisting ones by budding. The older \<
may also grow lengthwise, and become tortuous
and dilated.
Varieties. — Two varieties of hemangioma are rec
ognued, the distinction between them being ba
upon differences both in structure and in location.
These varieties are:
Hemangioma Simplex (nevus vasculosis; birth
mark; telangiectatic hemangioma). This form of
hemangioma comprises the small vascular nevi, and
most of the so-called mother's or birth marks, it
occurs in two forms: (1) As flat, round, or irregularly
outlined, usually sharply contoured, red or bluish-red
patches on a level with, or but very slightly elevated
above, the surface of the skin; in size, varying from
that of a flea-bite to that of the side of the face. The
skin over these patches is either smooth or thickem I.
and is sometimes covered with lanugo hairs. (2) As
telangiectatic warts, from pin-head to pea size, which
appear in the elderly. The blood found in them is
venous in quality. They do not really originate in
old age, but become conspicuous at this time. The
blood-vessels running to and from the wart suggest
the appearance of a spider — the "spider cancer" of
er quacks.
currence. — This variety of hemangioma is very
common; it is nearly always congenital. From
observations made by Depaul, it appears that one-
third of all the children born in the clinic of the Fac-
ulty of Medicine in Paris have such hemangiomata at
birth. The tumor is situated most frequently in
the skin of the face, neck, back, chest, abdomen,
sometimes of the extremities. More rarely it occurs
in mucous membranes, and beneath the serous sur-
s of the internal organs. It may be single or
multiple, and may attain a varying size.
Structure. — Histologically, the hemangioma simplex
consists of newly formed, much convoluted, more or
dilated capillaries lying in a stroma composed of
fibrous connective tissue or of fat tissue. This
stroma varies in amount, and may be infiltrated with
lymphoid cells, or contain pigmented connective-
tissue cells. The newly formed vessels often corre-
spond in distribution to the vascular districts of the
sweat-glands or the hair-follicles. The vessels com-
municate not at all or but slightly with the normal
blood-vessels.
Hi mangioma Cavernosum (cavernous tumor; erec-
tile tumor; cavernoma). — This form of hemangioma
isists of lobulated, sometimes fungoid tumors of
varyjng size, bluish in color, single or multiple, tending
diminish or disappear under pressure. Pressure
upon parts adjacent to the tumor causes it to swell by
venous congestion; other conditions, such as change
of position, weeping, sleep, digestion, the ingestion of
alcohol, and the like, may cause alteration in size,
owing to the erectile character of the growth.
Vol. I.— 2S
Occurrenci rhe ordinary M-its of this tumor are
the lips, check-, tongue, and muscles in general. In
exposed localities they cause much disfigurement.
A special form is cavernoma of the liver, The size
\ anea from that of a pea to t hat of a whole lobe of the
liver, The tumor i.s general!} single, sometimes
multiple. The liver of old i pie pn enl this form
of new growth in a great number of instances. Its
occurrence In this organ seems to vary in frequency in
different countries; according to the report of patholo-
gists, it is not so frequent in Norway and Swei
as it is in Germany. By the rupture of the vessels of
large cavernous hemangiomata through the capsule of
the liver, extensive hemorrhage has taken place int..
the peritoneal cavity, and fatal peritonitis has been
caused.
Fig. 243.-— Angioma Cavernosum Cutaneum Congenitum
Muller's fluid; hematoxylin.) a, Epidermis: b, coriumjc, cavernous
blood spaces. X20 diameters. (After Ziegler.)
This tumor also occurs, although less commonly
than in tin 1 liver, in the other abdominal organs, as,
for example, the spleen and the kidneys, and also in
the brain. It is found in the skin less frequently than
are the simple hemangiomata. Esmarch has re-
ported in Virchow's Archiv a very interesting case of
its occurrence in this position. A single tumor devel-
oped upon the middle finger of a girl eight years of age
was followed in subsequent years by t lie appearance of a
great many others. At the time of the first menstrua-
tion there was a great increase in both the number
and the size of the tumors. At each succeeding cat-
amenial period they seemed to grow more than at
any other time. In size they varied from that of a
pea to that of a hen's egg. They- were all successfully
extirpated, and in most cases were found to be situ-
ated on the wall of a vein, with which they were in
communication.
Structure. — The cavernous hemangioma upon sec-
tion presents an appearance quite similar to that
of the cut surface of the corpus cavernosum penis. It
is characterized by the presence of a firm, tough,
white meshwork, which in the recent state is empty
or contains some irregular blood clots. The meshes
frequently enclose small, round, calcareous masses
known as phleboliths. In some instances this cavern-
ous structure is sharply circumscribed and separated
from the surrounding structures by a firm capsule.
In others, where the tumor is small and to all appear-
ances in a state of rapid growth, it is surrounded by a
zone of h/mphoid cells. The consistence of the tu-
mor depends upon the amount of the fibrous connec-
tive-tissue meshwork, or stroma: when this is abun-
dant, the tumor is relatively hard, and when scanty,
soft and flaccid.
Microscopically-, the tumor presents trabecules of
fibrous connective tissue, in part newly formed, in
part belonging to the structure in which the tumor is
developed, of varying thickness, arranged in the form
of a meshwork. The cells of this tissue are numerous,
and it is usually infiltrated with lymphoid cells scat-
tered singly or localized in groups. The spaces of this
meshwork are lined with flat endothelial cells, and
contain blood. These spaces are of varying size, but
whatever their extent, they always represent capil-
laries, for they are interposed between an artery- and a
433
Angioma
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
vein. Adjacent large spaces may be separated by
exceedingly thin partitions. The connective-tissue
stroma in some cases has been ,found to contain
nerves, smooth muscle fibers, and elastic fibers.
Ribbert has shown abundantly by injection experi-
ments that the blood-vessels of the tumors do not
communicate with the general circulation in the great
majority of cases.
Etiology. — The cause of hemangiomata, in common
with that of most new growths, is not understood.
A large proportion of all tumors of this sort are con-
genital, and when they do develop after birth, it is
generally in the early years of life. It is seldom that
hemangiomata develop in adults, a fact which is
remarkable in view of the frequency of dilatation of
the blood-vessels in old age, and one which constitutes
Fig. 244. — Dilated Capillaries from a Telangiectatic Tumor of
the Brain, all the attached portions of tumor tissue having been
shaken off in water. X200. (After Ziegler.)
a strong objection to the theory that these tumors
arise from a simple dilatation of preexisting vessels.
Heredity seems to play some part in their occurrence;
numerous cases are recorded in which a child presented
one of these tumors in the same place on its body as
that in which one of the parents also had a birth
mark. Popular belief in all ages has associated the
presence of these growths in children with some influ-
ence exerted upon the mother during pregnancy;
maternal impressions cannot, however, be regarded
as definite factors in the development and growth of
offspring.
Different views have been held regarding the
genesis of the cavernous form of hemangioma and the
most distinguished pathologists have promulgated
positive views on the subject. The cavernoma of the
liver is well suited for study. Ribbert regards it as
the result of an error of development, an area of
embryonal liver tissue being involved with its imma-
ture cells, trabecules, and vessels. The vessels
develop at the expense of the other structures.
They become irregular and dilated. This, however,
does not explain the tumor formation, which develops
on the basis of the malformation and is brought about
by the appearance of buds in the walls of the sinuses.
These force their way between the liver cells in the
direction of the capillaries. In this way large tumors
are formed. A cavernoma then begins by dilatation
of embryonal vessels into sinuses and extends by the
continued formation of new vessels. In some cases
the growth undergoes a fibrous transformation, the
connective tissue increasing at the expense of the
blood-vessels.
Mmlc of Growth; Clinical Aspects. — The hemangio-
mata extend always by growth from within outward-
they show no tendency to infiltrate surrounding strut
tures; they do not cause metastases. Instances of
seeming exception to these conditions are probably
cases in which sarcoma with dilated blood-vessels
was mistaken for hemangioma. The pulsating tu-
mors of the long bones, whioti have been described
as cavernous tumors, are to be regarded as telangiei
tic sarcomata. The hemangioma is, therefore, si i
as its mode of growth is concerned, a benigti tumor
although the accidents incidental to its development
may cause death from hemorrhage or from intra-
cranial pressure. The growth of these tumors is
generally unaccompanied by pain; it is slow, ami
may be irregular. In some instances the tumor
constantly enlarges, in others it reaches a certain size
and then remains stationary. It sometimes under-
goes spontaneous cure by the ulceration of the overly-
ing skin, and the subsequent formation of cicatricial
tissue which includes the vessels and obliterates them
by contraction. When, as is sometimes the case. I !
tumor is connected with the skin by a pedicle, I lie
vessels in the pedicle may shrink, and the tumor
become desiccated and drop off. In yet other ca
a cure may be effected by thrombosis, and the con-
sequent deprivation of the tumor of its circulation.
Lymphangioma. — The lymphangioma is a tumor
composed of lymph vessels and lymph spaces in a
state of greater or iess degree of dilatation, lying within
a fibrous connective-tissue stroma. Strictly speaking,
the term lymphangioma is applicable to those lymph-
vessel tumors only in which the whole or the greater
part of the vessels is newly formed; but inasmuch be
in any single case it is often difficult to determine
how far the vessels are newly formed and how far
they are preexistent, dilated and thickened, it is con-
venient to include under the lymphangiomata certain
abnormal structures in which the essential patholog-
ical condition is lymphangiectasis. This form of new
growth occurs in a great variety of loci, and pre-
sents an external configuration determined very
largely by the organ or structure in which it is de-
veloped, as well as by its histological characteristics.
It is seen in warty tumors and diffuse thickenings of
the skin and mucous membranes, in macroglossia,
in certain congenital cysts, and in various other
conditions.
Fio. 245. — Section through the Margin of a Very Small
Cavernous Angioma of the Liver at a Time When This Mi
Was in Process of Active Growth. (Carmine preparation.)
X 150 diameters. (After Ziegler.)
These growths may be classified as follows:
Lymphangioma Simplex. — Asa true neoplasm this oc-
curs in the form of a circumscribed tumor, composed of
capillary and larger-sized lymph vessels. As lymph-
angiectasis, it is seen in the lymphatic varix, in dilata-
1 i< hi of the lymphatics resulting from obstruction,
in macroglossia and elephantiasis following erysipelas,
and in elephantiasis due to filaria. There are numer-
434
REFERENCE HANDBOOK OK THE MEDICAL SCIENCES
Lngloma Serplglnoguni
. dinical forma of lymphangiectasia, congenital
I acquired, bul Ribbert does not regard these as
angiomata, neither does he include here l\ inph-
. u ,„i atuberosum multiplex.a very rare skin di ea e.
lymphangioma Cysticum. — Some authors distin-
D betwei n cavernousand cysticforms, bul Ribberl
mllk , . oa b olute distinction for cystic and cavernous
tumors occur side by side. .
growths are practically isolated, their ve el
having little or no communication with the normal
lymphatics. \ true lymphangioma should shell out
,,,,, the surrounding tissues. The size may
thai of an apple or the list.
e is, however, a lymphangioma cayernosum
i i ricted sense « hich i urs as a diffuse
,: , embling in structure a hemangioma,
h ig congenital, and occurs in the lips, cheeks, and
tongue, causing an elephantiasis known respectively
tc'rocheilia, macroglossia, etc.
j
I -
.•9'n».'" , .--
!
Flo. 246.- Lymphangioma Hypertrophieum. Rounded summit
of :i rather large, .soft, smooth wart. (Formalin; hematoxylin;
Sharply limited nests of cells in the corium. X250
diameters. [After Ziegler.)
These lymphangiomata occur in various parts of the
body with especial preference for the axillae,
groins, mesentery, and intestinal wall. An atypical,
ill-defined form occurs in various localities about the
neck and is known as congenital cystic hygroma,
li may reach as high up as the ear, may extend down-
ward into the mediastinum or hang loose upon the
neck or shoulder.
The cystic lymphangioma of the neck is congenital;
it is probably not derived from hemangioma by the
obliteration of connections with blood-vessels and the
development of secondary communications with the
lymphatic system. The fact that the cystic spaces are
a with endothelium and not with epithelium is
evidence that these, tumors are not derived from
i- the salivary glands or the branchial clefts.
I'he tumor is situated upon the anterior or lateral
surfaces of the neck; rarely upon the back; it may
be unilateral or bilateral. Its size varies; it tends
to burrow and to extend under the cervical fascia
between the muscles of the neck. In this way it
may travel down the sheath of the subclavian vessels
to the axilla, or it may go into the mediastinum.
Sh'uctiirc and Nature. — Lymphangiectases, like
telangiectases, are not to be regarded as tumors.
Lymphangioma proper agrees in structure and
nature with hemangioma. That is, there i lii i m
ei i "i ni de\ 'In | 'Hi, which re nil in a new foi
i em ..i ves els and connective tissue, together with fat
and smooth muscle. In the simpli ' form there
new formation and dilatation 01 lymph vessels and
spaces. There is a tendency, however, to multiple
cyst formation, the cysts as a rule having communica-
tion with one another. \ sect! f such a growth
ihows a mass of cavernous tissue with cavities of
various size, including perhaps one largi ' ■ ity.
The dilatati E the lymph spaces to form cysl i
not due in the main to distention and wearing away
of trabecular, but to a true process of growth which
constantly increase the internal surface. As the
spaces thus enlarge, they keep filled with lymph.
( 111, i.i. I 'ii i.i, M LGRA1 II.
Edward Pbeble.
Bibliography.
Beneke: Zur Genese der Leberang Virch. Archiv, 1S53.
Burckhard: Path, Uiat. d, oavernoesen Ang. d. Leber, Wurz-
burg, I. !>.. 1894.
Esmarch: I ebei cavernoese BlutgeschwOlste. Virch. Arch.,
1853.
II. rtzler: Treatise on Tumors, 1912.
Lang] Beitrage Lehre iron den Gefat sgei chwulsten.
\ irch \ich.. 1879.
Losser: Lymphangioma tuberosum multiplex. Virch. Arch.,
1891.
Logez: Le Lpmphangiome congenital. These de Paris, 1902
Luschka: Cavern. BlutgeschwOlste des Gehirns. Virch. Arch.,
1854.
Muscatello: Angiom der willkOrl. Muskeln. Virch. Arch., 1894.
Ribbert: Geschwulstlehre, 1904.
Robin ei Laredde; Arch, de med. rap. et d'anat. path., 1896.
Rokitansky; Lehrbuch d. path, Anat., 1855.
Samte: Ueber Lymphangiome d. Mundhohle. Lang. Arch.,
1891.
Sutton: Tumors, Innocent ami Malignant 5th. ed., 1911.
Virchow: Ueber cavern. Geschwulste. Virch. Arch., 1S54.
Virchow: Hygroma cysticum glutcale congen. Virch. Arch.
102.
Virchow: Die krankhaften Geschwiilste, 1SG3.
Wegner: Lang. Arch., x\.
Weil: Beitriige Zur. Keuntniss der Angiome, Prag, 1877
Angioma Serpiginosum. — This rare cutaneous dis-
order was first described by Mr. Jonathan Hutchinson,
in his "Archives of Surgery," in 1891, under the title
of infective angioma or nevus lupus. Crocker's
name, angioma serpiginosum, would seem to be on all
accounts the more appropiate. But a handful of
cases, six or seven in all, have been reported, and it
may be doubted if one or two of these are reallyentitled
to a place in this group Hutchinson has also pub-
lished a short account of three other cases, those of
Lassar, Tay, and .lamieson. Besides White's case
one other, incompletely reported, has been described
in America, and Leslie Roberts refers to a case that
may belong in this category, although differing from
I he type in many respects. Schamberg has described
a peculiar progressive pigmentary disease that offers
certain resemblances with angioma serpiginosum.
In all the cases thus far reported the affect ion began
in early life, in four of them before the age of two years.
Small bright red papules; firmly seated in the skin, are
the first manifestations. These papules do not dis-
appear on pressure, and have been likened to Cayenne
pepper grains. They increase in size slowly, and
may reach the size of a pea, when central involution
occurs, while the edges continue to spread so that
circinate figures are produced. Outside these circles,
small new lesions, called satellites by Hutchinson,
are continually making their appearance, which also
enlarge and undergo central involution so that new
rings are formed, which may unite with the original
ones. There is no apparent atrophy in the central
part that has undergone involution, but in White's
case there was a dull pigmentation in this portion.
In none of the cases thus far reported has there been
any breaking down or ulceration of the papules.
435
Angioma Serpieinosum
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
In Hutchinson's cases the lesions were situated on
the back of the arm, spreading upward to the shoulder
and downward below the elbow. In the other cases,
the arm and side of the thorax, the face and upper
extremity, and the lower extremity, have been the
portions affected.
White's case, which was seen and studied by the
writer, concerned a boy of twelve years, who had
always been delicate and of a very nervous tempera-
ment. At birth a semilunar red mark was noticed
below the right shoulder blade, which increased very
slowly in an upward direction until he was four years
old, when another spot the size of a pin's head made
its appearance near the first one, which gradually
grew larger, and since then other spots have continu-
ally appeared and grown larger. When the patient
was first seen, the affection formed a band three inches
wide, which extended from the anterior edge of the
right scapula, about six inches forward toward the
nipple, and was composed of about twenty-four
different lesions, which varied in size from a pin's
head to circular patches more than two inches in
diameter. Minute elevated points, of a bright red
color, first made their appearance, which increased
slowly in size until they were from one-eighth to one-
twelfth of an inch in diameter. They were of firm
consistence, and only partially disappeared under long
pressure. Involution in the center then began,
while the growth spread peripherally, so that circles
were produced, until by confluence with other lesions
near by this shape was lost. The skin in the center of
the lesions appeared normal except for the presence of a
distinct pigmentation. New lesions were continually
appearing at a little distance from the older areas,
and in one or two instances small foci were apparent
in the old central portions. The anterior group of
lesions, some seven or eight in number, were at one
time destroyed by the Paquelin cautery. Pale cicatri-
cial tissue was formed at the site of the cauterization,
and it looked as if the operation was successful, but
after a time the lesions appeared on the borders of
these scars, and the original condition was produced.
In this case there was the greatest sensitiveness to
slight pressure upon the affected region, but it is not
improbable that this was due to the extreme nervous-
ness and fear of the patient. There was also some
itching complained of.
The only careful histological examination that has
been made of this remarkable disorder was that of
White's case. A typical lesion was excised and one-
half was studied by Darier of the St. Louis Hospital,
Paris, and the other half by Councilman and the
writer. Microscopically, the epidermis and the
epithelial appendages of the skin, such as the hair
follicles and sweat glands, were unaltered. The
lesion was characterized by groups of cells throughout
the corium, which were fairly well circumscribed, and
ran in their general arrangement parallel to the surface
of the skin. They were sometimes round, but more
often elongated in shape, and sometimes extended
out in long ribbon-like masses, which seemed to be
formed by a coalescence of neighboring groups. The
papillary layer of the corium was only here and there
invaded by the process. Under a high power the
nuclei were seen to be oval in form with a general
direction parallel to the course of the mass. They
were surrounded by a small amount of protoplasm,
and the boundaries of the individual cells could not
always be distinctly made out. The cells of all the
groups were arranged in smaller groups or clumps,
concentric in form, and in the center a lumen could
sometimes be seen, showing their connection with the
vessels of the skin. There were also various changes
in the vessels, consisting in a swelling and proliferation
of both endothelial and perithelia! cells. A striking
feature was the presence of small granular masses
here and there in the cell groups, which showed no
definite structure, and which were evidently produced
by a degeneration of the cells, as there was every
gradation from slightly granular, poorly staining cells
to a total necrosis. In some places the cell groups
were situated about spaces and fissures which evi-
dently corresponded to lymphatics. Taken as a
whole, the process is evidently one connected with the
vessels of the skin, affecting certain groups of vessels
notably the blood-vessels. It seems to begin by a'
proliferation of the endothelium of the vessels accom-
panied also by a proliferation of the perithelium
which is followed later by a degeneration and necrosis
of the central cells. There is apparently no com]
new formation of blood-vessels. Histologically, the
growth is to be compared to an angiosarcoma, and
its cause is possibly that underlying tumor formation
in general, and due to some congenital condition of the
vessels. Darier, from his investigations of the case
in question, proposes the name Sareome angioplas-
tique reticule. He considers that we have to do with
a peculiar form of sarcoma which is not massed to
form a single tumor, but has a reticulated structure
following the vessels of the skin, and that there i- a
tendency to form clusters of capillaries, approaching
in this way the characteristics of a true angioma.
He refers to the fact that in some of the soft nevi cell
forms are found very similar to those of this ca i
The number of reported cases of this disease
small to warrant any general conclusions as to its
course. In Hutchinson's case there was a recurrence
of the growth after cauterization. In White's case
the nodular infiltration made its appearance in the
normal skin beyond the scar left from cauterization.
This patient was seen six years later, when he had
reached the age of eighteen. There had been some
treatment by cauterization in the meantime, and
again the appearance of lesions jumping over the part
treated, to reappear beyond the cicatrix in the sound
tissue, was seen. There had been no breaking dowa
in any part, and on the whole it seemed as if the proc-
ess was gradually becoming less active. When last
seen, several years later, the process had undergone
still further involution.
Treatment of this affection has thus far proved
most unsatisfactory. Caustics or excision may con-
vert the territory occupied by the lesions into a cica-
trix, but hitherto they have failed to stop the
peripheral spread of the disorder, and sometimes new
lesions have recurred in the scar tissue itself. Elec-
trolysis applied along the edges that are progressim;
has been advocated, but no successful results from
this or any other method of destruction have been
reported. John T. Bowen.
Angioneurotic Edema. — This condition is better
described as acute circumscribed edema [Quincke],
since such a name makes no attempt to explain the
phenomena on the basis of a hypothetical vascular
neurosis.
The more striking skin edemas were described as
early as 1778 by Salpertus. Erichton in 1801 also
observed them, and Graves, who gave such an excel-
lent outline of exophthalmic goiter in 184S described
a patient with localized swelling of the face, forehead,
and eyes, in whom the edema persisted only a few
hours. Various aberrant localizations have bei n
reported, often under different names. Naturally
hysteria bulked large in the diagnosis in the earlier
days. Other synonyms indicate under what dif-
ferent rubrics it was grouped: Urticaria, urticaria
redematosa, urticaria tuberosa, giant urticaria, all
indicate where one should search the early literature,
further, one finds rheumatic edema, arthritic edema,
repeating rheumatic edema, intermittent rheumatic
edema, neuroarthritic edema, in the period when the
cases would be grouped among the rheumatisms,
etc. Then again, under the influence of the edema
concept, we find wandering edema, non-inflamma-
436
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Angioneurotic Edema
tory edema, transient swellings, local transien<
na intermittent edema, etc, etc. Quincke
ISS2 described it as acute circumscribed skin edema,
, | u -[ e i n a Kiel dissertation, one of his students,
Dinkelacker, broughl together many of the older de-
scriptions in I showed the unity of several apparently
dissimilar pr . He termed it acute edema.
Since Quincke's time a large bibliography has
accumulated, must of which is to be found in Cassi-
\ i omotorisch-trophischen Ne q, second
dition, 1912. A few of the papers in English are
Bannister, Journal of .Vervi '
1894; Bramwcll, Clinical Studies, 1907;
i f the Mt dical -
1892 Kohn, I U ■ , 1901;
Medicine.
OCCURRENCE. — The disorder is not frequent, yel
nol rare. Men and women appear about equally
nvolved. It may be present in young children—
i one-half months, Crozier, Griffith; three
months, Dinkelacker. Alter forty it appears very
•arely as an initial development, although in affected
ndividuals it may persist until late in life. Cas
.-,.,1 cases in persons oi seventy-nine and sixty-
urs in which the disease appeared compara-
ite in life. Raven reports a case in a woman
ighty-six.
Etiology. — Occupation apparently plays no role.
idity on the other hand is conspicuous. Many
luthors have mentioned this feature. Osier's family
; been freely cited. Ensor reports a family
if eighty members with thirty-three aff'
ndividuals, twelve of whom died of edema of the
glottis.
- nilar hereditary features an? reported by sev-
ral observers. The question of its transmission
been completely cleared up. In Apert and
Delille's families only the males were affected, but
:his does not seem to be the rule.
In many families, similar types of localized edema
ail in the members, while in others, apparently
nore often, all of the possible variants disappear.
; I ervous system involvements appear associated
n many of the families: how much of this is largely
^incidence, how much general neuropathic causal
bionship is difficult to determine from the studies
it hand. Much depends on the point of view of the
ndividual, whether he sees a relationship of the
s with those of epilepsy, migraine, chorea, gout,
manic depressive insanity, paresis, etc., all of which
lave been swept into the hereditary net. Some fami-
show no heredity factors of any recognizable
kind.
In the search for etiological factors, much industry
been evidenced, and the disease has been reported
having either direct or concomitant relationship
with acute articular rheumatism, alcohol poisoning,
■arbon monoxide poisoning, tobacco poisoning,
ating of fish, oysters, and mushrooms, and malaria.
ll has been found very frequently in certain places
in Lower Sehleswig where Lowenheim has reported
HO cases in the neighborhood of Liegnitz. No
family tree search was made, and this author is
in-lined to make certain climatic factors respon-
sible — damp swampy localities, with the heat of July
and August. Eschweider has reported its frequent
irrenee in Diisseldorf prison where certain pas-
tilles were made.
The disease infrequently shows itself in relation
to organic nervous diseases — tabes, myasthenia
gravis, spinal cord tumor, exophthalmic goiter, myx-
na, paraplegia — while it seems very frequently
iciated with many so-called functional neuro-
pathic states — hysteria, neurasthenia, tics, compul-
sion neuroses, migraine, etc. — and in certain psy-
chotic individuals with schizophrenia, manic depres-
sive psychosis, idiocy, amentia, etc.
Local traumata play a rule at limes, particularly
in determining the location of the swelling. Emo-
tional shock seems to bulk large aa a direct etiological
in tor, as does also the action of thermal influei i
Cold is very frequently an exciting factor in the
reaction. Menstrual facto) eem to enter into the
i iology of certain cases.
A moment's reflection therefore will show that
under the term Acute Circumscribed Edema one is
dealing with phenomena of greal variability and
multiform pathogeny. In discussing the patholo
a return will be made to this many Bided etiology.
Symptomatology. — The original conception of
Quincke lias been much employed, and Cassirer in
his Large monograph shows the present day trend to
include a large number oi is o sweUings
within tin cal group. Thus one distingui
localized edema of the skin, edemas of the mucous
ol thi eyelids, mouth, glottis, esophagus,
stomach, i respiratory tract: i the
joints, of the tendinous aponeuroses, possibly of the
kidneys, with polyuria, albuminuria, hemoglobinu-
ria, diminished secretions, etc.
The onset is usually acute, with some initial pro-
dromal signs of malaise, fatigue, chilliness, anorexia,
nausea, and slight rise in temperature.
A . This is localized,
variable in size, at times small, resembling urticarial
blotches (intermediary forms but usually as distinct
swellings, with an elastic feel, and due to a local
accumulation of clear colored serum within the skin.
The color of the swelling is usually that of the skin,
or paler, rarely red or reddish. The swelling comes
on with great rapidity, a few moments only, and
remains a few hours, mostly a few days, and then
disappears without leaving any trace. It is as a
rule non-irritating, painless, and causes only a dis-
comfort due to tension. Certain cases show burning,
itching, and intense pain.
The size of the edematous patches varies greatly.
At times very small — one-half inch — they- are more
apt to be three to four inches in diameter, or at times
involve the larger part of a limb. The scrotum may
at times swell up to the size of a foot-ball. The penis,
in cases reported by Bonier, has swollen to double
its diameter. The entire body was swollen also in a
remarkable case reported by Diethelm. At times
swellings are numerous, polymorphous, semi-
confluent. They rarely rise more than one-fourth
to one-half centimeter, but two to four inch swellings
above the skin are reported. The margins of the
sw-ellings are usually sharply circumscribed, but at
times may shade off imperceptibly into normal
anas. Circular or sausage shaped are the usual
descriptions of the swellings. The swellings invade
almost any layer in the skin, or musculature or even
appear periosteal. Some have been termed pseudo-
lipomas.
The consistency is semi-hard, non-pitting, or slightly
so. The color as stated is usually that of the normal
skin, or it may/ be paler, or have a cadaveric hue.
Again it is pinkish, to red, or even deep red. Often
the color disappears on pressure. The color may
change during the rise of all the swelling.
Local temperature varies. At times the skin is
colder, again it is warmer than that of the non-
affected parts. Exact studies are wanting. It
seems not unlikely that there is an initial increase
in the local temperature.
S< nsory changes are not present as a rule. Certain
cases have shown preliminary neuralgic twinges, no
perceptive sensory defect has been noted, but refined
methods of examination, such as those demanded
by Head, have not y r et been made. There is fre-
quently the subjective sense of great discomfort,
especially in marked swellings about the face.
There are rarely any residuals, although occasion-
437
Angioneurotic Edema
ally scaling or peeling has been observed, probably
for the more superficially lying edemas.
Si cretory symptoms have not been carefully recorded.
Local hyperhidrosis, dermatographia, increased tear
secretion have been noted. •
The location of the swelling may be almost any-
where, it cannot be said that one place more than
another is a favorite site (statistically). Exposed
portions of the body seem to be more often involved,
but when it is on the hands or arms, the distribution
is not of the glove type, nor are the swellings apt to
be symmetrical, nor docs there seem to be any
radicular or spinal distribution. There is a distinct
tendency for a recurrence of the edema to occupy a
position involved during a former attack.
Periarticular swelling constitutes a peculiar type,
so do also parotid and salivary gland edemas.
The mucous membranes are frequently involved
The lips, mouth, soft palate, tongue, pharyngeal
pillars, nasal membrane, larynx are all sites of
election. The last is particularly frequent and
dangerous to life. In these cases, other structures
than the larynx are implicated, especially the epi-
glottis and closely associated structures. In the
larynx the mucous membrane is swollen and tense;
the edema infiltrates throughout.
When the larynx is involved, the symptoms are
apt to be very marked. There is beginning tickling,
with rapidly oncoming difficulty in breathing, until
marked dyspnea may supervene, with death, unless
intubation or tracheotomy is performed. Some ot
these patients die within a few hours. Many cases,
on the other hand, clear up in an hour, after severe
dyspneic symptoms. .
Edemas within the bronchi occur in perhaps
twenty per cent, of the cases. They make up a
certain percentage of the cases of asthma. Certain
hay fevers possibly belong in this group. Lung
edemas have been described.
In edemas of the walls of the stomach, external
signs are also usually present. There may be inter-
mittent vomiting, or sudden acute pains, anorexia.
The attack may last a few hours with severe pain,
and more or less continuous vomiting finally ot clear
or bile colored watery masses, marked thirst, and
gradual disappearance of all of the symptoms. Bits
of gastric mucosa have been accidentally dislodged
which showed marked edematous swelling.
In intestinal localizations profuse diarrheas are
present, with colicky pains, meteorismus, tenderness
of the abdomen, diminished urination, great thirst,
and collapse. The diarrheas are purely _ nervous
diarrheas, so called, and occur in association with
other signs of a circumscribed edema.
Rarer localizations present in the tendons have
been described, particularly by Schlesinger. Muscle
edemas are also rarely described, although it is prob-
able that they are of frequent occurrence. Articular
edemas have been mentioned.
Optic-nerve edema is one of the rarer localizations,
as is also an edema in the labyrinth leading^ to a
Meniere syndrome. Acute conjunctival edema is not
infrequent.
The bladder, kidney, and heart structures are
among the rarest localizations. Meningitis serosa,
aphasia, are among some of the more problematical
occurrences reported.
Prognosis. — In general this is not good, lhe
tendency to laryngeal localization must always be
viewed 'with gravity. A great many individuals
have died from edema of the glottis. Remissions
are to be expected. Some patients suffer many years,
others, but the minority it would appear, have but
few attacks. There is some general tendency for
the disorder to become milder as the affected indi-
vidual grows older.
Transition forma are common, especially urticana-
like eruptions. Acroparesthesias, Raynaud-like at-
438
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
tacks, local asphyxias of the extremities, paroxysmal
hemoglobinuria, acroasphyxia chronica, erythro-
melalgia, epidermolysis bullosa hereditaria, herpes
zoster are all affections with which attacks have
been combined, singly or in groups of two or three.
Occasionally edema, acroparesthesia, and erythro-
melalgia may alternate in one and the same patient.
Pathogenesis. — Our conceptions concerning edema
are undergoing such vital modifications that it is
■ practically impossible to interpret the findings here
outlined along those present day lines that regard all
e lemas as cell phenomena and independent of the
mechanical conceptions of stasis, pressure, osmotic
tension of the vascular and lymph vessels, etc., etc.
In view of these studies in edema it is certain that
we may look in an entirely different direction than
vascular changes to account for this series of phenom-
ena. The term angioneurosis will then be not at all
applicable to this disorder. Whether the studies of
Fischer and others in edema can be brought
line here remains to be seen. At all events the sir
statement of this being an angioneurosis cai
weight than formerly, and one is tempted to look-
further I'm- a more adequate explanation.
The study of anaphylactic phenomena, especially
as seen in the so-called anaphylactic serum reactiOl
or serum diseases, has offered suggestive glimpses
indicating certain analogies with the series of chai
here outlined. We cannot go into these in any detail.
It can only be stated that precisely similar proce e
and appearances are found in the serum reactions,
and that it is not without profit to inquire more into
the mechanism of their production in an attempt to
understand acute circumscribed edema. Unfortu-
nately the mechanisms of the changes in the anaphy-
lactic reactions are still much in the dark.
One of the disconcerting features of acute circum-
scribed edema, whether one views it in the light of
a modified colloid absorption reaction, due to ti
influences brought to the cells of the deeper layers of
skin, muscle, or mucous membrane, or whether one
views it as a modified neural reaction passing through
intermediaries of the vasomotor system, which
in their turn control, in some unknown way reciprocal
tension relations, or chemical composition relations, is
the total irrelevancy of the whole process either to
vascular or to neural distributions.
This makes it all the in. .re probable that there are a
whole series of things in so-called acute circumscribed
edema. It is no unicum, and analysis will show that
a number of different pathological processes may
underlie precisely similar skin phenomena.
Cassirer adopts this view point, but consents to
make only two groups of cases— (a) a toxic ante-
toxic group, in which the poison works in some mys-
terious way, which a wealth of language can conceal,
better than it can reveal, and (b) a heredofamilial m
constitutional neuropathic group, which he regains
as intimately associated with instability in certain
parts of the sympathetic or vegetative nervous sys-
tem. This may be, he says, associated in some
manner with modifications in the internal gli
secretions. Here we enter another dark portal, .u
all events, Cassirer is loth to permit so-called angio-
neurotic edema to wander from the neurological told,
and concludes that the disease is conditioned— M
least his group (&)— by the lability of the sympathetic
nervous system.
Treatment.— This is purely empirical. It con-
sists first in avoiding all those things which experi-
ence has shown to be liable to bring on an attack.
If one has one of the more pronounced tOMC-
anaphvlaxis-like reacting types, careful study must
be made of all of the patient's protein reactions, and
attempts made calculated to eliminate such from J
diet. It seems plausible that it is through the gas-
trointestinal canal that such products gain entry,
REFERENCE HANDBOOK OF THE MEDICAL SCIENI ES
Anldro-ls
particularly in food, yet some may enter the respira-
tory tract. as seems to be the case in the related hay-
r reactions which are known to follow certain
tacts, variously ascribed to ragweed, rose, hay,
r poll, -us, or even the emanations from cattle.
From specific exclusion of certain protein
. the general hygiene of the intestine. This
means a sort of search in the 'lark 10] mysterious
ncies by chemical magic. One is justified not-
withstanding in trying to bring about altered bowel
liich empirically may do some good,
when a laissez-faire attitude seems to perpetuate the
disturbance. Naturally one should avoid cloaca!
ihould the patient be of an entirely
different type, say, the intensely neurotic forms with
ilial hereditary burdens, and emotional shock
lions.
Of the gastrointestinal antiseptics so called, few
are such. .Menthol, saline laxatives, carbonated
careful dieting (?) may be found among the
eatises on the subject. The taking of
a milk-vegetable diet has been coincident with better-
t in some individuals and coincident with retro-
sion in othi
In certain cases with associated toxemias, such as
-.. a specific therapy is indicated.
On the supposition that the bloi needed
ing up to prevent transudation through their
walls, also a hypothetical postulate, apparently ii
quate, such drugs as strychnine, ergot, arsenic, atro-
pine, morphine have been recommended. While all
of these will bring about vasoconstriction it is not
apparent whether they can alter a hypothetical tran-
quility or not. Calcium lactate is the modern
weapon for this latter. The writer has not seen it
i but it may be of service in preventing
transudates, as such are thought to be conditioned by
a diminution in the calcium content of the body
plasma Cassirer mentions calcium chlorate. At
all events the vasoconstricting drugs have not been
of any particular service clinically. Xow and then
they seem of service; none has been proven of pro-
phylactic value, which is a stricter test of their use-
fulness, since the disease is so self-limited.
In those ca mted with laryngeal symptoms,
intubation is often necessary — even tracheotomy.
There are records of certain patients condemned to
the persistent tracheotomy tube.
In the more strictly neurotic type — Cassirer's
group (6) — it is highly important that they be taught
a healthy morale. The substitution of reasonable
and intelligent actions for purely instinctive and
emotional reactions must be acquired by them if they
can hope in any way to control their hair-trigger
sympathetic nervous system. Perhaps it was so
given to them, defective and badly coordinated; even
then a rational pedagogy will prove of service. Many
will be helped by the methods outlined by Dubois or
Dejerine; others will need a psychoanalysis. Steckel
has reported some extremely interesting and severe
asthmatic cases, with pronounced symptoms of cir-
cumscribed edemas with psychoneurotic combina-
tions or complications. Just how the psychical
pathways become involved in these complex neuro-
biochemieal relations is one of the unresolved
anatomical problems. Physiologically it is known
that they do, as Pavlov's dogs nave demonstrated,
and as even the man in the street knows through the
profound disturbance of his bodily functions which
may be brought about by emotional states having
perhaps only mental representations, memories, as
their foundation. Smith Ely Jellifie.
Angiostomidse. — A family of nematode worms
which manifest in development the alternation of two
types of sexual generations, of which the first is free
and dioecious, while the second is parasitic, of
different structure and hermaphroditic. The genus
Strongylaidea is found in the intestine of man.
oda. A S P
Anguillula. — A genus of nematode worms. A.
aceti lives in vinegar and paste; tin has
occasionally b. i in the urine of man
oda. A S. P.
Anguillulidc-e. — A family of mi orms, for
the most part small and free living. The esophagus
usually ha- a double swelling, or two "bulbs." Many
es live in humus or decaying matter, other- live
on or in plant-: some, such :: I /.; aceti, \
in vinegar, paste, and urine, live inorganic
fluids. See A> matoda. A s. P.
Angustura. — See Cusparia.
Anhalonium.— See Mescal Buttons.
Anidrosis. — Anidrosis in the usual meaning of the
term denotes a disturbance of the function of the
piratory glands in which their secretion is .
absent or materially diminished. Under
circumstances tin- skin is dry and harsh, more oi
pruritic, and inclined to crack or fissure. Cold le
the amount of perspiration and heat increases it. and
this increase or diminution in the amount of sweat is
also influenced by certain drugs which may be readily
called to mind. The close connection between the
several functions of the kidneys, bowels, and skin
may al-o lie mentioned. Certain persons normally
sweat but little, even under conditions that ordinarily
provoke the secretion, as, for example, in the Turki>ii
bath.
Anidrosis is usually symptomatic, and is accord-
ingly observed in connection with some general or
local pathological condition. A general diminution
of sweat is frequently seen in diabetes mellitus and
insipidus, and in the states of malnutrition dependent
upon tuberculosis and the cancerous cachexia,
ating is apparently absent in the patches of
anesthetic leprosy and in localized areas in sclero-
derma, psoriasis, and eczema. The ichthyotic
notably suffer in this way. Aubert has made an
extended study of the secretion of sweat in various
diseases of the skin, to which the curious reader may
be referred {Ann. de derm, et de syph., tome ix.,
ls77-78). The association of anidrosis with various
disorders of the nervous system, and as following
direct nerve injury, etc., may also be referred to in
this place. Lastly, deficient perspiration may be due
to simple mechanical plugging of the sweat ducts,
the result of uncleanliness. Kaposi declares that
there is no absolute anidrosis, the insensible perspira-
tion never becoming abolished. This, he states,
becomes noticeable as a fluid secretion whenever the
skin, however dry it may feel, or even if affected
with one of the dry dermatoses (psoriasis, ichthyosis,
prurigo), is covered with some material that prevents
evaporation. It is certainly true, however, that
under certain circumstances, and in limited areas.
the sweat glands may be entirely destroyed or
undergo atrophy from a variety of causes, or that
paralytic conditions arise in consequence of nerve
lesions due to the presence of new formations (Geber).
Persons with abnormally dry skins are probably
more subject than others to inflammatory reactions
and to pruritus, especially the type of itching known
as pruritus hiemalis.
The prognosis and treatment must be based upon
the character of the primary cause. In a general way
it may be said that the skin should be stimulated by
warm alkaline baths and massage. Pilocarpine gives
only temporary relief. Cod-liver oil and glycerine
439
Anidrosis
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
are often prescribed in considerable doses. Unna
recommends arsenic and ichthyol separately or
together. Five lubrication with fats gives much
comfort in ichthyosis. William A. Hardaway.
Anidrotics. — See A ntisudorifics.
Aniline. — Aniline oil, phenylamine, amidobenzol,
C.II.H.N. Aniline is an aromatic amine presenting
itself us a thin, oily, volatile, inflammable, colorless
fluid of a vinous odor and hot, aromatic taste. It
dissolves only very slightly in cold water, but freely
in alcohol, ether, and fixed and volatile oils. It is
scarcely used in medicine, but its compounds are much
employed both in medicine and the arts, and its
repeated handling or inhalation results in poisonous
effects.
The most striking effect seen in aniline workers is
cyanosis, due partly to methemoglobin and partly to
oilier changes in the blood. It is believed that pig-
ment granules in the red corpuscles, or free in the blood,
are contributory to the bluish color of the skin.
The cyanosis is identical with that produced by
acetphenetidin (phenacetin), and the appearance in
the urine of para-amido-phenol both from this sub-
stance and from aniline shows the close relation be-
tween the two chemicals. Following the appearance
of the cyanosis there may be a subnormal temperature,
shallow respiration, prostration, and even convulsions
and coma. The drug may be detected in the breath
by its odor.
Chronic poisoning shows in anemia, wasting, loss of
appetite, constipation, lack of energy, headache, skin
eruptions, or sometimes itching of the skin without
eruption.
Aniline is sometimes used as a solvent for the pure
alkaloid, cocaine, for use in the external ear, the usual
watery solution of the hydrochloride of cocaine being
unable to penetrate the epithelium and therefore
useless. W. A. Bastedo.
Anilipyrine. — This drug is a combination of one
equivalent of acetanilide with two equivalents of
antipyrine, and it appears as a crystalline white
powder which is fairly soluble in water. It combines
the antipyretic and analgesic properties of its com-
ponents, and is claimed to be less toxic than either.
Its dose is gr. v. to x. (0.3-0.6).
W. A. Bastedo.
Animal Experimentation. — The Beginnings of
Experimental Medicine. — Although Galen had
studied functions of nerves by deliberately planned
experiments, although centuries later Harvey had
"frequent recourse to vivisections" in studying the
circulation, and although Hooke, Hales, and Hunter
had proved the value of the experimental method in
biology, the method was little used in the elucidation
of medical problems until about the middle of the
nineteenth century. Until that time disease had been
studied mainly by observation of the sick. This
observation had led, to be sure, to various theories
regarding the nature of the causes of disease, such as
miasms, the influence of stars, mysterious humors, and
vitiated air, but these notions were not put to test in
any rigorous fashion. Methods of treatment were
founded on these ill-supported notions, and on the
experience of persons who tried on human beings,
quite irrationally, all manner of curative measures.
By tl bservational method alone medicine had made
only slight progress in many hundreds of years.
The reasons for the failure to test experimentally
the notions regarding disease were many. In the
first place the experimental method appeared late in
Western Europe, even in sciences, such as chemistry
and physics, in which it is readily applied. And in
biology the difficulties of experimentation were so
great and the problems to be unravelled were so com-
plex that the application of the experimental method
lagged far behind its application in chemistry and
physics. The lack of a satisfactory general anes-
thetic and of methods for recording with exactness
the rapid changes in living organisms were also
obstacles to progress in experimentation in biology.
It is perhaps significant that the greatest impetus
to experimental medicine came from a chemist
Pasteur, whose labors established new conceptions
regarding the infectious diseases. Fortunately his
activities began about the time when ether and
chloroform were being introduced to abolish pain in
surgical operations. As a result of Pasteur's ideas
and experiments asepsis was devised. And nearh
simultaneously with these profoundly important con-
ceptions and discoveries, the graphic method was
invented.
Thus within a brief period, about 1S60, a funda-
mental and inclusive theory was propounded, and the
means were presented for trying on animals, painlessly,
without the complications of sepsis, and by exact
methods, experiments which could not justifiably be
tried first on men. Thus the era of experimental
medicine was initiated. And even in the first fifty
years of that era the progress in knowledge of organic
functions, of the causes of disease, and of new methods
of treatment has surpassed that of the previous
twenty-three centuries of medical history.
This extraordinary advancement of knowledge is
doubtless due to the nature of experimentation.
The essential characteristic of the experimental
method is such control of the conditions affecting the
phenomenon which is being examined, as to permit an
analysis of the relations normally existing, or capable
of existing, between that phenomenon and others.
Thus the experimenter deals constantly with factors
controlling or modifying the appearance or disappear-
ance of phenomena. And as the problems of medicine
are precisely problems of control, the results of
experimental study have often been immediately
practical.
The Opposition to Animal Experimentation. —
In spite of the benefits to man and to lower animals
which have resulted from the application of the ex-
perimental method to medical problems, strong
hostility to this method of studying disease is felt by
persons who designate themselves as " antivivisec-
tionists." Their hostility to the use of animals for
medical research is, in the main, based on two assump-
tions: (1) that pain is commonly inflicted on animals
in laboratories to a degree too horrifying to be en-
dured, and (2) that no good to man has come or can
come from studies of lower animals. In support of
the assumption that great pain attends animal
experimentation they circulate widely leaflets, pamph-
lets, and letters, in which they reveal that they are
quite ignorant of the methods they denounce, that
they are incapable of interpreting intelligently tin'
technical writings of the investigators, and that they
let imagination play uncontrolled in describing places
they have never visited and procedures they have
never witnessed. In support of the assumption that
animal experimentation is futile, they quote the
hostile statements of medical men long since dead,
or, ignoring the overwhelming testimony of practical
experience and the consensus of medical opinion
throughout the W'orld, they cite the words of so
unknown person possessed of a medical degree and
desirous of that prominence which comes to one who
claims that the earth is flat or the sky a great inverted
bowl.
However well-meaning the motives of the antivivi-
sectionists may be, the literature which they send
broadcast has for years been characterized by fraud,
trickery, and evil insinuation. These misstatements
440
REFERENCE BANDBOOK OF THE MEDICAL SCIENCES
Animal Experimentation
l,. n ,. been repeatedly pointed out, bul with no
, ,'|,.,. t . in this respect the English antivivisectionists
are like the American. The English Royal Commis-
sion, which reported in L912, after five years of study
and consideration of the subject, declared of the anti-
vivisectionists of England thai their "harrowing
descriptions and illustrations of operations inflicted
animals, which are freely circulated l>y post,
ment, or otherwise, are in many cases calcu-
lated to mislead the public." The active antivivi-
sectionists of both countries, therefore, have sought
ough garbled statements, false evidence and in-
irate description, to give the impression that
almost inconceivable cruelty is involved in animal
experimentation, and that the attempt to avoid pain
premature death by animal experimentation is
in the higl ee futile.
Not all antivivisectionists take exactly this view.
Seine anion;; them have been SO impressed by the
evidence of benefits to man derived from experimental
thai they are willing to grant these benefits.
■ till assuming the invoh ement of great pain in the
experimental processes they contend that the method
is immoral, that it has a brutalizing influence on those
who use it. and that it is therefore unjustifiable.
holder of this view has stated that he would not
have one mouse painfully vivisected to save the great-
est of human beings or the life dearest to him. In
short, intentional infliction of pain is a sin and crime,
and not to be tolerated.
views of the opponents of animal experi-
mentation raise three quest ions: What is the evidence
that animal experimentation has been beneficial in its
effects? To what degree is pain to animal- involved?
the use of animals for experimentation be
justified morally? These questions will be dealt
with in order.
P.F.XEFITS FROM ANIMAL EXPERIMENTATION. The
evidence that animal experimentation has been bene-
ficial to man. and to the lower animals also, is found in
a wide variety of results. It has given understanding
of bodily functions, insight into the nature of many
diseases, means of cure based on natural proce^e-.
for the detection of infection and for the quali-
ties of drugs, knowledge of the action of important
new medicaments, and numerous contributions to the
practice of surgery. This evidence is now to be
a ted.
Physiology. — The first of medical sciences in which
the experimental method was employed was physi-
ry — the science of normal functioning of organs.
In judging disease the physician is concerned with the
abnormal functioning of organs. Necessarily, there-
fore, the judgment of the physician must be based on
the normal standard which physiological investiga-
tions have revealed. It has been truly said that if
there were taken away from physiological knowledge
that which is based on experiments on animals,
almost nothing would be left. Probably no system
of organs in the body more frequently requires earnest
study by the physician than the circulatory system.
Practically all that is known of the course of events in
the heart, the proper interpretation of the cardiac
sounds, the factors determining blood pressure, the
nervous control of heart and arteries, the intelli-
gent treatment of cardiovascular disease — all has
resulted from studies on animals. What is true of
the circulation is true also of digestion. The activi-
ties of a succession of investigators who experimented
on animals, have revealed the changes which food
undergoes in each portion of the alimentary canal, the
nature of the digestive juices, the conditions under
which they are poured out. and, to a large degree, the
esand character of digestive disorders. Similarly,
through the brilliant researches of Sherrington and
others, illuminating insight is being secured into
some of the intricacies of the nervous system. These
and many other notable contributions to physiology,
which almost i b 1 1 1 \ stir man's wonder at the marvcl-
0US Organization Oi t he body, an' t he direct OUtCOl if
operations on animals. It cannot be too strongly
emphasized that almost the entire structure of
physiological knowledge on which the modern physi-
cian bases his judgment knowledge which in the
every-day practice of licine makes all tin' dif-
ference between understanding and blind bewilder-
ment — has grown from the application of the ex-
perimental met hod.
Parasitic Origin of Infectious Diseases. — As already
stated. Pasteur s ideas of the nature of infection gave
the greatest impetus to animal experimentation, [s
1853 his crucial discovery that the fungus, Penicilium
glaucum, destroyed dextro-tartaric, but not levo-
tartaric acid indicated a. significant and peculiar
relation between fermentation and living organisms.
His studies disproving spontaneous genera tii n i. under-
taken in I860, supported his views mi fermentation.
And by actually inducing in the healthy moths of silk
worms, solely by feeding them mulberry leaves, the
disease which was threatening the destruction of the
silk industry in France, he turned his ideas to practi-
cal ace,, nut. simultaneously saving France from great
economic disturbance, and bringing clear evidence of
the parasitic origin of silk worm disease. The infer-
ence was logical that other diseases which spread
rapidly as epidemics or epizootics are due to living
organisms. Thus Pasteur s studies stimulated num-
erous other investigators to try to find as active agents
in infectious diseases, microscopic germs, or bactera.
Through the activity of these men who, like Pasteur,
carefully tested their inferences by experiments on
animals, the parasitic origin of infectious diseases be-
came a firmly established fact. An account of the
role played by animals in developing our knowledge
of some of the more important of these diseases will
illustrate the value of animal experimentation.
Tuberculosis. — In 1S43 Klencke had demonstrated
the infectious nature of "tubercle" by inoculating
rabbits with "tubercle cells" and producing general
miliary tuberculosis. Little attention was paid to
these experiments, however, until Villemin, in 1S45,
repeated and confirmed them, and thoroughly proved
the infectiousness of tubercle by reinoculation from
animal to animal. Villemin also found that inocula-
tion of other morbid material, such as cancer, pus,
and bits of pneumonic lung, into rabbits, did not re-
sult in tuberculosis, and he inferred that the disease
was due to a germ. Although other experiments on
animals involving injection, inhalation, and ingestion
tests, showed the danger from tuberculous sputum
and milk, the identity of scrofulous disease and
tuberculosis in man, and tuberculous disease in
animals themselves, and proved the value of animal
inoculations for purposes of diagnosis, the characteris-
tics of the infectious agent were not known until
Koch reported, in 1SS2, his discovery of the Bacillus
tuberculosis. By rigorously exacting procedures —
the isolation of the bacilli in "pure cultures," the
production of the disease in animals by injection of
the pure cultures, and the recovery from the diseased
tissues of the injected animals bacilli in all respects
like those injected — Koch brought conclusive proof
that tuberculosis results from the growth of this germ in
the body. Later (1S90) through animal experiments
he demonstrated the value of tuberculin as an aid to
the early diagnosis of tuberculosis in man and in
cattle, and proposed the tuberculin test, as a practical
method of eradicating the disease from infected
herds.
Through animal experiments Cornet (1S90) proved
the danger of infection from the dried sputum of
tuberculous patients. Through animal experiments
Flugge (1S99) showed the possibility of droplet in-
fection from the spray of saliva in violent coughing.
Through animal experiments Trudeau (18S6) con-
441
Animal Experimentation
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
finned his belief in the efficacy of dietetic and open-
air treatment as a means of combating tuberculosis —
a treatment now everywhere adopted. Thus all the
preventive and diagnostic and curative measures
employed in the campaign against tuberculosis are
the result of experiments on animals.
The new knowledge proved that tuberculosis is
notinherited, that because infectious it is preventable,
and that in its beginnings it can be cured. These facts ,
together with the possibilities of early diagnosis,
dependent on animal tests, have led to a widespread
hope that the disease can be conquered. This hope
serins justified by the decline in death rate from
tuberculosis in various parts of the world since
hygienic measures began to be adopted. During the
twenty years before Koch's discovery of the tubercle
bacillus (1SS2) the death rate from tuberculosis in
Boston was forty-two per 10,000; during the twenty
years following the discovery the rate gradually fell
to twenty-one per 10,000 — a drop of fifty per cent.
It has since fallen to less than eighteen per 10,000.
In New York City the death rate from tuberculosis
dropped forty per cent, between 1882 and 1902. In
Prussia the death rate was fifty per cent, less in 100:;
than in 18S5. In Edinburgh, after partial hygienic
measures had been enforced, the death rate was
seventeen per 10,000 in 1897; during the following
decade, by cooperation of the agencies tending to
control the infection, the death rate was reduced to
eleven per 10,000. These bare statistics imply an
immense reduction of mortality throughout I ln-
civilized world — a saving of lives, furthermore, in
large degree for the years of service and working
efficiency.
The alternative to these great achievements has
been vividly stated by Trudeau (1909): "If it were
not for the knowledge which science has won by
animal experimentation in the field of this disease
in the last twenty-five years, we should still be
plunged in the apathy of ignorance and despair
toward it, ami tuberculosis would still be exacting
its pitiless toll unheeded and unhindered."
Bubonic Plague.- — The terror of the Black Death
is well founded in man's experience with the pesti-
lence. Defoe, in his "Journal of the Plague Year,"
in London, tells how the streets became hushed as
the infection spread insidiously from parish to parish,
how the carts moved about at night receiving the
heaped bodies of the dead, and how the bodies were
dumped pell-mell and by hundreds into huge pits dug
for their burial. Thousands died week after week
in London alone. What was true of London in 1665
has been true of every other large population in
which the plague has raged without control. In one
year, 1905, the number of recorded deaths from
plague in India was 1,040,429. It has wrought
disaster and desolation in China and other portions
of the orient in similar degree.
Because of increased knowledge of the disease,
largely gained by animal experimentation, plague in
any well organized community can be promptly
controlled and even eradicated. Attending the large
increase in commercial relations with the orient,
epidemics have started in recent years in several
great seaports — Oporto, Rio de Janeiro, Glasgow,
Liverpool, San Francisco, Seattle, and others — but
have been promptly stopped by radical measures.
In India, however, opposition to the sacrifice of
animals, and in China ignorance and apathy, have
hitherto prevented application of the knowledge
about plague which animal experiments have yielded.
The first step in the conquest of the plague was
taken in 1894 when Yersin and Kitasato, working
independently, discovered the Bacillus pestis. The
concomitance of an epizootic in rats and an epidemic
of plague had been previously noted, but no causal
relation had been established between the two. In
1898, Simond found that fleas placed on a plague-
442
infected rat drew blood containing the plague bacillus
and that these fleas transferred to a healthv rat
could transmit the disease. Then it was shown that
healthy rats and guinea-pigs failed to take the
disease from infected animals, if fleas were absent.
Later, monkeys placed in cages to simulate human
beings were found infected by rat fleas. These
animal experiments led to observations on human
conditions, especially in India, which indicated that
the great majority of cases of plague are due to
infection of man from rats through rat Ilea-.
This knowledge revolutionized the methods ef
dealing with an epidemic of plague. When formerly
the prevalence of the disease was attributed to
climatic conditions or soil infection, intelligent
measures for the suppression of the epidemic were
impossible. Now rat traps are set, rookeries and
vermin-breeding hovels are torn down, and the
victims already infected are isolated so that they
shall not be the occasion for further spreading of the
disease.
The part played by animal experimentation in
tracing the relation between the pneumonic ami
bubonic type of plague, in assuring diagnosis, and in
the development of prophylaxis and treatment of
individual human beings cannot here be considered.
It is sufficient to point out that through the knowledge
which has been secured the panic and terror formerly
induced by the Black Death have been reasonably
dissipated — a deliverance from bondage for which
mankind is indebted wholly to experiments on rats,
guinea-pigs, and monkeys.
Diphtheria. — The search of the internal organs of
diphtheria patients by Klcbs (1881) revealed no
constant presence of bacteria. Two years later he
demonstrated small rod-shaped bacteria in micro-
scopic sections near the surface of the diphtheritic
membrane, but with these were various other kinds
of bacteria. It was necessary, therefore, to test
experimentally for the organisms which excite the
production of the membrane. By feeding and
inoculating various animals with pure cultures of the
accessory bacteria, Loeffler (1884) was led to the
conclusion that these forms are of secondary import-
ance. With pure cultures of the rod-shaped bacteria
Loeffler was able to reproduce both in guinea-pigs
and rabbits characteristic, grayish-white, tough,
false membranes. And since the bacteria were found
only at the seat of inoculation, and not in the orgs
the inference was drawn that a poison produced at
the seat of inoculation must have circulated in the
blood. By these experiments on animals the role
of the Klebs-Loeffler or diphtheria bacillus in the
production of the disease was definitely determined.
Loeffler's idea that the general bodiiy disturbances
in diphtheria are due to circulation of a soluble
poison or toxin was substantiated by Roux and
Yersin, who found that filtrates from bouillon
cultures of the Klebs-Loeffler bacillus produced the
same changes in guinea-pigs as were produced by
infection with the bacteria, and were highly toxic
in small doses.
By tests on guinea-pigs, also, the identity of fatal
croup with diphtheria was established, mild cases of
the disease were discovered, and the bacteria were
demonstrated in the throats of some persons who had
recovered from the disease and who as "bacillus
carriers" were capable of innocently spreading the
infection. Thus by animal experimentation the
bacteria which excite diphtheria were discovered,
the manner in which they produce their effects was
indicated, and some of the methods of extension of
the disease were made clear. All this information
was highly valuable for the intelligent management
of diphtheria patients.
More important than these discoveries, however,
was that which gave insight into the mechanism of
immunity. In 1890 von Behring and Kitasato found
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
\ niiii.ii Experimentation
that laboratory animals, injected with weakened
toxin-, became immune to doses of the whole toxin
that were fatal to the normal animal. < H still greater
practical significance was the demonstration that the
blood of the actively immunized animals injected into
normal animals would protect these animals against
later injections of fatal doses of toxin, or would cure,
within reasonable time limits, animals that already
l,. 1( | received a fatal dose. That the toxin was
neutralized by a definite antidote or antitoxin was
shown by mixing the toxin « it li some of the protective
hi | or serum in vitro. The poison wa thus com-
ely counteracted, and when the mixture was in-
ed it had no harmful effect whatever.
ese experiments on animals were t he basis of the
antitoxin treatment of diphtheria. A horse is Ln-
ed with diphtheria toxin, and when he has devel-
oped in his blood the maximum amount of antitoxin,
he is bled, and the serum of the blood, which contains
the antitoxin, is prepared for use in cases of diphthe-
ria. Thus the natural antidote to the poison pro-
duced by diphtheria bacilli is injected into persons
by the disease, and the persons are pro-
nn the action of diphtheria toxin just as were
laboratory animals studied by von Behring and
Kitasato.
Antitoxin is useful both for the prevention and the
treatment of diphtheria. Numerous instance
been reported in which diphtheria has broken out in
large institutions, and been promptly checked by
rophylactic injection. In a large insane asylum
near New York City an epidemic started in the sum-
mer of 1910. Many cases among doctors, nurses, and
patients developed within a few days after the
discovery of the first case. As soon as possible over
2,000 members of the institution were given antitoxin
(1,000 units each). No immunized person was at-
tacked and the epidemic was stooped in less than a
week.
When antitoxin is used for treatment of diphtheria,
it does not restore to a normal state tissues that
already suffered serious injur}' — it acts solely as
a preventive of further poisoning. Its efficiency,
therefore, would be expected to be greatest when it is
administered on the first days of an attack. Such is
the fact. In the Hospital for Contagious Diseases in
New York City, in 218 cases of diphtheria treated with
antitoxin on the first day, there were no deaths; in
1,153 cases treated on the second day, the death rate
was 4.59 per cent.; in 880 cases treated the third day,
the death rate was 12.50 per cent.; and in 59S cases
treated on the fourth day. 16.4 per cent. These
results have been duplicated elsewhere, both in in-
stitutions and in private practice.
Because of the prevalence of epidemics the mortal-
ity statistics from diphtheria for any one city for the
period of a few years will show variations which do not
permit proper conclusions to be drawn. By taking
the records of death from diphtheria and "croup"
from nineteen large American and European cities
fin which records are carefully kept), from 187S
(fifteen years before antitoxin was introduced) to
1908 (fifteen years after), W. H. Park has largely
eliminated these errors. Although marked fluctua-
tions of the absolute mortality per 100,000 population
occurred in the preantitoxin years, in no period did all
the cities show a decrease. Not until 1894 did all the
cities begin to show uniformly a decrease in the
mortality per 100,000. Furthermore this drop has
continued until the present — a betterment doubtless
due to more extensive use of antitoxin, and to recog-
nition of the value of large doses and of early treat-
ment. In 1894 the average mortality in these cities
was 79.9 per 100,000; in 1907 it was 17 per 100,000
population. This difference is so great, the time of
its beginning so clearly coincident with the beginning
of antitoxin treatment, and the betterment of results
so progressive since that time, that it is difficult to
give any other explanation than that the saving of
life was due to antitoxin.
Clinical observati I p iti ho appear without
having had antitoxin treatment indicates that there
ha been no marked change in the average virulence
of diphtheria Clinical experience has from the
beginning testified to the remarkable specific effect
which antitoxin has in checking the course of the
di ease. Hospitals for the care of diphtheria patients
througl t the world employ antitoxin treatment.
States manufacture antitoxin and provide it freely
for the inhabitants. Thus the action ol individ >
and communities supports the results of animal
experimental ton.
In 1894 the number of deaths from diphtheria in the
nineteen large cities previouslj referred to was 15,1 25;
then the steady drop began, and in 1904 the number
oi deaths was 1,917. In ten pear there had come a
red in i i f more than 10,000. This great aving of
human lives, which is to continue indefinitely, is the
direct re ult of experiments on animals, and the
I ions which horses have to undergo in suppl
antitoxin.
Epidemic Cerebrospinal Meningitis.— Epidemic
meningitis has in the past brought consternation to
the laity becau e of its mysterious onset and its
terribL and has brought distress to the phy-
sician n of his helplessness in its presence. The
first step in the conquest of the disease was taken
when Weichselbaum discovered, in 1887, the menin-
ii cus which is always associated with tin- disease.
The final practical -tip was taken in 1906 — 1907,
when Flexner announced the effectiveness of intradural
inoculations of antimeningitis serum.
Attempts to use the serum subcutaneously in
human cases had previously been made in Germany,
but had proved unsatisfactory. The reasons for
this failure appeared when the problem was attacked
experimentally. Flexner found that the disease
could be induced by injection of active cultures of the
meningococcus subdurally in certain species of lower
monkeys. The antimeningitis serum was found to
have (1) the power of stopping the growth of, or
destroying outright, the meningococci, (2) the prop-
erty of increasing phagocytosis and intracellular
digestion of these bacteria, and (3) the ability to
exert a neutralizing action on the toxic products set
free by their growth and disintegration. Weak
dilutions of the serum have little or no effect, however,
in destroying the meningococci — the serum must be
applied in full strength at the site of inflammation.
When administered by lumbar puncture to monkeys
sick with epidemic meningitis, the inflammatory
process was stopped, the meningococci were de-
stroyed, and the monkeys were quickly restored to
normal condition. Furthermore, no perceptible in-
jurious effect resulted from the serum itself.
By further animal experiments it was proved that
injection of, first, heated and later, living cultures of
the meningococcus into a horse, the animal became
immunized, and his blood serum rich in curative
properties.
The mortality from this disease (in cases which
received bacterial diagnosis), wherever it has been
studied, has ranged from sixty-eight to ninety-one
per cent, with an average of about seventy-five per
cent. It has been highest in infants, ranging between
ninety and one hundred per cent. In 1909 Flexner
analyzed 712 cases which had been treated by the
antiserum prepared under his direction. The mor-
tality among children under three years of age (104
eases) was 42.3 per cent. From two to fifteen years
(326 cases) it was 23.4 per cent. After the fifteenth
year it was thirty per cent, and over. As in diph-
theria, the mortality is less if the serum is used early
in the attack. In 180 cases injected within the first
three days the mortality was 25.3 per cent.; in 179
patients injected between the fourth and seventh day
443
Animal Experimentation
REFEREXCE HANDBOOK OF THE MEDICAL SCIENCES
it was 27. S per cent.; whereas 129 injected later than
the seventh day had a mortality of 42.1 per cent.
In seventeen children under two years of age injected
within the first three days of the illness only one died!
Similar results have been attained in Germany and
France with serum prepared in those two countries.
In general by methods < leveloped in animal experimen-
tation the percentages have been reversed — from
about seventy-five per cent, mortality to about
seventy-five per cent, recovery — with a resultant
saving of fifty lives in every hundred cases.
Besides the saving of life there is a noteworthy
abatement of the symptoms of the disease. Within
twenty-four hours after the serum is injected there is
often a permanent return of consciousness, disappear-
ance of the mental dulness or delirium, removal of the
racking headache, relief of the hyperesthesia, control
of the vomiting. "To see patients pass within
twenty-four hours, after one or two injections of the
scrum, from a state of great distress or unconscious-
ness to one of almost normal mentality is something
the impressiveness of which is not easily to be over-
estimated." (Dunn). When one considers that
epidemic meningitis is an infection tending to a fatal
termination or to a prolonged course with frequent
relapses, this rapid change (about twenty-five per
cent, of recovery in treated cases is by crisis) is one of
the most important results of the new treatment.
A still more important result, however, is the ab-
sence of disabling permanent sequelae of the illness.
In former times deafness, blindness, paralysis, and
idiocy were not unusual consequences of epidemic
meningitis. To increase the percentage of recovery,
while leaving the percentage of fixed sequelae un-
changed, might not be regarded as a blessing. Clin-
ical observations, however, show that serum-treated
patients, who recover, rarely have the serious handi-
caps which afflicted those who recovered in pre-serum
days. Some instances of deafness which nave been
reported were noted as already present when the
serum was injected.
In the animal experiments which led to the present
serum treatment for epidemic meningitis Flexner
used about twenty-five monkeys and perhaps 100
guinea-pigs. Already records of approximately 1,000
cases treated by this method imply a saving of 500
human lives — unafflicted with blindness, paralysis
or mental defectiveness.
Pus and Pyemia. — Within the memory of surgeons
still active, pus was regarded not only as a natural
product of the healing process, but as a needful
accompaniment. In amputations the ligatures tied
about blood-vessels were left hanging from the lips
of the wound; soon they were covered with pus
which poured from the cut surfaces; the patient tossed
about the bed, sleepless with pain, fever, and thirst;
from time to time the ligatures were pulled upon
to determine whether they had "rotted" loose; not
infrequently the tied artery was not closed when the
ligature was pulled away or loosened by inflammation,
and serious secondary hemorrhages followed; from
ten days to three weeks were required for the ligatures
to rot loose, though they might remain and keep the
wound open for months. The long convalescence \\ as
complicated in many cases by erysipelas, lockjaw,
blood poisoning, or hospital gangrene. Hospital
gangrene in the Civil War had a mortality of 45.6 per
cent.; lockjaw 89.3 per cent.; and pyemia or blood
poisoning 97.4 per cent. Of these complications of
wounds there were thousands during the War.
Wounds of the knee-joint followed by amputation had
a mortality of fifty-one per cent., and without amputa-
tion sixty-one per cent. About sixty-six per cent, of
patients with compound fractures were sure to die.
To open the cranial case or the abdomen was an
operation of extreme risk, so certain was fatal inflam-
mation to follow.
The revolutionary change in surgery in the last
444
forty years is traceable to Pasteur's work on fermenta-
tion. Struck by Pasteur's studies Lister began inves-
tigations which led him to the use of phenol sprays to
keep out of wounds the pyogenic cocci. Beginning
with compound fractures and abscesses, lie obtained
such extraordinary success that he felt justified in
trying his methods in surgical operations. By means
of experiments on animals he developed the means of
tying arteries with embedded catgut ligatures. Later,
to be sure, what is now known as surgical cleanliness,
asepsis, took the place of antisepsis. But the later
development grew out of Listers demonstration of
the possibility of healing without pus, if bacteria are
excluded from wounded surfaces.
What a marvelous change these conceptions and
experiments have wrought! With catgut ligatures
the wound is closed at once, the ligature i> absorbed,
the wound heals in less than a week with little, if any,
immediate suffering and with none of the old compli-
cations. Pyemia has almost wholly disappeared,
lockjaw is heard of only occasionally after accidental
cuts which have not been cared for, and erysipelas
after operations is exceedingly rare. Compound
fractures and opened joints heal as if there had been
no break in the skin. Arteries can be tied anywhere
without fear of secondary hemorrhage. The body
cavities are now opened for surgical conditions with-
out serious risk. In short, the evolution of asepsis
has brought to pass the most momentous revolution
in the entire history of surgery — a revolution which is
of immeasurable benefit to mankind and the lower
animals as well.
Surgical Technique. — The advancement of surgery
has depended on animal experimentation not only in
the development of asepsis, but also in the devising
of operative procedures. Physiological experimi
on monkeys have shown the surgeon where to operate
on the human brain. Experiments on dogs and cats
have shown how nerves regenerate, the proper
met hod of suturing cut nerves, and the possibilities of
cross-suturing nerves of different function — a proced-
ure now being employed to obviate facial palsy.
The principles to be followed in suturing the severed
bowel were discovered on animals. The amount of
small intestine that maybe removed without endan-
gering life was also learned by animal experimentation.
The same may be said of the removal of kidney sub-
stance, of spleen, of lungs, liver, and other viscera.
The surgery of the widely opened chest has been the
direct outcome of Sauerbruck's studies on the effects
on animals of differential intrapulmonary pressure.
Through experiments on animals the surgery of blood-
vessels has been perfected to such a degree that now
the effects of hemorrhage, or the requirement of fresh
blood, can readily be met by transfusion. What
the future may hold for surgical ability can perhaps
be conjectured. Already in animal experiments,
organs such as kidneys and ovaries have been im-
planted and have continued functioning; pieces of
blood-vessel, preserved for w-eeks in the cold, have
been sewn into gaps in large arteries with no per-
manent disturbance of the circulation; parts of joints
have been introduced and established in the new-
surroundings. These instances must be regarded as
merely hinting the part played by animal experi-
mentation in the advancement of surgery in the past,
and now being played in the present progress of
surgical art. Many other instances might be cited.
Enough has been stated, however, to indicate that
death, distress, and enduring pain have been incal-
culably lessened by the application of experimental
methods to surgical problems.
Puerperal Fever. — In preantiseptic days puerperal
fever ravaged the lying-in hospitals throughout the
world. It was estimated that 30,394 deaths from
this disease had occurred in the Paris Lying-in hos-
pitals up to 1S64. From 18(50 to lsc.-i the death
rate in the Maternite (Paris) was 12.4 per cent., and in
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Animal Experimentation
December, 1864, it rose to the appalling height of
fifty-seven per cent, [n the sixty years ending with
[895, the number of deaths from puerperal lexer in
Prussia alone was 363,6241 On the assumption thai
each marriage would resuh in four or five children, it
was estimated thai every thirtieth married woman in
Prussia would fall a victim. In the United States
serious outbreaks occurred which were bej I
control; in the Bellevue Hospital in 1S7'_' an epidemic
occurred with a mortality of eighteen per cent. In
all countries the usual death rate ranged between
two and seven per cent.
Although Gordon (1792) had staled that he had
himself been the " means of carrying the infection to a
freat number of women," and Oliver Wendell
[olmes (1843) had argued that puerperal fever wa
'• a private pestilence, " and Semmelweis (1847), after
presenting evidence that the affliction was due to
contamination of patients by the soiled hands of the
obstetrician, had greatly reduced the mortality by
insing his hands in a solution of chlorinated lime,
liscrepancy of opinion on the subject long con-
tinued to prevail. The condition was regarded as
unavoidable, and was attributed to cosmic, atmos-
pheric or telluric influences, the fainted air of old
wards, the power of mind over body, the visitation of
Providence, and to various other conditions. Not
until about 1875, when Lister's views of wound in-
fection began to receive attention, was credit given to
bacterial origin of puerperal fever. And not until
Pasteur, in 1879, had cultivated the streptococcus
from cases of puerperal infection and demonstrated
on animals its power to produce blood poisoning, was
there general acceptance of the opinions long pre-
viously urged by Gordon, Holmes, and Semmelweis.
By means of surgical cleanliness, which is practical
bacteriology directly dependent on animal experi-
mentation, the mortality from puerperal fever has
been greatly reduced. In 1909 Markoe reported
60,000 births in the Xew York Lying-in Hospital
with a mortality of 0.34 of one per cent.; Pinard
reported 15,633 deliveries between 1890 and 190S
with a mortality of only 0.15 of one per cent.; and
Mermann in 1907 reported on S.700 patients delivered
ler his supervision with a septic mortality of only
0.0S of one per cent! In other words, death from
child-bed fever litis fallen from the former usual rate
of four or five in every hundred mothers to approxi-
mately one mother in 1,000. As Williams has said,
" Had animal experimentation led to nothing more
than the discovery of the bacterial nature of puer-
peral fever, whereby a means was provided for doing
away with its former hideous mortality, it would
abundantly justify the sacrifice of all the animals
which have thus far been used for experimental
purposes."
Pharmacology. — The whole modern science of drug
relation and drug action is founded on animal tests.
The pharmacologist is a chemist studying the chemical
character of substances, and a biologist studying tin 1
action of these substances on living organisms. Such
experimentation on animals has yielded all the sopor-
ifics (chloral, sulphonal, trional) that have been dis-
covered during the past forty-five years. It has
yielded also all the local anesthetics, such as cocaine
and eucaine, which render painless small surgical
operations. All modern drugs which reduce fever
fantipyrine, acetanilide), the diuretics caffeine and
tl bromine, the emetic apomorphine were all intro-
duced by animal experimentation. Adrenalin also
was thus found. During experimentation on animals
aniyl nitrite was discovered, the only drug giving
prompt relief from the severe pain of angina pectoris.
Through animal tests some drugs have been proved
worthless and have been discarded. Others have had
their action more precisely defined — digitalis is an
example. Others have been proved harmful. With
still others animal tests have been used to stand-
ardize the action. Thus no method of chemical anal-
ysis has been devised to determine the efficiency of
a given preparation of ergot. The manufacturing
ehenii t has to resorl to ti physiological tesl of every
specimen of ergol which he uses. Any woman who
takes ergot for I he control of hemorrhage becomes
thereby the recipient of benefits from animal experi-
mentation. The future growth of our knowledge of
alterations which drugs Can pro, Inc.- in the body,
whether normal or diseased, must either depend on
experiments performed on animals or be tested firsl
on human beings. There is little question which is
(he more justifiable procedure.
Syphilis and Salvarsan. — One of the most interest-
ing examples of the use of animal lor the study of
drug action is found in Ehrlich's discovery of salvar-
san as a treatment for syphilis. Of the calamitous
nature of syphilis little need here be stated. It may
kill in its acute slage, or pave the way for other dis-
ease, or lead lo mental degeneration; it may cau-e an
e 'mously high mortality in still-births and abor-
tions; it may result in the production of wizened
offspring lacking in vitality and subject to infections,
or idiots, or monsters, or those unfortunates whose
syphilitic heredity falls as a blight upon them in
their youth and is passed on as a scourge to their
descendants.
Although clinical study had revealed many of the
characteristics of syphilis, knowledge of the disease
was lacking in several important particulars. It
was impossible to make an early diagnosis; and
diagnosis in the late stages or in "latent" forms was
often extremely difficult. Furthermore no one could
tell how long treatment must be continued before a
complete cure was obtained. All of these deficiencies
in knowledge of the disease were of great social
importance. Fortunately through animal experi-
mental i. and rotates very -lightly to the left.
At a temperature of from 15° to 19° C. it congeals.
More than ninety per cent, of it is anethol (y.r.). which
gives its properties, and which may the more advan-
ously he employed. a< uniformity is thus secured.
It belongs to the more carminative class of volatile
oils, and shares the diffusive stimulant properties of
volatile oils in general. It is. at the same time, of
an unusually pleasant flavor and much used for purely
'ring purposes, especially as an addition to liquors.
[ta pleasant flavor also makes it of special use in
treating the flatulent colic of infants, and in adding
ti> medicines which have a tendency to gripe. The
dose is ntiij. to xv. The official preparations are the
Aqua, of one-fifth of one per cent, strength, and the
Spiritus, of ten-per-cent. strength. The Spiritus
Aurantii Compositus contains one-half of one per
. and the Tinctura Opii. Camphorata two-fifths of
one per cent. It also flavors several other peparations.
H. H. Rusby.
Anise, Star. — Illicium. "The fruit of IUicvum
ri rum Hook. (fain. Magnoliacece)" (U. S. P.). The
cies here named is the Chinese, or sweet star anise.
besides which there is a poisonous Japanese species.
When I.inne applied the name /. anisatum, supposing
that he had the former, he really had the latter, as his
description and figure clearly show. As a result of
this mistake, the poisonous species must always bear
the inappropriate name I. anisatum L. (Syn.: I.
religiosum Zucc), and Hooker's later name, I. vcrum,
pertain to the useful species.
The plant is a handsome small tree.
The fruit consists of the eight carpels, united to a
carpophore, from which they can be easily separated,
hut distinct from one another. Each carpel is short,
laterally compressed, "boat-shaped," pointed at the
upper and outer cxtremitv. and dehiscent at the
upper and inner border. The pericarp is deep brown,
rather woody, brittle, fragrant, and spicy. The
seeds, which can !><■ seen through the -split jn the
carpel, although this is not usually wide enough to
lei them fall out, are also brown, but very smooth and
shining. They are less fragrant than the carpels, hut.
contain considerable fixed oil in their kernels. Both
te la and pericarp show, under the mici pe,
numerous oil cells, and the parenchyma of the seeds
re\ eals drops of fat.
Composition.-- Re-ides sugar, gum. and fixed oil,
which, although abundant, have no practical value,
tar anise is remarkable for containing a large
percentage (from three to live) of an e- I niial oil, SO
Fig. 2-ts — TUicium verum or Star Anise, n. Flower; 6. gyneecium;
c, fruit; d, seed, entire,; e, seed in longitudinal section.
similar in odor, taste, properties, and composition to
that of anise, that no means can be relied upon to
distinguish them from each other, except by the
greater percentage of anethol in the latter, on account
of which it congeals at a higher temperature. Illicium
is never prescribed, and is recognized only as a
commercial source of "oil of anise." This oil, owing
to its weaker action, should not be indiscriminately
substituted for oil of anise. H. II. Rusbi .
Ankistrodon. — A genus of snakes containing two
of the most poisonous species in North America — ■
.1. contortrix, the copperhead, and A. piseivorus,
the moccasin. A. S. P.
Ankle Joint. — As this joint (Articulaiio talocruralis,
UNA) supports the weight of the body, considerable
stability is required of it. This is secured mainly by
the shape of the articular surfaces, which interlock
like a mortise and tenon. The tibia and fibula,
strongly united by ligaments (interosseous and infe-
rior tibiofibular, Figs. 1214, 215, and 21S), form the
mortise by embracing with their extremities (malleoli)
the tenon-like astragalus. The joint is a hinge, its
movement angular, and in a single oblique plane
I corresponding to the outward pointing of the toes)
through an arc of some eighty degrees. A slight
anteroposterior ridge on the tibia fits into a corre-
sponding depression on the astragalus giving a
"trochlear" character to the joint. The arc of the
astragalus is from a circle somewhat smaller than that
of the tibia, but it comprises about one-third of the
circumference while the tibia has not more than one-
fourth. While standing erect the facet of the astrag-
alus is partially uncovered in front and behind and
there is a slight interval between the curves at these
points. In the fetus of six weeks (Henke and Rey-
her) the joint is arranged like that of some marsupials,
so as to admit of rotation, the astragalus sending a
process up between the tibia and fibula. To guard
Vol. I.— 29
449
Ankle Joint
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
against the thrust of the tibia and fibula when alight-
ing on the extended toes (the commonest form of
dislocation arises thus), the astragalus is narrower be-
hind than in front, averaging 35 mm. behind and
Interosseous liga-
ment.
Ext. lat. ligament.
Synovial cavity.
Deltoid ligament.
Tarsal canal with astrag
ealcanean ligament.
Fig. 249. — Froutal Section of Right Ankle.
40 mm. in front. It is doubtful whether lateral
movement is possible within the joint itself, that
which apparently occurs being really due to the play
of the small bones of the foot upon each other. The
Post, tibio-fibular ligt.
Ext. lat. ligt.
Deltoid ligt.
Post, astrag. calc. ligt.
Fig. 250. — Rear View of Left Ankle.
malleoli are held against the articular surfaces in
all positions by the elasticity of the shaft of the fibula
which bends inward when the wedge pushes the
malleoli apart, springing back during extension. The
Long plantar ligt.
Tarsal canal
and astrag. calc. ligt.
Fig. 251. — Sagittal Section of Right Ankle.
axis of rotation of the curved superior surface of the
astragalus (Fig. 251) passes through the most fixed
part of the bone, viz., the tarsal canal, touching
the outer malleolus but passing below the inner,
which does not descend so low (Figs. 249 and 250).
The original capsular ligament (see Arthrology) re-
mains in front and behind as a thin and somewhat
lax layer of fibers connected with the synovial mem-
brane and strengthened by the extensor tendons in
front and the tendon of the flexor longus hallucis be-
hind. Effusion into the joint usually shows first in
front. On the sides strong bands are developed.
The internal lateral ligament
(Figs. 249, 250, and 252), also
called the deltoid, from its
triangular form, is the strong-
est of these; in dislocations
usually tearing the bone apart.
It is a thick bundle, ensheath-
ing the internal malleolus and
passing to the calcaneum, the
astragalus, the scaphoid, and
the calcaneoscaphoid ligament.
Although these are not dis-
tinct from each
other they have
received special
■■-- ,
Long plantar ligt. Inf. calc. scaphd ligt.
Fig. 252. — Inner Side of Right Ankle.
names (ligamenta calcaneotibiale, talotibiale anterhis,
talotibiale posterius, and tibionaviculare, UNA). The
tendon of the tibialis posticus strengthens it. Deeper
fibers also pass to the astragalus (ligamentum taloti-
biale profundum). In amputating at the ankle the
joint is opened on the inner side, because of the short-
ness of the malleolus, and the existence of this deep
band should be remembered. The external lateral
ligament (Figs. 249, 250, and 253) is composed of three
Post.
Post. Middle Ant.
hand. band. band.
Ext. lat. ligt.
Fig. 253.— Outer Side of Right Ankle.
distinctly separate bands which radiate from the
lower part of the malleolus, the anterior and posterior
bands passing to the astragalus, the middle one to the
calcaneum. The names of these are quite similar to
I hose of the internal ligament, viz., ligamenta talo-
fibulare anterius and posterius, and calcaneofibulare.
The synovial cavity is quite extensive, communicating
above with the inferior tibiofibular articulation. It is
said to contain more synovia than that of any other
joint (Morris). Its capacity is not affected by the
450
REFERENCE HANDBOOK or Till: MKDICAI, SCIKXt ES
Ank> losls
position of the foot, and no change of posture lake.--
place during inflammation of its membrane.
Sensations of pain are sometimes fel< in t ho ankle
without lesion of the joint, caused by some injury to
the long nervous trunks which supply it, viz., the long
saphenous, connected with the lumbar plexus, and the
anterior tibial (deep peroneal BNA), with the sacral
us, The vascular supply arising from twigs from
the anterior and posterior tibial arteries, ami dis-
trging by both saphenous veins, may be interfered
with by tight boot laces and occasion a dull pain.
FltANK BaKEK.
Ankylosis. — Synonyms: English, Stiff joint, fixed
joint; French, Roideur articulaire; German, Gelenk-
verwachsung, Gelenksteifigkeit.
A strictly correct definition would designate a
i angular position of a joint, but this restriction
i i . longer obtains, t he word now being used to describe
joints that have become more or less stiff in any
position. Qualifying terms are used to indicate the
extent of the stiffness, such as false, spurious, true,
bony, ligamentous, partial, complete, incomplete,
all of which can be best understood with the
i i possible confusion if the word ankylosis is
ed as a synonym for stiffness.
i: piologt. — Traumatism, gonorrheal rheumatism.
uration in joints, tuberculous osteitis, tuberculous
01 itis, syphilitic affections of joints, long fixation
ii a fracture is near or extends into a joint,
1 is deformans, etc.
Pathology. — In complete, i.e. bony ankylosis,
the bones forming a joint are limited by callus in the
same manner that union takes place after a fracture
in the shaft of a long bone, or bridging by callus takes
eat one or more places around the joint. Usually
us ankylosis is preceded by a more or less pro-
longed stage of fibrous or cartilaginous union. In
IUS ankylosis bands of fibrous connective tissue
unite the bones forming a joint, thereby limiting the
motion. Accordingly as these bands are short or
Jung t he stiffness is complete or partial.
In cases of joint stiffness produced by extra-
articular, fibrous, tendinous, or cicatricial contracture,
the joint remains free from adhesions for years when
it has not been involved in inflammatory action.
Diagnosis of bony ankylosis is usually unattended
with difficulty except where there are a number of
joints near together, as, for example, the carpus,
tarsus, and spine. This limitation of motion in one
joint is generally compensated for by excess of motion
in another, thereby rendering all the surrounding
parts capable of functionating in a very nearly normal
manner.
Fibrous ankylosis is more difficult to discern,
especially if pain accompanies the required manipu-
lative procedures. It is most apt to be confused
with fibrous, ligamentous, or cicatricial contractures
of soft parts outside of a joint, but having direct
functional relations therewith. Extraarticular con-
tractions may often be differentiated by the existence
of resistance to free joint motion in one direction
only, i.e. that produced by the contracture, while
the joint moves more or less freely in other directions.
Muscular contracture, whether voluntary or invol-
untary is but temporary, and the rigidity of the
surrounding parts is clearly discernible.
U muscular rigidity is one of the most important
and reliable symptoms of joint inflammation, it is a
serious error to anesthetize a patient for examination
oi a joint until the absence of muscular fixation has
been clearly proven. In such cases the anesthetic
relaxes the muscles, leaving the joint free for move-
ments which are seriously prejudicial and which were
instinctively guarded against by the patient.
If there has been no muscular fixation much may
be learned by I lie careful study of a joint while the
patient is unconscious, h ran be definitely deter-
mined whether it is ankylosed or only partially
The yielding of the soft part above and below the
joint suspected may be prevented by tightly bandag-
ing them, the joint itself being left uncovered.
Treatment. — The most important part of the
treatment lies in prophylaxis, prevention of the
occurrence of ankylosis, or, if it is inevitable, in o
disposing the parts that the best position for future
usefulness may be obtained. The trend of modern
surgery is greatly to shorten the time oi fixation of a
fractured bone, in the effort to avoid impaired joint
function, as well as to secure a freedom from mn cle
atrophy. The earlier application of passive motion
and massage is being resorted to, and many of the
serious deformities which formerly followed fractures
are now less frequently seen.
Bach individual joint has special features and
presents special difficulties that must be carefully
considered in applying any form of treatment. The
st useful position for a stiff joint is still subject to
discussion ; no general rule can be laid down. Fibrous
or incomplete ankylosis may require attention to
overcome a faulty position, or to increase the extent.
of the mot ton. This is to be accomplished by passive
motion made in the direction of the normal action
of that joint. Brisement force, is a term applied to
the use of such force as the surgeon can judiciously
apply, bearing in mind the danger of breaking the
shaft of the bone used as a lever or of producing a
separation of the epiphysis. It is wise to begin all
manipulations well within a safe limit, and gradually
to increase the power employed as the range of
motion increases; remembering that the strength of
the long bones often diminishes from disuse and that
they will break if a sudden corrective force is applied.
The above methods are greatly facilitated by pre-
viously subjecting the limb to dry hot air at a tem-
perature of from 300° to 400° F. for an hour. For
this purpose some one of the many forms of ovens
made for the purpose may be employed. Care should
always be taken to wrap thoroughly the parts in
flannel, but never in cotton. The latter is highly
inflammable and holds the moisture. The interior
of the oven should be kept as dry as possible, as the
perspiration, which is often profuse, renders the
atmosphere within the oven moist, and is apt to
result in scalding the patient.
Ovens are now made for use with alcohol, gas, and
electricity as means of generating heat. Each has
its peculiar advantages, but the results are not
different. The effect is to soften the fibrous adhesions
very much in the same way that old glued joints of
wood are softened, enabling the surgeon to obtain
movements of a partially stiff joint with very much
less force and therefore, with less danger and less pain.
The pain accompanying corrective manipulations
following the use of the oven is generally inconsid-
erable, although varying greatly in different subjects.
When the pain is very great, the employment of an
anesthetic that acts quickly enables the operator to
proceed with greater despatch. The anesthetic that
I have found most satisfactory for this purpose is
ethyl bromide; ethyl chloride is also satisfactory. I
have also used chloroform and at times nitrous oxide
gas.
Fixation appliances of any kind are contraindicated
during corrective procedures in fibrous ankylosis,
as increased freedom of movements is desired rather
than fixation. Voluntary motions are to be encour-
aged to increase the mobility and to regain the
muscle function which is required for proper use of
the joint.
The employment, of electricity has been extolled
for its effect in restoring lost or impaired muscle
function, and when used by skilful physicians it is
451
Ankylosis
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
more likely to produce the desired effects than when
crudely applied by a more or less non-medical
attendant.
Massage is a means of restoring impaired muscle
power that should not be overlooked, and, like all
other therapeutic measures, should be carefully
prescribed as to methods and time. The object
sought should be the voluntary control of the affected
joint and the mechanism that actuates it; this should
be impressed on the patient.
In true ankylosis the object sought is the most
useful position of the parts, and here careful study is
necessary to avoid attempting to obtain a movable
joint when greater usefulness could be had from a
stiff joint in an approved position. The greatest
diversity of opinion exists as to the most desirable
position for ankylosed joints. In the elbow a fully
extended position of the arm is generally conceded to
be the least useful, while the exact angle of flexion has
been the cause of much discussion. Some advocate
a right angle, others a lesser angle, to enable the
patient to bring the hand to the mouth; and yet
any rigid position is more or less conspicuous and
cumbersome.
The hip when ankylosed at various angles can be
made useful by the increased latitude of motion im-
parted to the other hip-joint and to the lumbar verte-
bral articulations. To such an extent is the lower spine
reciprocal in loss of function of one or both hip-joints
that it has been called the third hip-joint. Ankylosis
of a hip at right angle to its fully extended position
has frequently been observed to be useful for progres-
sion. The third hip-joint has also developed in
efficiency in cases in which a hip-joint was ankylosed
in the most approved position, i.e. that of almost full
extension, facilitating the movements of the entire
pelvis in walking and especially in sitting, and
approaching very closely normal action.
The arguments in favor of a fully extended leg
versus slight flexion in cases of bony ankylosis of the
knee appear to be about equally divided. _ The
sl'ghtly flexed leg is certainly somewhat less in the
way in sitting, and it enables the patient to develop a
more graceful carriage, but all of these are cast into
insignificance by the mechanically faulty position of
flexion. Ashhurst refers to a case in which the knee
remained straight with apparent bony union for
eight years and then began to yield, and within a year
was bent to a right angle and rotated. The fully
extended or straight position is less liable to bend
because its weight-bearing function is disposed in the
mechanical position in which it was designed to act
most efficiently. Where the quadriceps attachment
to the tibia is maintained or properly substituted, the
powerful flexors will have less opportunity of pro-
ducing flexion, which, as experience has shown, tends
to increase with use.
The operative procedures most frequently resorted to
are: excision to obtain a false joint (pseudarthrosis);
excision to obtain a better position of the limb;
osteotomy, breaking the bone after partially cutting
it with an osteotome; and osteoclasis, breaking the
bone without any cutting. These different procedures
have especial advantages in different joints, and can
be fully studied and appreciated only under the head-
ings of the individual joints.
Adolf Lorenz 1 has elaborately considered the con-
servative aspect in an article on the " Indications for
Arthrodesis and Arthrolysis," the latter term being
the one that is now generally accepted as meaning the
intentional production of mobility in ankylosis by
operative procedure. His conclusions arc that there
are only two joints in the body that should be made
mobile after ankylosis, viz., the elbow and the jaw.
He bases this view upon the fact that there are so few
cases that have been operated upon that have re-
sulted in permanent restoration of function. The
inability to secure a restoration of muscular control
often necessitates the employment of varying forms of
apparatus to give stability to a joint that has become
mobile by operative methods. His belief is that an
ankylosed joint in proper position affords higher
degrees of efficiency than such joints offer when they
are made free, but still lack muscular control.
The very many methods of producing mobile joints
following ankylosis may be taken as an indication of
lack of success of any of them. In some instances a
greater number of successful results have been ob-
tained than in others. Rhea Barton 2 of Philadelphia
in 1826 removed a wedge from an ankylosed hip and
instituted passive motions after three weeks, and
obtained mobility which, however, became more and
more limited, finally ending in recurrence of ankylosis.
J. R. Rogers in 1830 attempted the same pro-
cedure with equal results. In 1S3S Berard 3 advised
section of the condyles after the method of Rhea
Barton for temporomaxillary ankylosis. In 1840
J. M. Carnochan' operated on a case of pseudoarthro-
sis by division and inserting wool or cotton between
the cut ends. In 1853 Schuh freed an ankylosed
patella with a chisel, but the adhesion returned.
T. Wolff 5 reported nine successful cases following
what he terms "arthrolysis," i.e. incision by scalpel
and chisel of all the fibrous tissue which hindered
movement. Eiselsberg, in two cases in which he
employed this was, however, successful in only o
and Kocher, while in favor of "arthrolysis," modi
it by putting the components of the new joint after
"arthrolysis" in a position of dislocation for a week
or two, when he reduced the dislocation.
Helferich, in 1S99, proposed, but did not carry out,
his suggestion of inserting a portion of the vastus
internus between the patella and femur to prevent
reunion. Cramer 6 reported ten cases of ankylosis of
the patella alone, in seven of which the vastus inter-
nus was interposed, and six were successful.
Chlumsky 7 reasoned from the reports of Mikulicz,
Helferich, Leuz, and Riegner, that, notwithstand-
ing the good results obtained at times by the inter-
position of muscle and fascia, in large joints the
procedure, through failure of preservation of the
interposed tissues or on account of technical difiienl
ties, was not all that could be desired. He therefore
conducted a large number of experiments based upon
the interposition of such non-absorl:able substances as
plates of ceDuloid, zinc, rubber, silver, cambric, and
layers of collodion and absorbable material, such as
magnesium, ivory, or decalcified bone. In some in-
stances there was a tendency to joint formation, but
the end results were unsatisfactory on the whole.
Mellhenny 5 removed in the inferior maxilla a wedge
of bone half an inch wide from the neck of each
condyle just above the insertion of the external
pterygoid, for temporomaxillary ankylosis, with a
successful result.
Murphy 9 in October, 1901, interposed flaps of
fascia and muscular tissue from the vastus externue
between the patella and femur and tibia and femur
for an ankylosed knee, with fair result. He reports
twelve cases in all, up to January, 1905, some with
remarkable result, for the correction of ankylosis of
the knee, hip, and elbow, which he accomplished by
the interposition of flaps with broad p dieles obtaini d
from fascia, fat, and muscle adjacent to the anky-
losed joint. His paper is most interesting, extensive,
and valuable.
Hubscher 10 failed to secure permanent freedom of
the patella by the use of the interposition of magne-
sium foil half a centimeter thick.
Berger 11 successfully used the pronator radii teres
between the extremities of the bones sutured to the
brachialis anticus for elbow ankylosis, and attributes
the satisfactory result to the muscular interposition.
Hoffa'- also successfully used muscle flaps. Quenu. 13
in 1902, interposed soft parts after re ection of the
elbow for ankylosis. Delbet also praises this method.
452
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
.\no DBS
Foderl" after experimental ankylosis produced by
resection, produced mobility again by the insertion « »f
pj , ces f bladder or the wall ol an ovarian cyst.
Baer' 'in 1909 reported three cases in which he had
used Cargile membrane between the separated com-
ponents of the joints with no resultanf motion, and
with fever fur a few days alter the operation. In a
fourth case, a knee in which he used Cargile membrane
Bn d in which fever occurred, the end result wa 10°
lotion, \iiir the method of Foderl, he then also
used bladder from the pig, which he had chromicized,
this he sutured in the newly separated articulation
, the result in the reported cases of 35 motion in a
hip, 35° in a knee, 50° in a hip, 75° in a knee; and 100°
in the upper radioulnar articulation. The objection
to the method seems to be the postoperative fever,
trusion of the pieces of bladder through the
wound or adjacent tissue at times with resultant
formation and suppuration, and in some in-
stances return of ankylosis, as reported by Osg 1"
and in personal communications from three cases at
Si. Agnes' Hospital and Ashbury's observatioi
I'lu' advantages claimed by Baer over the bulky
muscle Hap and fascia method is that the resultant
illation has a in n eh more stable mot ion and there
less waddling gait.
I in mi' 7 reported a trail nia tie ankylosis of the elbow
eleven year old boy. He broughfabout a mobile
! then interposed a free transplanted fascial
from the thigh. Systematic mechanical treat-
t movements and massage were used, and t welve
ths after the operation the elbow had good move-
I of 55°. Recently Ilauer of Johns Hopkins
Hospital in a case of ankylosed elbow, used a flap
i the fascia lata of the patient's thigh with sat-
isfactory results.
R. Tunstall Taylor 18 presents for consideration the
result of his experiments in the introduction of vary-
ing formulas of white wax ami lanolin for the produc-
tion of mobility ill joints that have been ankylosed.
The latter possessing many advantages over the sepa-
rating material used by other operators. Taylor's
results indicate a successful future for this method.
H. Augustus Wilson.
References
1. New York Medical Journal, June 22. 1012, page 1301.
2. North American .Medical and .Surgical Journal, 1827, p. 290.
3. Diet, de Medecine, vol. xviii., p. 440, 1838.
4. Lectures on .Surgical Anatomy and Operative Surgery.
5. Berliner Chirurgen Vereinigung, 1895 and 1897.
0. Thirtieth Congress of the Deutsche Gesellschaft fiir Chirurgie,
Berlin. April 13, 1901; Archiv fiir klinische t'liirurgie, 1901,
Ixiv., p. 696.
7. Centralblatt fiir Chirurgie, Sept. 15, 1900; Wiener klinische
Wochenschrift, 19(12-3.
s New Orleans Medical Journal, April, 1901.
'.» Journal Am. Med. Association. May 27, 1905, p. 1671.
in. Correspondcnzblatt fiir Schweizer Aerzte, .Dec. 15, 1901,
xwi.. p. 7SY
11. Bull, e.t Mem. de la Soc. de Chir., 1903, xxix.
12. Zeitschrift fiir orthopadische Chirurgie. xvii.
]:; Societe de Chirurgie, Paris, June 25, 1902.
1 1. Ueber Knochen und Knorpelersatz, Wiener klinische
Wochenschrift, 1903, xvi, 1424-1429; Jour. Am. Med. Ass'n.,
1905, p. 1756
l.">. Amer. Jour. Orth. Surg., August, 1909.
16. Boston Medical and Surgical Journal, July 20, 1911.
17 Zeitschrift fiir Chirurgie, Bd. cviii., H. 3-1. S. 424.
is Surgery. Gynecology and Obstetrics, vol. xiv., April, 1912,
p. 327.
Ankylostomiasis. — See Uncinariasis.
Ankvlostomum. — f T urinaria, Dochmius. A genus
of nematode worms, family Strongylidoe. A. duodenale
lives in the intestine of man. causing severe loss of
blood. The eggs develop in mud and moist earth,
and enter the body in drinking water or perhaps
through the skin. See Nematoda and Uncinariasis.
Annatio. Aknotta [Orleana). This coloring mat-
ter is obtained from the seed of Bixa OreUana I... a
mall tree of South America, belonging I" tin family
, ,r. The plant is also cultivated in all tropical
countries. Commercial annatto i prepared in a
variety of ways, having foi theirobject the eparation
from the seed of its coloring matter, and its preserva-
tion in a is! or dry condition. The bruised eed is
sometimes washed over a ieve and the liquid allowed
io stand until the annatto subsides; or it is separated
by fermentation. The product i a brownish-red,
resinous substance, usually in moist ma se . but
sometimes in dry, brittle cakes. It has often little or
no. sometimes a sweeti h, re i is odor, ami a saltish-
bitter ie-te. Some lots have a very disagreeable
smell, and are said by Hager to be prepared with
urine. Two kinds are said to lie imported from
French Guiana, one without unpleasant smell, the
Me. A i inrd variety comes also In. in
I. but this is not. so highly esteemed as the be
French.
Annatto is a mixed substance, nearly insoluble in
water, soluble in alcohol, ether, fatly and essential
oils, making orange-red solutions. It consists princi-
pally of a yellow (firellin) and a red Qrixin) resinous
coloring matter.
The principal demand for annatto is for dyeing
fabric.-,, I. m it is also extensively employed to color
butter and cheese. In the tropics it is largely em-
ployed tor coloring foods for table use.
II. II. RuSBY.
Annonaceae. — (The Custard-Apple family.) A fam-
ily of nearly fifty genera, pertaining almost wholly to
the tropics, of both hemispheres. They yield a
number of the most delicious of known fruits, such as
those of .1 mama and Duguetia. They are classed near
the Magnolias and Myristicas, and, like them, are
rich, chiefly in the bark, in volatile oils, for which
they are considerably used in domestic practice.
H. H. Rusby.
Annulata. — An old term used to include the leeches,
earthworms, and other segmented worms.
A. S. P.
Anodynes. — This term (a, privative, and &divq,
jiain) is applied synonymously with analgesics (a,
and aKywia) to a small class of drugs whose peculiar
action is to relieve pain. The anesthetics, which also
relieve pain, but by suspending all sensation, together
with consciousness and motility, are not anodyne's.
By far the most important member of this group is
opium (which see). Though other remedies occasion-
ally relieve the milder degrees of pain, opium alone can
be relied upon to remove severe suffering. It has its
limitations, in occasional paroxysms of agony such as
attend the passage of renal and gall stones, when
nothing short of absolute anesthesia will bring relief.
Here opium, in doses so high as-even to endanger the
life of the individual, is without effect on the pain. In
the ordinary forms of severe pain a failure of opium to
give relief is almost always due to improper ad-
justment of the dose. Of course, the subsequent ill
effects of opium, such as nausea, constipation, and
narcotic addiction, may be so marked as to form a
contraindication, more or less strong, to its use. Hut.
the point here emphasized is that, as an anodyne pure
and simple, opium, if properly administered, is
almost always successful. In certain subjects, partic-
ularly women and nervous persons, the intoxicating
effect of opium predominates in the moderate doses.
In such cases the dose must be cautiously increased
beyond the limits usually prescribed, or else the
opium must be combined with some nervous sedative,
as bromide of potassium or chloral. For it should
453
Anodynes
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
be remembered that opium is, in analgesic doses, by
no means always a hypnotic. In many cases in which
it completely removes pain, the patient does not close
his eyes in sleep the whole night.
The common cause of failure in securing the anal-
gesic effect of opium is conformity with a strict ami
arbitrary posological standard, and forgetfulness of
the fact that there is much difference in the capacity of
different individuals, and of the same individual at
different times, for the drug. Under the influence of
severe pain, the toleration for opium increases enor-
mously. In general and pelvic peritoneal inflamma-
tions, for instance, it may be necessary, in order to get
the full effect of opium, to administer it in doses up to
four grains (or its equivalent in morphine) at a time,
and to repeat with sufficient frequency to keep the
patient just short of narcotism. This bold use of
opium in pelvic inflammation has come into practice
of late years, and some of the figures published of the
amounts actually administered are very large. They
are not given here, however, for the reason that no
definite figures reported in one case should have any
weight in determining the amount to be given in an-
other case. It is needless to say that, in the case of a
patient suffering from a frank peritonitis, which calls
for the employment of these heroic doses, and when
the individual is held just on the verge of narcotism,
with respirations perhaps lowered to ten_ or twelve
per minute, no standing order should be given in ad-
vance for a stated administration of the drug, and that
each dose should be given by the practitioner himself,
who should on no account leave the case, and who
should have at hand atropine and a faradic battery
ready for instant use in case the narcotism goes too
far.
Among the derivatives of opium, morphine, as an
anodyne, stands facile princeps. Its convulsant,
constipative, and diaphoretic properties are all less
than those of opium, while as an analgesic it is even
more active than the drug from which it is derived.
Of the other principal alkaloids, the analgesic effect
upon man is in the following order: narceine, the-
baine, papaverine, and codeine. The interval be-
tween the strongest of these and morphine is, however,
great, one authority claiming that narceine is four
times weaker than morphine, and in practice it is
found that none of them can be relied upon with
certainty in pain of a severe character. The prompt-
ness and effectiveness of morphine as an anodyne are
usually enhanced by the hypodermic method of
administration. Dionin is an opium derivative use-
ful when instilled into the eye in 5-10 per cent.
solution.
Chloroform is at times an anodyne. This is es-
pecially t he case when injected subcutaneous]}' in
the vicinity of a nerve, as in sciatica and other forms of
neuralgia. Administered by the mouth it also has a
local analgesic effect, due partly, no doubt, to its
revulsive counterirritant action. It is thus of use in
gastralgia and flatulent colic. The spirit of chloro-
form, in doses of o i- in hot water, is an eligible form
for the internal administration of chloroform, and the
Spiritus ^Etheris Compositus, commonly called
Hoffmann's anodyne, may be used in the same doses
for abdominal pain. The so-called chlorodyne, a
British nostrum, has under various modifications
been pretty widely used. One of its many formula?
is this:
Morphina? hydrochloratis gr. viij.
Aqua? fl " 3S.
Acidi hydrochloriei fl 3ss.
Chloroformi fl ."> iss.
Tinct. cannabis indicse fl 5i.
Acidi hydrocyanici dil. U. 8. P.. . . n\ xij.
Alcohol" fl Bss.
01. menth pip n^ ij.
Oleoresinse capsici n\ i.
The adult dose is from five to ten drops. This may
be well replaced in the same dose by the Tinctura
Chloroformi et Morphinse, B. P., which was intended
to be its official substitute.
Belladonna may be considered a feeble anodyne.
Administered with opium it has not only a corrigent
effect, mitigating some of the unpleasant symptoms of
the latter drug, but is also apparently, to a certain
extent, an adjuvant.
The various coal-tar products, whose name is now
legion, have a certain anodyne value. Antipyrine,
acetphenetidine, acetanilide, lactophenin, are a few
among the many. (See also under Antispasmodics.)
Cannabis indica is a still weaker anodyne, if it
deserves the name at all. Its hypnotic action can
overcome a moderate degree of discomfort, but not
much actual pain. It is of some repute in the treat-
ment of chronic migraine.
There are, besides the foregoing, one or two drugs
which deserve mention as local anodynes, although
their commoner use is as local anesthetics. For ex-
ample, cocaine is chiefly employed to produce an-
esthesia, as of the cornea, or by injection to anesthe-
tize the field for a circumscribed operation. Its
anodyne action may be obtained, however, in con-
junctivitis, in painful hemorrhoids, etc. A four-per-
cent, solution may be employed. But the ever-pres-
ent danger of» establishing the cocaine habit must
always be borne in mind before resorting to cocaine
as an anodyne.
Cocaine itself is much less soluble in water than its
salts, e.g. the muriate; but the former is soluble in
fats, while the latter are not. Hence in ointments the
cocaine itself should be used, and not its salts.
Eucaine has been found in many respects a useful
substitute for cocaine.
Charles F. Withington.
Anopheles. — A genus of mosquitos which transmits
malaria. No other genus of mosquitos is known to
carry this disease. Anopheles is distinguished from
Culex, a mosquito often associated with it, by the
fact that, though the body is straight, when at rest the
anterior end is lower than the posterior; Culex stands
with its body nearly parallel to the surface on which
it rests and has a distinct bend or hump. A. pun/li-
pennis and A. maculipt mi is range nearly all over (he
United States; A. crucians is a southern species.
See Insects, poisonous. A. S. P.
Anophelinae. — The family to which the malarial
mosquito belongs. The eggs are laid singly on the
surface of the water; the larvae, or "wigglers," when
at the surface of the water hold the body parallel
with it; and the adults have palpi that are as long, or
nearly as long, as the proboscis. See Insects, poisonous.
A. S. P.
Anoplura. — Lice. Small wingless insects: the head
bearing a short tube furnished with hooks; feet
terminated by a single long claw. These animals are
exclusively blood sucking in their food habits. Man
is infested by three species of the genus Pediculus.
See Insects, parasitic. A. S. P.
Antacids. — See Alkalies.
Antenatal Pathology. — See Embryos, Human.
Anthelmintics. — Agents rendering harmless or
killing worms. A vermifuge is an agent which expels.
worms, a vermicide one which kills them, but these
terms are occasionally used as synonyms.
A priori any agent thus used must cither be in-
soluble in the gastrointestinal juices, and therefore
non-absorbable, or else, if soluble, must possess the
454
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Aflthi'inls
faculty of being innocuous to the host at the same time
thai it is destructive to the intruder. Drugs of this
latter class arc few, and the employment of nearlj
all absorbable drugs is distinctly hazardous, for their
dose is necessarily large, and they uot infrequently
luce various phenomena of poisoning.
,,. convenience worms may be divided into four
p , each with its own treatment: tape worms or
, ; round worms; hook worms; scat, pin, or
thread worms.
Tapeworm or Tania. — Drugs used in tins condition
arc: male fern, pelletierine and pomegranate from
which it is derived, pumpkin seed, thymol, kamala.
and numerous others of minor importance.
In the treatment of tapeworms the method of
cedure is of as much importance as is the choice of
edy to be employed. An absolute essential
is the withholding of all food from the patient for
a twelve to twenty-four hours. If this is imprac-
ticable the drug should be administered before break-
fast, a light supper only having been partaken of the
previous night. About three-quarters of an hour
after the administration of the anthelmintic an active
e should be administered. Castor oil, from
half an ounce upward, appears to be preferred to all
other.-., but should not be used with male fern. As
desideratum is the removal of the head or heads
e ..inn or worms, the stools should be carefully
lined for their presence, and in any case a high
tal injection should be given, preferably of saline
'ion, as this is most useful in bringing away the
head of the taenia, which may be narcotized but not
dead. It is of the utmost importance that the
bowel discharges be destroyed.
(if the agents used against this worm, five are
largely and successfully employed, though at times
two or even three drugs may have to be successively
I. and the treatment may even then fail. Male
fern (aspidium) is most useful in the form of the
oleoresin, given in four capsules of fifteen minims
each, at one dose, or in two doses half an hour apart
in combination with calomel. Pepo is most effective
and may be used by taking two ounces of the pow-
dered pumpkin seeds to make an emulsion or a con-
fection, this amount being the usual dose. Thymol
is one of the most available remedies, and may con-
veniently be given in capsules of ten grains each, one
ule being taken every quarter of an hour until
two drams are taken. Alcoholic beverages should
be avoided when thymol is used. Pomegranate is
used by taking two ounces of the bark, adding this to
two pints of water which is boiled down to one pint,
and of this a wineglassful is taken ever}' half-hour; and
it> alkaloid, pelletierine, in the form of the tannate,
may also be used in three-grain doses. Kamala is
by Brumpt to be insipid and therefore very well
suited to children, but inert in adults. It sometimes
produces gastroenteric irritation. Dose, half to
one gram for each year. All other teniacides are
either inferior to the preceding or dangerous (chloro-
form, turpentine).
Children under two years of age react badly to
teniacides as a rule, and great care must be taken in
treating them for this condition.
Round Worm or Ascaris Lumbricoides. — These
worms affect children rather more than adults, and
infest the upper part of the small intestine, though
rarely they work their way up into the stomach, and
n into the esophagus and pharynx. Santonin,
the active principle of santonica, is regarded as a true
ific vermicide for round worms, and when given
with castor oil (5ss) in doses of gr. £ (0.01) for
each year of the child's age it should occasion no
toxic symptoms. The adult dose should not exceed
gr. iii. (0.2). To augment its action thymol or calo-
mel may also be given. The older drugs like worm-
seed and pink root hardly have any special field of
usefulness, being less certain of action.
[n treating any patient for the presence of a caride .
it is in ce ary, as in the case of tapeworm, that food
lie abstained from for twelve or, better, twenty-four
hours; that an active puree be administered about
three-quarters of an hour after the re ly ha been
taken; and that the bowel discharges be destroyed.
Haul: Worms. — The parasitism of Necator ameri-
cantlS or hook worm, and il - closely related congi
Ankylostomum duodenale, with the disease which
I hey produce is naturally eon idered in full elsewhere.
From the therapeutic standpoint thee intestinal
parasites are amenable to vermicides like the preced-
ing. As in the case of the teniae th mo I efficacious
arc male fern and thymol. In the mines where anky-
lostomiasis prevails, male fern (oleoresin) is freely
combined with both castor oil and chloroform, all in
full doses, very energetic treatment being necessitated.
In the uncinariasis of the United States thymol is
given in full doses of the powdered drug. Oils, alco-
hol, or other solvent substances must be avoided
during the treatment lest fatal poisoning results.
Water is of course permissible. With this precaution
the drug may be given hourly on the fasting stomach
in fractional doses, the full amount not to exceed
150 grains (10.0). The number of other substances
having some power over the hook worm is large.
It comprises oil of wintergreen, oil of eucalyptus,
/3-naphthol, etc.
Seat, Pin, or Thread Worms; Oxyuris Vermic-
\daris. — These worms generally infest the rectum and
colon, and are most common in children. Anthel-
mintics used against the tape and round worm can be
employed, as many of them are equally destructive
to the seat worm. The only rational procedure, in
fact, is to attack the worm from above. Thymol,
santonin, and calomel are all eligible, given as in the
case of round worms and tapeworms.
In regard to local injection treatment there is no
good reason for the belief that infusion of quassia, that
time honored empirical remedy, is superior to in-
fusions of wormwood or tansy; or that these vegetable
bitter infusions are superior (when internal treat-
ment is used) to simple clysters of oil, glycerin, and
water or saline infusion. If a parasiticide is indicated
there is nothing superior to an injection of infusion of
santonin itself. Before using this or any other injec-
tion the bowel should be thoroughly cleansed with
soap and water, and it is imperative that the injec-
tion be retained, by pressure over the anus, for fifteen
or twenty minutes, and that the region around the
anus be thoroughly washed with salt and water.
Failure to observe these precautions will render the
treatment of little avail.
For cleansing with soap and water and for injecting
the medicament a soft rubber catheter or rectal tube
will be found most useful in aiding the solution to
go well up into the colon, and it is advisable to repeat
the treatment two or three times at intervals of a
day or so. Charles Adams Holder.
Edward Preble.
Anthetnis. — Chamomile; Roman, English, or Garden
Chamomile. "The dried flower-heads of Anthemis
nobilis L. (fam. Compositie), collected from cultivated
plants" (U. S. P.). In this definition the Pharma-
copoeia recognizes the fact that under cultivation the
aroma and flavor of the chamomile grow finer and less
rank and heavy, notwithstanding that the percentage
of volatile oil, and very likely the medicinal strength,
are somewhat decreased.
The chamomile plant is a native of Europe and is
largely cultivated in temperate regions. It is a low
perennial, hairy herb with a branching rhizome,
and rather numerous stems, most of which are short
and bear leaves only. The flowering stems are long,
slender, prostrate, often rooting at the base, but
ascending and branched above, and bearing the
flowers at the ends of the branches. Flower-neads
455
Antliemls
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Fig. 254. — Chamomile,
"Wild or Single-Flowered
Plant. One-third natural
size. (Baillon.)
radiate, about two centimeters (f in.) across with,
in the "single" (natural) form, a single row of
white rays and a yellow disk. Involucre of two
or three rows of blunt, appressed, scarious-margined
.scales. Receptacle chaffy, conical, solid, longer than
broad; ray flowers fertile, limb three-toothed; disk
flowers perfect, tubular below,
bell-shaped above. Achenia
obovate, slightly compressed,
pappus none. The oil glands
are mostly on the corolla tubes,
and less abundant on the ray
than on the disk flowers. Un-
der cultivation, ligulate flowers
largely replace the tubular
disk flowers, so that the heads
become "double" and large
and white, which condition, by
careful and rapid drying,
should be preserved in the
dried heads.
Chamomile contains nearly
one per cent, of a blue volatile
oil, turning greenish or yellow-
ish with keeping and having a
specific gravity of .905 to .915.
The important constituents of
this oil are anthemol (C, H 1(i O)
and cumin aldehyde (<',II 4 .C 3 -
Hj.CHO). The composition of
the remainder of the oil is very
complex. With the oil there
are an amaroid, some resin,
and a little tannin.
Chamomile is one of the
very best of the aromatic bit-
ters, and is strongly carmina-
tive and somewhat antispas-
modic. The dose is gr. xv.-lx.
(1.0-4.0). There is no official preparation. The best
form of administration is a tincture, so as to contain
all the oil. As a simple stomachic a decoction or
infusion is excellent. This should be well diluted,
taken slowly before meals, and the dose should be
small. The oil is often given as a carminative and
antispasmodic, in doses of iro i. to v. (0.00-0.3).
Allied Plants. — The genus contains about eighty
species, and includes the common mayweed (Anthemis
cotula Linn.). They are generally less agreeable
than chamomile, and although of simiar qualities, not
in use. Chrysanthemum parthenium Pers. (feverfew)
is sometimes used as a substitute or adulterant of
this article. It can be told by its flatter and less
chaffy receptacles. Henry II. Rusby.
Anthracosis. — The deposit of fine particles of carbon
in the body tissues is known as anthracosis. Carbon,
either in the form of soot from smoke or dust from
unburned coal, is one of the most common forms of
dust, and under the ordinary conditions of civilized
life is almost constantly present in the atmosphere.
It may gain entrance to the tissues either through
the respiratory tract or through the alimentary canal.
The inhalation origin of anthracosis has been accepted
without question until recently when, through the
investigations of Calmette, Guerin, Van Steenberghe,
and Grysez, the opinion has gained ground in France
that the deposits of carbon dust in the lungs and
bronchial glands are the results of ingestion and not of
inhalation. Experiments on rabbits showed that
ligature of the esophagus prevented anthracosis;
while, when swallowing was permitted in animals
having one bronchus plugged with cotton-wool, the
corresponding lung developed anthracosis in the same
degree as the other lung. Repeated experiments by
the investigators named have shown that finely
powdered coal dust, cinnabar, and India ink may pass
the intestinal wall into the lymphatic system and
thence into the lungs and bronchial glands. The
intestinal epithelium apparently plays no part in the
transmission of the dust particles; it is accomplished
chiefly or wholly by the leucocytes. In young
animals the pigment thus taken in through the
intestinal mucosa is largely filtered out by the mesen-
teric glands, but in older animals a larger port ion of
the dust or pigment particles passes on through the
thoracic duct and thence into the lungs. Feeding
experiments show that pulmonary anthracosis may
develop rapidly in this way. Calmette argues,
therefore, that physiological anthracosis is chiefly due
to an ingestion of carbon dust. Only after a pro-
longed stay in a very smoky atmosphere does inhala-
tion play an important role in the production of this
condition.
Biondi has confirmed Calmette's statements in so
far as experiments with powdered graphite are con-
cerned, but points out that metallic dust acts in a very
different way from carbon dust. When ingested the
former is dissolved or chemically changed and is nol
deposited in the lungs or bronchial glands, so that
deposits of metallic dust occurring in the lungs i
be the result of inhalation. Petit has also confirm. 1
Calmette's views by the feeding of charcoal dust to
infants suffering from fatal conditions such as tuber-
culosis and marasmus. To prevent the entrance of
any of the dust into the respiratory tract it was given
in a suspension through an esophageal tube. At
autopsy the mesenteric glands, lungs, and bronchial
glands of the tuberculous infants showed anthracosis,
but it was absent in the glands of the marasmic
infants.
In Germany the work of the French observers has
been generally discredited, and the German patholo-
gists have not accepted Calmette's views. Schultze
found in feeding experiments carried out upon
guinea-pigs and rabbits that deposits of the pigment
were present only in the intestine and lung, and
regards this as evidence that some of the carbon dust
had been inhaled accidentally. Aschoff's experi-
ments with the feeding of carmine were negative.
Miranescu in a series of feeding experiments with
India ink, carmine, and charcoal emulsion obtained no
pulmonary deposits as the result of ingestion alone.
Likewise the feeding experiments conducted by
Feliziani proved negative. On the other hand, inhala-
tion experiments carried out by various workers upon
the guinea-pig, rabbit, and dog show that inhaled
carbon dust can penetrate the lungs and after entering
the lymphatics pass to the bronchial glands.
In this undecided state the matter stands at the
present time, and a thorough investigation of the
whole subject of anthracosis seems necessary in order
to settle this and the other important questions arising
out of Calmette's claims. If the ingestion theory of
anthracosis is shown to be correct, it would appear
not at all improbable that many of the inflammatory
affections of the lung, as well as tuberculosis, are the
result of infection by way of the intestinal tract.
Other recent contributions to our knowledge of
anthracosis deal with its relation to tuberculosis.
Among these may be mentioned Ribbert's view that
anthracosis is largely determined by a previous
healed tuberculosis, although he rejects wholly the
ingestion theory. Wainwright in a study of the
miners of the anthracite region in Pennsylvania found
the death rate from tuberculosis among them to he
only 3.37 per cent, for adults as opposed to 9.97 per
cent, in all other occupations. Wainwright and
Nichols have also carried out experimental investiga-
tions to determine if pulmonary anthracosis rendered
the lungs less susceptible to tuberculosis, as has been
claimed in the case with miners. Two sets of guinea-
pigs were given intratracheal injections of tubercle
bacilli. One set had been kept for two months in an
atmosphere saturated with coal dust. In this group
456
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Anthrax
of animals the lungs remained practically free,
although abdominal tuberculosis developed. The
control group developed pulmonary lesi 3. No
satisfactory explanation of this phenomenon wa
discovered, bul il was thought thai the soluble all
f |ime contained in coal raighl have an inhibiting
,n upon the growth of tubercle bacilli, or thai
. ., i,, changes occur in the structure of the lungs
that render them less susceptible to infection. On
the other hand, marked anthracosis of the lung 1
often associated with a chronic fibroid tuberculosis.
Avnn; u osi ~ l' rl M " sl M - "The lungs of the
arc grayish-pink wil ;ment, but in a very
ler ordinarj condit ions deposits of blai
pigment appear in spots over the surface of the ■
\. a rule it i not well marked before the
.,. bul may be - arly as the third or
fourth month after birth. It increases with age and
ording to the conditions of life of the individual
.,,..,, engineers, coal-miners, dwellers in smoky
:.). Only a very small portion of the carbon
tied cains entrance to the tissues, the greater
g thrown out in the exhaled air, in mucu
tic cells, aided by the cilia of the respiratory
epithelium. Desquamated epithelial cells and 1>
ntaining carbon pigment are always presenl
in the alveoli. In early stages of anthracosis the
lungs 1 >ver with small black granules on the
surface, often arranged regularly about the lobules.
In more advanced cases the pleural surfaces of the
lungs may -how heavily pigmented bands corre-
iding to the intercostal spaces, while the portions
urface corresponding to the ribs are less
: pigmented. The posterior and middle por-
e usually chiefly affected, although occasion-
ally the apices show it. The parietal pleura may be
ilarly marked in black bars or stripes. Small
flattened black nodules are often seen in or beneath
the visceral pleura. They are hard and dense, and
often calcified. For the greater part they repre-
healed tubercles; in these the pigment shows an
cial tendency to collect. Microscopically the
nent is found chiefly in the primitive lymph nodes
along the course of the lymphatics in the peri-
bronchial connective tissue, interlobular septa.
1 walls of the arteries. The bronchial nodes arc
heavily pigmented. In the ordinary physiological
■ the anthracosis does not extend beyond the
bronchial nodes, and no ill effects result.
In the more marked cases (coal-miner's lung) the
lungs may be slaty and black throughout, and either
are diffusely indurated (anthracotic induration) or
present nodular areas of black induration. Softening
of the latter may occur, leading to the formation of
ities filled with a black granular material {phthisis
a). This softening may be non-bacterial in origin,
1 should not be regarded as tuberculous without
microscopical examination. On microscopical exami-
nation the advanced case of anthracosis shows
usually chronic bronchopneumonia and induration
erstitial pneumonia). The epithelium of the
iles and alveoli is granular, pigmented, and
quamating. The loss of the epithelium increases
the tendency for the pigment to gain direct entrance
into the capillaries. Chronic adhesive pleuritis is
usually present also. The bronchial glands are black
and indurated, but softening (suppuration, tuber-
culosis) is not uncommon and the softened node may
break through into the blood-vessels, bronchi, or
trachea. The pigment may then be carried to spleen,
liver, kidneys, etc. Even without such a rupture into
the vessels, pigment may be found in these organs in
severe cases of anthracosis, so that a direct passage of
carbon granules from the pulmonary alveoli into the
capillaries must be regarded as possible. In severe
anthracosis the lymph nodes of the mediastinum,
cervical and retroperitoneal regions may become
anthracotic. In the ca e ol the abdominal lymph
nodes the anthracosis may be the re nil of a retro-
grade metastasis. From the softened bronchial
nodes the pigmenl ma} be carried into the walls of the
trachea, bronchi, bl [-vessels, and esophagus,
u ually after tdhi to these si rucl urea have
occurred as the resull of a periadeniti . Ei n and
perforation may lead to the establishment of com-
munications between esophagus and bronchus with
resulting moisl gangrene of the hum. Indurated
anthracotic bronchial nodes may al I tion-
dh erticula of t he i ophagus.
Anthracosis of the Spleen. — Following the
rupture of a softened or tuberculoid I hial node
into the bl l-ve i I (pulmi mai j ' ein pari ii le of
carbon enter the arterial circulation, and tire carried
to the various organs where they lodge first upon the
helium. They are then passed into t he I
ic phagocytic cells so thai within a relatiyelj hort
time the pigmenl disappears from the circulation.
In the spleen it is cull, ■del around the trabei :
the adventitia of the arterie , and follicles. _ Pign
lies may til-" be found in the endotheliui
splenic veins. To the naked eye the pigment appears
as small black points, scattered over the cut surface,
but in very severe cases the spleen may be slate
colored and indurated. A moderate degree of anthra-
cosis of the -pleen is not uncommon in old people,
particularly those with emphysema, and who live
in a smoky place. It is probable, therefore, thai the
pigment can pass directly into the _ pulmonary
capillaries, and thence into the systemic circulation.
Anthracosis of the Liver. — Carbon gains en-
trance to the liver under the same conditions as jn the
case of the spleen. The pigment is found first in the
endothelial cells of the liver capillaries, and then col-
lect s about the central vein and the periacinous
tissue, particularly in rudimentary lymph nodes.
To the naked eye it may appear as small black dots
beneath the capsule or on the surface. The portal
glands may be slaty or black. In very severe ca
the interlobular connective tissue may become in-
creased (anthracotic cirrhosis); or the deposit of the
pigment is coincident with a cirrhosis.
Anthracosis op the Kidneys. — This occurs under
the same conditions as anthracosis of the spleen and
liver, but is more rare, and is usually less marked.
The pigment is found about the larger blood-vessels.
Anthracosis of the bone-marrow, tonsils, and prr-
iphi ral lymph nodes has also been observed in cases in
wdiich a large amount of carbon has gained entrance
to the circulation through the rupture of a softened
bronchial gland into a pulmonary vein. In the case
of tuberculous softening of these glands a metastasis
of tubercle bacilli may occur at the same time as that
of the pigment. Aldred Scott 'Warthix.
Anthrax. — Synonyms: Carbunculus contagiosus;
Milzbrand; Charbon; Wool-sorter's disease; Mai de
rate; Mycosis intestinalis; Anthracemia; Malignant
pustule; Splenic fever. (See also Carbuncle and
Furuncle.)
A specific, highly infectious disease, common to
most vertebrate animals and communicable to man
(though in varying degree). The disease is not con-
tagious in the ordinary sense of the word, but it is in
a high degree transmissible by means of secondary
media of infection. It maintains its virulence for
long periods, and suffers no deterioration from trans-
portation or variations of climate or other external
conditions. It appears as an acute intoxication,
usually of a restricted part of the body, but later of
the entire body, and is due to the invasion of the
tissues of its host by the Bacillus anthracis. The
disease is primary in animals, and occurs in the hu-
457
Anthrax
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
man subject in two distinct forms, viz., by direct
inoculation, or indirectly by eating the flesh of ani-
mals infected with anthrax or by inhaling dust which
is contaminated with the poison of anthrax, as in the
operations of currying hides, upholstery, mattress-
making, etc. The blood, tissues, and excretions of
an animal dead from anthrax are found to contain a
minute organism, in the form of a rod bacillus,
which has been demonstrated to be the specific and
invariable cause of the disease, and may be obtained
in every fully developed case of anthrax. At the
point of invasion the bacillus first acts as a purely
local poison, producing only a local irritation, but, it
soon multiplies rapidly, and later is conveyed by the
circulating blood into all parts of the body, where
by its enormous numbers it blocks the capillaries
with embolic masses of bacilli, causing innumerable
hemorrhages into the organs and tissues, and effu-
sions into the serous cavities and cellular structures;
and by its specific toxin acting upon the sympathetic
nerve centers it produces great depression of the
vital functions, which often ends in death within a
few days.
Koch first demonstrated that the development of
anthrax is inseparably associated with the life and
development of the Bacillus anthracis, and that only
infected substances which contain bacilli capable of
growth and development, or the spores of the anthrax
bacillus, are able to produce the disease; and that the
propagation of pure cultures of Bacillus anthracis,
obtained from actual cases of the disease in animals,
through more than a hundred generations by trans-
plantation to fresh media, does not change the nature
of the infection; but that material from the last
experimental transplantation possesses the power to
produce anthrax just as certainly and in as typical
form as the original material which was obtained
from the diseased animal.
Anthrax is the most widely spread and the most de-
structive of all communicable diseases which affect ani-
mals. The malady is primary in the herbivora, and is
found in all countries. It is very prevalent in parts
of France, Germany, Italy, Persia, North and South
Africa, and South America. It is least prevalent,
though not absent, in Australia, North America, and
the British Isles. Epidemics of the disease often
appear among cattle and sheep of affected regions, ami
may be fatal at the rate of from fifty to seventy per cent,
of the animals attacked. It also attacks human
beings in infected districts by inoculation from the
lower animals, and is often attended with great fa-
tality. All classes of vertebrate mammals are sus-
ceptible to anthrax. The disposition of the mam-
malia to anthrax may be expressed in this ratio:
herbivora, omnivora, carnivora — the first having the
greater, the last scarcely any susceptibility under
natural conditions. Both omnivora and carnivora
appear to be absolutely immune to local infection,
even when living in notoriously infected districts,
frequently drinking the same water, and roaming
over the same territory in which herbivora may have
been infected, and are dying at the time.
There is no other source for anthrax in man than
direct contact with a diseased animal, or indirect
acquisition through some product of a diseased or
dead animal. Of two hundred persons who ate of
the cooked flesh of a diseased ox, not one became
diseased; while five who handled the fresh meat
became diseased and three died. Whatever the
anthrax toxin may be, it certainly is either not dan-
gerous to man if taken into the stomach, or is de-
stroyed in the pickling and cooking of the flesh.
The disease does not spread by contact or associa-
tion; it can be acquired only by the introduction of
the infective organisms into the body, either through
an abrasion of the skin or a defect in the mucous
membranes, or by the spores of the bacilli finding
their way through the epithelial lining of the alimen-
tary canal or respiratory tract, and so causing gen-
eral infection. The inoculation of these organisms
produces the same fatal effect upon animals as does
the infection from the original source of the primary
disease. Blood taken from a diseased animal is
also fatal if introduced into the tissues of another
susceptible healthy animal; but if the blood is filtered
previous to its introduction, so as to remove all germ-,
it is no longer infectious to a healthy animal (Klebs,
Pasteur).
In Great Britain, anthrax is included among the
maladies specified under "The Contagious Diseases
Acts." In England, numerous outbreaks of anthrax
have been traced to the refuse of washings from wool,
hair, etc., which are discharged into streams or
sewers, and from the solid residue which is used for
manure.
Animals rarely take the disease from other animals,
but obtain it indirectly from the soil or other second-
ary medium of infection. Thus, certain restricted re-
gions or localities become centers of infection where
the disease shows itself year after year. This may
arise from the superficial burial of animals dead from
anthrax, which leads to the infection of the soil,
which, once produced, is not easily eradicated. In
portions of the province of Brandenburg, the owners
of cattle have learned by oft-repeated experience the
exact boundaries of limited districts, and even of
certain fields, where anthrax contamination persists
in the soil. The same condition prevails in certain
portions of the Bavarian Alps.
No ordinary changes of temperature, such as freez-
ing of the ground, affect the vitality of the organism.
Stable implements, veterinary surgical instruments,
etc., may spread the disease among healthy animals.
The bodies of animals when buried are not so dan-
gerous for the propagation of anthrax as are the
blood, intestinal contents, etc., which may be scattered
on the surface of the ground or adhere to gra-s
shrubs, etc.
Herbivorous animals, such as cattle and sheep,
are more susceptible to the intestinal form of anthrax,
but are less often affected by the external form of the
disease, the so-called " malignant pustule."* Others,
such as guinea-pigs and rabbits and white mice, are
less often attacked by the intestinal forms, but are
more susceptible to subcutaneous inoculation by
experiment. The carnivora are less susceptible than
other classes. Animals ordinarily acquire anthrax
by way of the intestinal canal, through infected fodder,
stable litter, manure, or from water polluted by an-
thrax infection; or from infection of the pastures or
fields ow-ing to the exposed bodies of animals dead
from the disease; or from the contamination of the
grass by the anthrax germs from the dead body of an
animal which has been buried in the vicinity.
Direct inoculation of anthrax in man is not very com-
mon. It can happen only in those whose calling
brings them in direct or personal contact with the
diseased or dead animal. There must be also either
an abrasion of the epidermis or a wound of the skin
to insure infection. Veterinaries and knackers have
been more frequently affected than physicians, nurses,
undertakers, or butchers. Herley (the Lancet, Dec.
4, 1909, p. 1664) reports a case of anthrax in a butcher,
one of whose cows had suddenly died; he skinned and
cut up the carcass the same day. The meat was sold
to his neighbors, and the hide to a dealer. Ten days
later the butcher was admitted to the hospital with a
typical anthrax "pustule" on the front of the left
forearm, where he had received a scratch while skin-
ning the dead cow. The whole of the limb was
swollen, and there were several bulla? on the fore-
* "The name 'malignant pustule* is a misnomer, as it does not
contain pus; and when it remains the only manifestation of
the disease, is not particularly malignant" (Bryanl and Buck).
"Suppuration does not occur unless there is a mixed infect
(Keen).
458
i;i:i u;i:\ri. n wdkook or i in: mkdical sen mis
Anthrax
nnii. Temperature was in:; , pulse 92, and respira-
tions 24. This patient nil imalely recovered after a
very severe illness. The flesh of the cow, as stated,
was snlil tn " neighbors" at reduced prices, ami prob-
ably over inn persons partook of it. One woman
who handled the raw meal developed a malignant
pustule mi her face; but no ea se (if iiite-l inal ant hra \
was recorded. A second cow in the same herd con-
tracted anthrax and died, bul was cremated in the
orthodox fashion. There is danger in man from Hies
about those affected with anthrax, as it has been
ived that the virus of many infectious diseases may
ved by insects, either from soiling of their
bodies or limbs with the infectious material, or from
their dejections which may contain the germs of an
infectious disease.
Anthrax in man, in this country at least, is almost,
exclusively limited to those working in animal
products imported from other countries where I he
disease exists. The dead animal is far more dan-
us when thus distributed than is the living
animal to the human beings in its own immediate
vicinity. Infection may occur through the skin.
the intestines, or the lungs. In a guinea-pig a single
Nils of virulent anthrax: is capable of producing
fatal infection. In infected localities the anthrax
bacillus lives in the soil, and may thus render certain
portions of a field or pasture where the bodies of
animals dead from the disease have been buried a
permanent source of the disease to other susceptible
animals through long periods.
The greatest source of danger in this disease lies in
the fait that the virus may be introduced through
the smallest abrasion or injury of the skin or of the
mucous membrane of the alimentary canal. The
degree of susceptibility of different animals to the
poison of anthrax is not uniform. Strong, healthy
animals are more easily affected than the lean or
sickly. One attack affords no protection against a
recurrence of the disease. To show the ravages of
this disease, it may be stated that in Russia, in the
year 1804, no less than 72,000 horses were destroyed
by it. In the province of Novgorod, within four
years, more than 56,000 horses, cows, and sheep, as
well as 525 men, fell victims to this terrible
- 'nirge.
Statistics for the years 1901-1903 show that about
150,000 cases of anthrax were reported in European
Russia and the Caucasus, and about 1,500 in Ger-
many, and 12,000 in Italy. The source of infection
from horsehair could be traced to that brought from
China. Russia, Siberia or South America. In hides
and skins, those imported from China, Bombay, and
t lie East Indies were the most common carriers of
lion. In 1899, Russell traced cases occurring
in Wisconsin to hides received from South America
and China; while Revenal in 1897, attributed twelve
fatal eases in man, and sixty in cattle to Chinese hides.
That material imported from these countries is par-
ticularly liable to contain anthrax infection is due to
climatic conditions; "Places liable to be flooded, and
drying out to a considerable degree in summer,
characterize districts in Persia, Asia Minor, and the
plateaus of Central Asia" (Billings). Willard col-
lected ten cases near Philadelphia, with a mortality
of fifty per cent. The months of July and August
witness the greatest number of cases, when the soil
contains much putrefying organic matter believed
to favor the growth of the organism. Males are af-
fected far more frequently than females; ninety-six
per cent, of 261 cases collected by Legge in Great
Britain being males. (Keen's Surgery, vol. i., 1906.)
There are three portals of entry, corresponding to
the three clinical types of the disease: when the
organisms are (1) deposited in wounds or abrasions
of the skin; (2) are inspired; and (3) when they- are
ingested into the gastrointestinal tract. In Legge's
oases, six only were of the internal variety; the
remainder occurred in eighty-five per cent, upon the
head, face, and neck. In 923. cases collected bj Koch
(1886), mo i of which were contracted from hides
and skins, the head and face were affected in forty-
eight per een!., a n.l I he 1 1| i| ier e\l remit y, particularly
I In hand and lingers, in forty per cent.
The disease spreads among men in proportion as
they are exposed to infection from diseased animals
or men.* Shepherds, farmers, butcher-, coach lie n,
stablemen, as well as veterinary surgeons and tho 6
individuals who handle animal products, such as
wool sorters, curriers, mattress-makers, etc., are
especially exposed. Horsehair is particularly dan-
gerous. Further, articles like hid.-, horns, wool,
eie., from countries where i he disease is prevalent,
which may be transported great distances, are liable
to convey I he infection and Ihus give rise to the mal-
ady among those employed in their transportation or
manufacture. Trousseau mentions two factories in
Paris, in which horsehair from Buenos Avres was
used in upholstering furniture, and in which not,
more than six or eight workmen were employed:
during ten years twenty laborers died in these estab-
lishments from anthrax. Even after the hair has
been long in use, the disease may be induced in the
form of true malignant pustule in those employed
in renovating the upholstering. A small scratch or
crack in the skin or mucous membrane is sufficient
for inoculation, and frequently the disease is intro-
duced into the system by the unclean nails or fingers
of workmen in scratching the face or arms.
At an inquest held recently at St. Pancras on the
body of Henry Stephen Thurston, laboratory at-
tendant at University College Hospital, it was proved
that the deceased had died from anthrax poisoning.
He had developed a boil on the side of his neck which
had been removed after microscopic examination of
matter from it had shown that it was due to anthrax.
After the operation he had progressed so favorably
as to appear out of danger, but a rise of temperature
followed and he died several days after the opera-
tion. The actual source of infection was obscure.
Dr. Francis Thiele, lecturer on bacteriology at the
hospital, stated that experiments in connection
with anthrax had been conducted in the laboratory,
and explained to the jury the possibility of a tube
having been left out in error, in which case it might
have been handled by the deceased. If this happened,
the tube might have been in a condition to require
sterilization outside, and it, would, in fact, have been
sterilized if the attendant had reported having found
it. As he had suffered from toothache, he might
have touched his face and neck and infected the
latter through a scratch. The jury returned a verdict
of "death by misadventure." (The Lancet, July 22,
1911, p. 272.)
The deputy coroner recently held an inquiry into
the death of a workman in the Mersey Docks and
Harbor Board's wool warehouse, which occurred at
the David Lewis Northern Hospital on Dec. 2. The
deceased had been employed at the warehouse for
the last ten years. His duties were to deal with
bales of Persian wool, which had been imported into
Liverpool by a ship from Bombay. Shortly after
6 p.m. on Nov. 29, he drew his landlady's attention
to a pimple on his neck, and said to her, "That's
anthrax. He went to the hospital, where the
lesion was dressed, and returned home. He returned
*"An extensive outbreak of anthrax among cattle has been
discovered on the East Kami, which has evidently been in progress
for some time. This disease is always specially dangerous in
South Africa, as most natives will feed readily on the half-cooked
flesh of animals dead from disease. A large number of cattle are
officially reported to have died from the disease already, and one
adult native. It is probable, however, that there have been other
deaths which have not been recorded. The Agricultural Depart-
ment has taken up the matter and has imposed stringent quarantine
over the area. It was, however, uncommonly slow in acting in
the first instance." — The Lancet, March 9, 1912.
459
Anthrax
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
to the hospital on the following day and was advised
to heroine an in-patient, where an operation was
subsequently performed. In spite of this he died
on the following day. A verdict of death from
"anthrax poisoning" was returned by the jury.
[The Lancet, December 16, 1911, p. 1741.')
Ih. disease may be spread from man to man. The
discharge from the pustule (anthrax carbuncle)
contains the bacilli of the disease, and its inoculation
will be followed by the development of anthrax.
Repeated transmissions of virus do not cause a dimi-
nution of virulence: the last generation is as highly
infectious as the first. Anthrax is observed in men
in the proportion of fifty-nine per cent., to forty-one
per cent, in women. The seat of the primary sore,
the malignant pustule, was found by Virchow to be
confined to the face, hands, fingers, forearm, or neck
in eighty-four per cent, of cases. In the rest, sixteen
per cent., the arms and lower extremities were the
seat of infection, and in these cases the patients were
chiefly women and children, in whom these regions
are more exposed than in men.
There is a varying susceptibility to anthrax among
different families of the same race. This has been
observed in both men and animals. Thus the negro
is less susceptible than the white man, and certain
breeds of sheep, notably the Algerian variety, are
less susceptible than are other breeds. Deer, reindeer,
and elephants are also liable to the disease.
The bacillus of anthrax is famous as being the first
microorganism to be discovered as the actual cause
of an infective disease.
" The bacilli of anthrax can live only a relatively
brief time; but the spores have unusual tenacity
of existence. They may remain dried up for year-.
and then be brought to further development if placed
in favorable conditions of heat and moisture. If the
spores are transferred to animals, they develop into
bacilli, and there is scarcely room to doubt that men
and animals are quite as often infected by spores as
by full-grown bacilli. There are facts which render
it nut impossible that the anthrax bacilli may exist
in other places than the bodies of men or animals,
and may there complete their cycle of development.
Such places are marshes, the banks of streams, and
the like. If it is possible for them to be carried by
high water to the pasture lands, we have an ex-
planation of those sudden endemic appearances of
anthrax which sometimes occur in places pre-
viously free from the disease." (Struempell, ''Text-
book of Medicine," translated by Vickery and Knapp,
1912, Vol. i, p. 15S.)
The infection with anthrax in man is little common
in comparison with its ravages in certain animals.
In the years 1S93-1S99 in Germany, according to
statistics, 604 human beings were infected with
anthrax, with ninety-six deaths; while 29,686 animals
were attacked with the disease. Even in "anthrax
districts" this disease occurs only in single occasional
cases, and never in the form of an extensive pestilence.
A partial explanation of the relative exemption of
human beings is an apparently lessened disposition
to the disease in the human subject than in cattle,
as the human anthrax in the great majority of cases
recovers, while this disease in animals gives only a
small percentage of recovery.
In Santo Domingo in 1770 it was the cause of the
death of 15,000 persons in the space of six weeks
from eating the flesh of animals dead from the disease.
Other observers in mostly tropical countries report
as low as twelve per cent, or even five per cent,
mortality. Such a statement should, however, be
taken with some amount of reservation. In forty-
eight cases of external anthrax treated at Guy's
Hospital in London, thirty-nine recovered after
operation for the destruction of the local disease.
The infection of a wound of entrance by the poison
cannot be prevented by the immediate irrigation
460
of the wound by corrosive sublimate or carbolic acid
if the bacilli have once gained entrance into the flesh.
The disease is by no means always fatal to animals.
Fagge states the average mortality among horses and
horned cattle to be seventy per cent.
Clinical Course. — External Anthrax. — During
the first day the seat of infection is more or less
irritable, sometimes painful. The continued itch
of the part, with augmentation of the redness, an
edematous swelling, together with shooting pains in
the locality, with red lines beneath the skin, marking
the course of the swollen lymphatics, are among the
strongest initial symptoms of anthrax. As the disease
progresses, these conditions increase in inter it.y,
and the tissues about the point of infection become
discolored and variegated in tint. The formation
of a vesicle at the point of infection, with subsequent
rupture, and the appearance of a crust or seal,
decidedly characteristic, lever is often pre
even at this stage, though it may not be observable
in the early stages. Diarrhea is frequent. Malig-
nant cases may terminate fatally in from twenty-
four to forty-eight hours, often preceded by colla]
During the second day there usually* app.
vesicle varying in size from one to three centi-
meters with a yellowish or brownish exudation. At
about the third day, the vesicle bursts and shrinks,
leaving a brownish base, exuding serum. On the
fourth day there is a black, dry. depressed crust or
scab, often called the eschar, which is surrounded
with a very characteristic, slightly elevated bolder
or wreath of small new vesicles. There may be other
discrete or confluent vesicles in the neighborhood.
Pus is first observed at the end of the tenth or fif-
teenth day, if the patient lives so long, when the
separation of the sloughing eschar, accompanied with
suppuration, occurs in the usual manner. There is
then usually a mixed infection.
The initial symptoms of anthrax are similar to
those of other acute febrile diseases: weakness, ma-
laise, chilliness or moderate rigor, headache, thirst,
restlessness with or without mild delirium, some-
times vomiting, and disturbed sleep. The subse-
quent symptoms vary in character and intensity
according to the external localization of the disease.
If this is in the stomach, there may be obstinate
vomiting; if in the intestine, persistent diarrhea; if
in the pulmonary structures, rapid breathing, with
symptoms similar to those of extensive pneumonia,
cyanosis, and speedy collapse. Serious disturbance
of the brain may be associated with any of these
conditions, accompanied with convulsions and coma.
The temperature curve is similar to that in other
acutely toxic febrile conditions, ranging from 102°
to 105° F.
Dr. Hamer reported a mortality of forty per cent,
in eases of anthrax of the neck, while the mortality
in cases in which the primary lesion was situated
upon other parts of the body was twelve per cent.
Anthrax is less fatal in tropical countries, where
the condition of the climate, heat, sunshine, etc., may
produce diminished virulency of the specific organism
of the disease. Perhaps a greater resistance to the
effect of the bacilli, or of their toxins, on the part ol
the inhabitants, or a greater toleration of the infective
poison, may account for the less fatal character of
the malady in those regions where the mortality has
been reported as extremely low, varying from zero to
one per cent.
A pronounced systemic reaction with much local
inflammation has been thought favorable to recovery.
In asthenic conditions of the system the prognosis
is less hopeful. The pulse, respiration, and tem-
perature are not always indicative of the gravity of
the disease or of the probable result.
Dr. Bell gives the following table of mortality in
relation to the duration of the disease:
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Anthrax
2d
:i,l Ith 5th 6th 7ih -
1!
1 I
r nine days, 1 case; total, 55 cases.
Internal Anthrax. — Fur convenience of description
anil clinical study, this type of the disease is divided
into intestinal anthrax and pulmonary anthrax, or
wool-sorters, disease.
inal Anthrax (Myco I "alis). — In some
oases tin- primary lesion of anthrax, the main
En-nil^', is seated upon the internal surface of the
id produces the symptoms known as those
rycosis intestinalis, followed by the same train of
fatal results as when the primary lesion is upon the
external surface. Often the milk and the flesh of
diseased animals are taken as food, and doubtless
the infection frequently occurs from this source.
The course and symptoms of this form of the disease
are not well understood. Often the workmen
engaged in slaughtering diseased animals become
infected by direct inoculation, while those eating the
flesh of the same animals experience no harm. It is
probable that the bacilli are destroyed bytheproi
of cooking, which generally require an elevation of
temperature sufficient for their sterilization; or pos-
sibly they may be rendered harmless by the gastric
digestion: but if they succeed in passing the stomach,
they may then become seated in the mucous mem-
brane of the bowel and there produce the disease.
Intestinal anthrax is rare in man, though it has
bee ally reported. (For a most intere
al and Surgical Reports," Boston
City Hospital, ls'.i;. p. 126.) The distinction be-
tween the intestinal and pulmonary forms of anthrax
is not easily made, and doubtless the two may often
be confounded with other acute diseases affei
these organs, unless the anthrax bacillus is identified
by microscopical examination, or the disease is
reproduced by inoculation in animals. The diag-
nosis of intestinal anthrax may be quite impossible,
owing to the rapidity of its progress and the sim-
ilarity of its symptoms to those of other gastro-
- 1 inal diseases, especially to those of so-called
"ptomaine poisoning". The course of intestinal
anthrax is almost uniformly fatal, and Bell states
that no case demonstrated during life to be intestinal
anthrax has recovered.
The actual seat of the primary lesion in anthrax
of the abdominal organs is at times uncertain, but in
general the disease is supposed to be conveyed by
means of food, which has been contaminated by
the anthrax bacillus or its spores. Keen in his
- rgery" has called attention to the localization of
the abdominal focus of the disease, and makes the
following observation:
Primary Gastric Anthrax. — "Though infection of the
stomach by anthrax might reasonably be expected
to occur occasionally, so far as I can discover, the
condition is an extremely rare one, a case reported
in the Medical Press, 1904, p. 199, being the only one
1 ran find recorded." An original article by Schmidt
confirms the diagnosis of bacilli from a necrotic
anthrax ulcer in the stomach.
Treatment of this variety of the disease should
comprise rapidly acting evacuants, followed by the
administration of internal antiseptics (germicides),
with supporting measures according to the conditions
present; but the nature of the lesion and the rapid
progress of the disease would preclude the hope of
much benefit from any available means of internal
medication.
Pulmonary Anthrax, Wool-sorter's Disease, Anthra-
cemia. — Primary lesions of the lung occur, but they are
rare, and the channel through which the exciting bac-
teria gain entrance to the pulmonary tissue remains
in question. It is asserted that the bite of certain
cts, particularly the fly and the mosquito nay
convey the disease.
As an aid in diagnosis, the nature of the occupation
of the patient is highly suggestive. This form of
the malady may be acquired by inhalation of the
dust from any of the products of diseased animal-.
I'll us it ha bi en ob i red among those employed in
the handling or manufacture of animal hairs and
woolen rags; among wool-sorters, rag-pickers, and
those concerned in the further manipulations of these
articles into woven textures: and to some '
among paper-makers. Dr. Bell says: "Thesoi
of wools and hair- is unhealthy in proportion to the
contamination they produce in the air inspired by
the workmen. First, the dus( and fine short hair-,
acting mechanically, excite chronic di ' the
lungs, such as bronchitis and phthisis. Se<
ilu-t from dried and decomposing animal ma
produces a low form of septic pneumonia. Third,
the virus arising from the blood and discharges of
animals that have died from anthrax an- specifically
on the lungs."
Pulmonary anthrax is peculiarly a human complica-
tion. It is not often observed as a coincident con-
dition in either cutaneous or intestinal infection.
'"From the paramount dignity in the human econ-
omy of the organ invaded, and the specific tendi
in anthrax to the development of edematous condi-
tions in the tissues invaded, il is not surprising that
pulmonary invasion leads to a most acvite and ge
ally fatal manifestation of anthrax, rei Hi-
ring but seldom." (Billings, "Twentieth Century
Practice of Medicine.")
Laryngeal Anthrax. — In the Munchener medizinische
Tier/,, nschrift, vol. i., p. 40 >, 190d, Emil (das reports
a case of this rare condition, occurring in a carpen-
ter, forty-one years of age, who was brought to the
Klinik on May 9. The disease began on May 2, with a
feeling of chilliness, weakness, and a swelling in the
region of the angle of the lower jaw on the right side.
Three days before admission he suffered from nausea
with acute pain in the region of the stomach. The
patient rapidly became worse and the swelling of the
jaw increased to a considerable degree. On admis-
sion the patient was much prostrated and presented
the appearance of a severe general septic infection,
which seemed to have originated in the phlegmonous
inflammation in the neck. The pulse was 140, very
weak, almost imperceptible at wrist. The abdomen
was moderately distended, sensitive only at epigas-
trium. There was edema over the sternum as well
as over the lower portions of the thorax and in the
region of the lumbar spine. No other changes were
observed on the cutaneous surface nor in the region
of the swelling on the jaw, nor was there induration
of the lymphatics. Xo pain in muscles or joints.
There was much swelling of the right wall of the
pharynx with edema of the adjacent parts, but no
ecchymosis of the mucous surfaces; there was edema
of the right vallecula, where the mucous membrane
hung over the right side of the epiglottis in loose folds
and presented .numerous punctate hemorrhages on
its surface. The patient died the same night. At
autopsy, the stomach showed numerous confluent
edematous elevations on the posterior wall, which
at many points were ulcerated and presented a black-
ish surface. These swellings were scattered over the
interior between the cardia and the pylorus. The
aditus laryngis and the adjacent portions of the
pharynx were edematous, the mucous membrane
was covered with gray spots of superficial necrosis of
the epithelium. Those changes extended on each
side to the interior of the larynx as far as the location
of the vocal cords. In the hemorrhagic edema of
these portions of the submucous tissues the bacilli of
anthrax were found in great abundance. The re-
porter of this case said that in the Handbook of
461
Anthrax
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Larnygology by Heymann no mention was made of
such a case, and he could find no observation of this
form of primary anthrax invasion in the literature of
the subject; so that this seemed to be the first case
of anthrax of the larynx which has been recorded.
In a communication to the Journal of the American
Medical Association, Feb. 3, 1912, is another account
of this rare location of primary anthrax. The patient
was a young woman who had been employed in manip-
ulating different varieties of wool mostly of the gray
and brown Persian kind, which, however, had gone
through several processes before it had reached the
combing-room in which she worked. Exactly how the
infection occurred is not known, for her sister, who
had had anthrax, stated that nothing objectionable
had been noticed in the wool which they had been
handling. At the necropsy made by Mr. F. W. Eurich,
bacteriologist to the Anthrax Investigation Board,
anthrax was found in the larynx, from which general
infection of the system had taken place. In his ex-
perience a lesion in the larynx is unique and does not
appear to have been previously observed. The lungs
were not affected.
The general duration of the pulmonary invasion
before the fatal termination is from two to five days.
The bacilli are often present in the sputum.
Pathology. — The pathology of malignant pustule
consists of the series of changes which follow inocula-
tion with anthrax through either the skin, the alimen-
tary canal, or the lungs. These changes are some-
what different, according to the particular circum-
stances of the individual case. When the virus is
introduced through a scratch or abrasion of" the
skin, the period of incubation, or the space of time
before the local symptoms of anthrax appear, may
vary from a few hours to three days; in rare cases a
somewhat longer time may elapse.
"No matter from what point infection occurs,
when the bacillus enters the circulation widely dis-
tributed changes occur in the tissues. The muscles,
including the heart, are darker than normal, and
frequently contain minute hemorrhages; ecchymoses
may also be found beneath the serous membranes;
even the meninges and brain are affected. In man
splenic enlargement is less constant than in lower
animals. The organ is usually increased in size,
dark in color, and the pulp diffluent. The bacilli
may readily be cultivated from all the organs and
are often present in enormous numbers." (Coplin,
Manual of Pathology.')
Anthrax produces upon the external surface a
somewhat elevated papule, five millimeters to several
centimeters in diameter, with a central depressed
seal). The corium and papillary body become
infiltrated with serocellular exudate and with bacilli.
The perivascular and connective tissue spaces become
filled with leucocytes, and the pressure of this serous
and cellular infiltrate together with the toxins of
the bacteria cause the central coagulation-necroses;
though suppuration does not occur unless there is a
mixed infection. When the serocellular exudation
extends upward to the epithelium, • it elevates the
latter, and produces the typical vesication. In the
edematous variety; the swelling is due to the diffuse
serous infiltrate and to the effect of the bacteria block-
ing or inducing coagulation in the capillary vessels.
The course of the disease may be divided into
three stages. The first or prodromal stage is that of
incubation (period of latency). During this period
the patient presents no marked symptoms of any
serious disturbance. There are localized burning
and itching at the seat of infection, which are gener-
ally thought to be due to the bite of an insect, such as a
flea, which the spot closely resembles. After a period
of incubation lasting from a few hours to three days
(rarely longer) the local symptoms suddenly change.
The second stage, that of eruption, now ensues, in
462
which a small papule is seen at the seat of the pre-
vious irritation. This rapidly increases in height and
in circumference, and generally presents a spot of
dark discoloration at its summit. The itching and
burning increase, and within a few hours a vesicle
appears at the seat of discoloration In the papule.
The vesicle now rests upon an indurated base, and
contains a small amount of a serous, frequently
bloody fluid. In the earliest stage the bacilli of
anthrax are present in the central point, but as these
tissues become necrotic, the bacilli approach the
confines of the lesion, where they are present in great
numbers and from here they invade the tissues in
the vicinity, find their way into the lymphatics and
lymph glands; eventually they gain entrance to the
circulation and are distributed by the blood over the
system. Bacterial embolism is common. The sur-
rounding skin swells so as to form a slight elevation
around the vesicle, which now exhibits the peculiar
appearances to which it owes its name of "malignant
pustule," although this is not an accurate definition
of the pathological condition at the seat of the local
disease. The vesicle, soon ruptures spontaneously,
or is ruptured by the scratching of the patient, and
reveals a dark red base, which quickly dries, forming a
livid or brownish crust. This is the commencement
of the central gangrene or necrosis of tissue commonly
observed in the carbuncle of anthrax. The crust
becomes gradually larger, until it sometimes reaches
a diameter of from one to three centimeters, ami
the swelling and tension of the surrounding skin be-
come more extensive. A line of new-formed vesicles
develops around the margin of the crust, and the^e
vesicles contain a yellowish or brown fluid content.
The crust now gradually becomes free from pain and
tenderness, and a doughy or boggy infiltration is felt
for some distance in the tissues around the primary
sore. The local condition, however, has no diagnostic
value as an indication of the infection of the general
system. In rare instances the local symptoms be-
come less serious, the swelling subsides, the slough
separates and is thrown off, and the ulcer heals by
granulation. In such cases the chief danger is from
septicemia arising from the absorption of gangrenous
matter. It is probable that in such conditions there
is a mixed infection from the presence of other bac-
terial organisms. When general infection occurs the
swelling increases and becomes doughy, the lymph
channels are detected as reddened lines of induration,
the glands become swollen, and burning heat is felt
in the part, which gradually becomes very painful
and later is the seat of stiffness and numbness.
The veins are often seen as dark-colored channels,
and are sometimes plugged by thrombosis.
The foregoing appearances are caused by the local
multiplication of the bacilli of anthrax in the part
which is the seat of the primary infection. The
germs may be found in the central part of the car-
buncle and in scattered groups in the rete Malpighii.
At times large interwoven masses of them are found
in the tissues at this early period, and may be ob-
served to spread into the neighboring parts by ex-
tension beneath the epidermis. In a carbuncle
extirpated by Bardeleben on the twelfth day, which
measured five centimeters in diameter, the bacilli
were present in such enormous numbers that the tis-
sues were eve^where crowded with them; they even
filled the spaces between neighboring cells and ob-
scured the normal structures of the part. In a car-
buncle examined by Wagner the bacilli were so
abundant as to hide the normal tissues. The center of
the pustule is generally the seat of hemorrhage, and
the effused blood is prone to undergo putrefactive
changes. This accident is also frequently observed
in the edematous tissue immediately surrounding
the pustule. From this center of the disease gen-
eral infection of the body (third stage) may now
quickly take place, sometimes requiring but a few
—
REFERENCE IIAXIHWniK of THE MEDICAL Si'llAU -
Anthrax
hours (so-called cas fovdroyants), while others occupy
from three to four, sometimes eight to ten days
for general poNoning of the system.
\ second form of the disease is the "ccdema carbun-
o uiaseu malignum,""Milzbrandoedem." Thisis
observed in rases in which inoculation occurs: in pails
ered with thin delicate skin, such as the eyelids,
axilla, and occasionally the extremities. In the e
. the local sore, the pustule, is not formed, there
is no crust, no central gangrene, nor an erupt i f
icles, but a rosy, bluish, or even livid swelling
appears at the scat of primary infection, and rapidly
spreads in all directions. Generally the spot « here t he
Illation occurred may be seen as a dark point
more or less elevated above the surface, but sometimes
there is no visible point of origin. The swelling is
[uently enormous, so that the arm may be three
or four times its normal size, or the eyes may be en-
tirely closed by large effusions of translucent fluid
in the tissues. Like the previously described local
manifestations of anthrax, this malignant edema may
subside spontaneously without causing destruction of
issues, and the part may be restored to its normal
condition. There is generally abundant desquama-
of epidermis after the disappearance of the
na. At times the swelling is so enormous that
the skin becomes gangrenous to a greater or less
it, and often the edematous area is the seat of
vesicles or blebs which are filled with a bloody serum,
and at the base of which is generally found a slough
comprising the entire thickness of the skin. When
the neck is the scat of extensive edema and sloughing,
the loss of tissue may be so great as to lay bare the
i vessels or other important structures, and death
may ensue from hemorrhage or from some other
it not belonging to the course of anthrax.
< leneral infection of the system corresponds to that
period in the development and multiplication of the
illi in which they have penetrated beyond the seat
of primary infection, have reached the internal organs
by means of the blood channels or other paths, and
■ commenced to multiply in these structures.
The bacilli are probably carried by the blood corpus-
el,-,, which often contain them in considerable num-
bers. The disease progresses much more rapidly in
the intestinal form, probably from the sudden libera-
tion of larger numbers of bacilli, which enter the
circulation from many points at once. The local
tissue changes which ensue upon inoculation with
bacillus anthracis whether the seat of infection be in
the skin, the lung or the intestine, are due to a block-
ing up of the capillaries of the part by the multiply-
ing bacilli. The blood-stream is further impeded
by the inflammatory swelling of the tissues sur-
rounding the vessels, due to the irritation of the ba-
cilli or their toxins, causing ischemia and necrosis.
When the bacilli enter the blood stream directly
or through the lymphatic system, and the infection
becomes general, the bacilli are found most abun-
dantly in the spleen; and the inflammation and
swelling of that organ are characteristic of systemic
anthrax. They are found, too, occluding the capil-
laries of the liver, kidneys, and brain, causing tume-
faction and hemorrhagic infarction of internal organs,
and multiple hemorrhages into the skin and mucous
membranes.
The anatomical appearances in anthrax are those de-
pendent upon a multiplication of the bacillary organ-
isms in the body, and there is hardly a structure or a
tissue in the dead body in which they may not be
found in great abundance. They form thrombi in
the capillaries, the lymphatic channels and glands;
th ■ brain, kidneys, and intestinal glands are found
more or less crowded with them. The most striking
changes are hemorrhages in the tissues, varying in
amount from mere points to large extravasations.
Edematous exudations and serous effusions in the
various cavities, and serous infiltration in internal
■ ■mans frequently ensue. The abdominal organ
generally found in a normal condition, with the ex-
ception of the spleen, which is usually enlarged and
softened iii structure, and contain- enormous col-
lections of bacilli. There is a marked increase in the
number of white corpuscles, and death is quickly
followed by strongly developed rigor morti .
In general appearances the clinical picture of fatal
anthrax closely resembles that of other Form
virulent blood-poisoning. As a rule, cases of malig-
nant pustule terminate fatally in from three to seven
days, though in cases of special virulency death may
occur within a few hours.
The General symptoms of anthrax are usually the
following: Chilliness, or a well-marked rigor, faint-
ness, pains in the limbs, loss of appetite, sometimes
seven' distress in the region of the stomach, colic,
meteorism, vomiting, and diarrhea, frequently accom-
panied by bloody stools. There is excessive thirst.
The patient retains consciousness to the end, unless
coma should supervene shortly before death. Fre-
quently there is great agony with distressing anxiety;
the patient begs for relief in the most piteous manner,
and feels that dissolution must soon ensue. In other
cases there is stupor from the first, or the patient
becomes delirious, or sinks into a deep coma, or the
body may be convulsed by clonic cramps or contin-
uous trismus or tetanic contractions. Occasionally
there are harassing cough and dyspnea with bloody
expectoration. There may be frequent hemor-
rhages in the tissues or from the mucous membranes,
and sometimes secondary pustules are formed which
are similar in all general characters to the primary
lesion. Usually there is considerable elevation of the
body temperature at the period of invasion of anthrax,
the thermometer often registering 40° C. (104° F.),
or higher, for some days, when there is a sudden fall
to a temperature at or below normal, frequently as
low as 36° C. (97° F.). The pulse is generally acceler-
ated, and increases in frequency until death. The
action of the heart is often feeble, and the sounds are
hardly audible. Death usually occurs from collapse
and general cyanosis.
Cases of intestinal anthrax are generally more
virulent than the ordinary forms of malignant pus-
tule, and they result fatally sooner than those in
which the infection takes place from the external
surface. These effects seem to depend upon the me-
chanical action of enormous masses of germs within the
body, and upon the destruction of large portions of
tissue by the growth and multiplication of the bacilli,
together with the added action of the specific toxin
produced by these organisms, which may be sup-
posed to be more rapidly disseminated from this origin
than when the initial lesion is situated upon the cu-
taneous surface. See a very interesting account of
"Charbon" by Larrey in his "Memoirs," vol. i., p.
59, an abstract of which, by Sir H. G. Howse, appears
in the Lancet, December 23, 1S99, p. 1720.
The progress of anthrax when acquired by inhala-
tion is variable, but usually the course of the disease
is rapid, and tends toward a fatal termination. The
symptoms are often unimportant or insignificant
until near the end. In some cases the invasion of
anthrax is followed by sudden collapse with speedy
death of the patient, as from shock; but generally
there is more or less reaction, followed by collapse
and death, without the signs of any inflammatory
lesion in the lungs. When the patient survives a
sufficient time for inflammatory processes to develop
in the lungs, the risk from the anthrax poison is
reduced. The duration of pulmonary anthrax varies
from one to ten days. A large proportion succumb
to the disease within the first four days.
The bacilli may or may not be found in the blood, but
if the disease is really anthrax, the subcutaneous injec-
tion of the blood in a mouse will certainly prove fatal.
463
Anthrax
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
The specific action of the bacillus upon the
body of its host, aside from its presence in enormous
numbers, has been sought in the morphological char-
acter of the organism; the germ belongs to the aero-
bic class of organisms, and is a greedy consumer of
oxygen; and it has been thought, that the great pros-
tration of the system, and the signs of the destructive
action of the disease, as well as its rapid progress,
may be due to the fact that it depletes the red blood
cells of their supply of oxygen, and thus induces a
sudden collapse of the vital powers. This view is
supported by the appearances presented by the dis-
ease in grave cases, in which there is cyanosis to a
marked degree, and the patient dies with all the
appearances of asphyxia. In this respect the organ-
ism of anthrax produces in the animal system an effect
similar to that of certain poisons of the cyanide group,
in which death is uniformly associated with asphyxia.
In cases in which the disease progresses slowly, the
secondary toxins formed by the bacilli are probably
the cause of the fever and other constitutional disturb-
ances. "There can be but little doubt that in the
living body the bacillus elaborates bodies which
either directly or indirectly are toxic to the tissues.
In no other way can the extensive inflammation and
edema be explained. It is perfectly possible that
in the body substances are formed which are not
elaborated in cultures." Osier, "Modern Medicine,"
iii. 46.)
The dissemination of the bacilli through the sys-
tem is chiefly by way of the lymphatic channels
and the glands. Only after passing these physio-
logical barriers can they obtain entrance into the
general circulation and pass to all parts of the body.
Therefore they would not be detected by microscop-
ical examination of the blood, as an aid to diagnosis,
until a period when the condition of the patient is
beyond relief.
Very instructive results relative to the patholog-
ical activity and the paths of dissemination of the
anthrax bacilli in infected animals have been observed
after injection into the anterior chamber of the eye
of the guinea-pig.
After aseptic introduction of a pure culture of
anthrax bacilli in this location, the death of the ani-
mal is often delayed until the fourth or the fifth day
or even longer. No trace of macroscopic suppuration
can be observed in the eye ; and aside from a more or
less evident chemosis of the conjunctiva bulbi, one
would from external appearance consider the eye
perfectly normal. Examination of the aqueous
humor shows that it is swarming with anthrax bacilli.
By microscopical sections the path of the bacilli may
be distinctly traced from the anterior chamber
through the space of Fontana, following the lymph
channels of the sclera and conjunctiva, as has been
demonstrated by Weigert. After similar injection
into the vitreous humor, according to Clifford's
statement, the bacilli are transported by means of
the lymph stream which leads from the vitreous
through the central canal and the central vessels to
the posterior part of the orbit, and from here to the
cavity of the skull, from whence they are carried
along the sheath of the optic nerves to both sub-
arachnoidal spaces. From this location they are
borne by recognized lymph channels to the thoracic
duct, and thus enter the blood stream.
After entrance into the general circulation, the
organisms of the disease invade every tissue and
organ in enormous numbers. Bacterial embolism
is common; the heart muscle is invariably swollen
and anemic, and at times the seat of petechial hemor-
rhages. The same appearance with more or less
ecchymosis may be observed beneath the endocar-
dium, pleura, and pericardium, as well as in the sub-
stance of the lungs. The same condition may also
exist in respect to the vessels and serous membranes
around and within the brain.
Diagnosis. — The diagnosis of anthrax is often
very far from easy. Dr. Bell says: "The slightest
illness occurring in those exposed to infection from
anthrax should be looked upon with suspicion until
tin' possibility of its being anthrax has been nega-
tived. Often it is impossible to make an early diag-
nosis, as the symptoms may resemble those of ordi-
nary illness. The progress of the disease is frequently
not characterized by alarming indications until mar
the end of life, hence not infrequently it is unre
riized until the patient is cold, livid, almost pulsi
and dying."
The bacillus anthracis will be found in blood ob-
tained from the initial lesion, both by culture methods,
and from stained smears, and by inoculation of
animals. The urine becomes scanty, darker, and of
high specific gravity. In 1908, Royer and Holmes
reported the following data: Anthrax bacilli were
frequently discovered in the circulating blood both
in smears, and by cultural methods. In thirteen
cases, study was made in reference to the leucocytes,
and in these, leucocytosis was the rule, the highest
count obtained being 25,000 in a cubic centimeter,
whereas the average count for all the cases was 13
In two fatal cases the leucocytes numbered 12,000
and 9,600 respectively. In eleven eases differential
count gave the following averages: Polymorpho-
nuclears 77.6 per cent., large lymphocytes. 17.7 per
cent., small lymphocytes 5.3 per cent., eosinophils :; c
per cent., basophiles 0.1 per cent., myelocyte- 0.4 per
cent.
The occupation of the patient may afford a valuable
clew, or at least awaken suspicion of the disease in
a given case. Under such circumstances, a papule
upon any exposed surface of the body would exi
apprehension of the disease, thoi gha positive diagi
might at this time be impossible. When the di
has advanced to the vesicular stage with serous exuda-
tion, there would be less uncertainty as to its nature.
Implication of the lymphatic channels and swelling
and tenderness of the neighboring glands would add
weight to the probable diagnosis, though all these
symptoms may be associated with other infections
diseases. The most certain method is that of taking
a drop from the contents of the pustule or vesicle, and
subjecting it to microscopic examination. If the
case is one of anthrax, this fluid will be seen to con-
tain the bacillus. This at once establishes the
character of the disease in distinction from simple
non-specific carbuncle and furuncle. In doubtful
cases the liquid may be subjected to cultivation in a
moist chamber, when a definite result may be obtained
within a few hours. Or the experimental inoculation
of guinea-pigs and rabbits or other animals susi
tible to the disease may be carried out; and if anthrax
develops in them, there will then be no doubt in regard
to the nature of the malady ; but a negative result does
not entirely exclude malignant pustule.
In districts in which malignant pustule is known to
prevail, the surgeon would suspect this disease in the
early stages of simple carbuncle, or of furuncle, and
in the stings of wasps and other insects. Malignant
pustule also resembles to some extent the early stages
of erysipelas. Boils or furuncles are frequently very
similar in their early stages to the first appear-
ances of anthrax. In certain tissues they
often commence by the development of a vesicl
the seat of irritation. In furuncle, however, there is
not so extensive inflammation in the vicinity, and
the central gangrene, the crust, the wreath of vi -
ieles, and the febrile action are absent ; these symptoms
belong exclusively to anthrax. The ordinary simple
carbuncle is very painful, the carbuncle of anthrax,
on the contrary, is only slightly sensitive. Bites of
insects generally show a small yellowish point, which
is not observed in anthrax. Erysipelas, especially
when accompanied by serous effusions (bulla:), re-
sembles the malignant edema of anthrax to some
464
REFERENCE HANDBOOK OF Till'. MEDICAL SCIENCES
Anthrax
extent, but in erysipelas the chill and lever usuallj
precede the eruption of the disease, while in anthrax
these occur simultaneously.
Anthrax distinguishes itself from erysipelas in the
following ways: Erysipelas begins most often with
a chill; in anthrax edema the fever appears afterthe
edema is present. Erysipelas has always the vivid
, ,1 border, which is slightly above the level of the
normal skin in the vicinity; its accompanying edema
is much less pronounced than is that of anthrax, and
is limited to the immediate vicinity. In anthrax the
redness gradually shades to normal color and the
edema extends beyond it into the tissues of the parts.
The Ascoli reaction by precipitin makes possible
the diagnosis of anthrax even in cases in which the
microscopical and cultural evidence and that from
inoculation of animals have proved negative. There-
in is specific, as the characteristic "ring-forma-
is never obtained with material or organs from
ces not containing the anthrax infection. The
establishment of the diagnosis succeeds also with
organs infected with anthrax even when they have
been preserved in alcohol for four months, whether
or not these organs have previously given a positive
! act etiological diagnosis. The "ring-formation," a
peculiar cloudiness, appears most promptly and
distinctly by employment of extractive sub-
es from the spleen. This method makes it
possible to prove the precipitinogen of anthrax not
only in fresh filtrates of visceral organs, but also in
material which has been preserved on ice for more
than three months. The extractive may be prepared
by means of physiological salt solution, or by dis-
tilled water or ordinary water. The intensity' of the
reaction and the promptness of its appearance are
modified by the dilution of the extractive, and by
the reduction of the amount of precipitin contained
in the serum; while putrefaction of the extractive
- not materially interfere with its accuracy.
This new test and its technique are thus described
by Prof. Dr. Alberto Ascoli, in Zeitschrift fur Initnii-
mtatsforschung vnd experimentelle Therapie, 1911,
Erstes Heft, Lifter Band, p. 103. The technique of the
thermoprecipitin methods consists of the two follow-
ing proceedings: (1) Boiling of the suspected mate-
rial in five to ten volumes of physiological salt solu-
tion, which may be rendered acid by addition of
acetic acid in proportion of 1:1,000, if desired: this
need occupy only a few minutes, and the resulting
fluid is filtered, preferably by means of an asbestos
filter. (2) Examination of the clear filtrate by
means of a layer of precipitating serum, with a
control-tube treated in the same way with normal
M'i am,
This method has been in constant use in the vet-
erinary high schools of Milan, Modena, Parma, and
Naples, and the author has employed it in hundreds
of personal examinations, with the result that its
'""elusions in every instance agree with those of
microscopical examination, and also prove effective
even when the material obtained for examination is
already in a stage of putrefaction. This peculiarity
pecially recommends the method when the sus-
pected material is obtained from animals which have
been found dead, or are removed from a distance to
'he place of examination.
lor the ready performance of this test, the author
has recommended the following simple appliances;
( I I A tall, slender reagent-glass with a suitable foot
for support; (2) a small funnel, with an attachment
at the lower end, which is drawn out into a long tube,
bent at nearly a right angle, and ground at an angle
.-o that the resulting filtrate will be discharged on
the side of the receiving tube; a portion of asbestos
in the bottom of the funnel makes the best kind of
filter.
The test is carried out as follows: The test-glass
is filled to a certain definite point with water, in
Vol. I.— 30
which is then dissolved a proper amount of salt, BO as
to make the physiological solution. In a test-tube
of ordinary character, a leu grams of the -u pected
material is suspended in water, and I lie iiiti.' i- placed
for a lew minutes in boiling water. When the tube
litis cooled, this fluid i poured into the funnel with
the asbestos filter, which is placed in the top of the
glass first described: as the clear fluid Hows slowly
dow n the inner surface of the reagent-glass a ring-
formed cloudiness is soon observed if the material
added contains anthrax infection. With material
which contains no anthrax infection, the te I hi
no cloudiness. This reaction therefore would appear
to be a valuable and time-saving addition to our
pie ent means of diagno is in tin di ease.
In glanders the carbuncles are smaller, generally
multiple, and accompanied by intense febrile reaction.
Cases of intestinal anthrax, mycosis intestinalis,
may be very difficult of diagnosis. The symptoms
often resemble those of poisoning by arsenic or
phosphorus, though the appearances due to anthrax
are frequently more suddenly developed and advance
i e rapidly to a fatal termination than in cases of
poisoning by these substance . Often the patient
is dead within a very few hours.
Prognosis. — The prognosis in anthrax is always
very grave, but is least so in the cutaneous form
where the local lesion is well marked and lends itself
to local therapeutic measures. When death ensues,
it follows as a result of general infection. The pulmo-
nary type gives the highest death rate, fifty per
cent., according to Eppinger; seventy-five per cent,
as estimated by British writers.
The collective mortality to be expected from all
forms of anthrax in man, treated and untreated, is
about twenty-five per cent. In Great Britain during
the six years, 1S99-1904, 267 cases were reported, with
sixty-seven deaths. Pulmonary and intestinal an-
thrax and those eases,- at first localized, in which
general infection supervenes are almost invariably
fatal. The mortality varies greatly in different
countries and climates. Anthrax in the tropics is
less fatal than elsewhere, probably because of the
attenuation of the virus in high temperature and
sunlight.
Extensive eruption and multiple pustules render
the prospect of recovery less favorable. In children
and in feeble persons the disease is almost always
fatal. Pregnant women are especially liable to abor-
tion from the invasion of anthrax.
The prognosis in cutaneous anthrax bears a direct
relation to the promptness and thoroughness with
which the local lesion is treated. If the seat of the
primary invasion be destroyed by efficient cauteriza-
tion or complete excision before the bacilli have entered
the lymph channels or gained access to the blood-ves-
sels, a fatal result need seldom be apprehended.
Fagge states: "Hitherto, so far as I am aware, no
instance of recovery from the intestinal form of an-
thrax has been recorded. In pulmonary anthrax
the spleen is less subject to enlargement and softening
than in any other form of the disease. The appear-
ance of any illness of however trifling nature in a per-
son exposed to the infection of anthrax should lead
to a very guarded prognosis until such a time as the
disease may prove to be some other ailment. The
greater number of cases of anthrax are fatal within
four days from the appearance of the first symptoms.
Pronounced febrile reaction with chill and a tempera-
ture above 102.5° F. would be a possible sign of
successful resistance to the entrance of the bacilli
into the general circulation, and the localization of
the disease to the seat of invasion. No recorded case
in which the presence of the bacilli in the blood has
been proved has recovered."
The danger to life cannot be estimated by the extent
of the local lesion. The prognosis is more favorable
465
Anthrax
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
■pith a high temperature than with a lower degree of
fever. A falling temperature with increase of the
gravity of the general symptoms, is a precursor of a
fatal result.
Duration of illness in intestinal anthrax: Number
of cases fatal within 3 days, 3 ; -1 days, 23 ; 5 days,
11; 6 days, 13; 7 days, 12; 8 days, 6; 9 days, 6; over
9 days, 2; total S3. In pulmonary anthrax: Number
of cases fatal within 1 day, 5; 2 days, 22; 3 days, 21;
4 days, 16; 5 davs, 7; 6 days, 3; 7 days, 3; 10 days,
2; over 10 days, 3; total 82.
Mortality. — In Europe, about twenty-five per cent,
of all cases prove fatal. Thus in Great Britain, of
320 reported cases (1899-1905) eighty-five were fatal^
26.6 per cent. Of these, thirteen were of the internal
variety, and all were fatal. Excluding these, the
proportion of deaths to attacks in the cutaneous form
was 23.4 per cent. In Italv, in eleven years (18S0-
1890), of 24,052 cases 5,812 were fatal — 24.1 per cent.
Koch (18S6) noted 422 fatal cases out of 1,473 pub-
lished cases of cutaneous anthrax — 32 per cent.
In pulmonary anthrax among rag-sorters in Lower
Austria (1870-1SS6), the mortality was 88.6 per cent.
It is universally agreed that neglect of early treatment
in cutaneous anthrax is one cause of its high death
rate. At Guy's Hospital between 1S96-1904, of fifty-
six cases treated, only four proved fatal — 7.1 per cent.
The number of cases of anthrax contracted in factory
or workshop (England) during the period from 1899
to 1905 was: males, 270; females, 50; total, 320;
fatal, 85; the mortality was therefore 26.6 per cent, of
these cases. (Bell and Legge give a valuable resume:
■ of the pathological conditions in cases of the various
forms of anthrax, with records of autopsy findings in
each form.)
Industrial Anthrax. — Anthrax is still a fairly com-
mon disease in Great Britain. In the Journal of
Hygiene for June, 1912, E. E. Glynn and F. C. Lewis
present the following table of cases' of the disease in
man in Great Britain and Ireland:
1906
1907
190S
1909
1910
Total
Cases
76
71
69
71
79
366
Deaths
26
15
13
15
12
81
The total number of cases among agriculturists
was: in 1906, 8; 1907, 12; 190S, 19; 1909, 15; 1910,
24; total, 78. Of these 78 cases, 5 occurred in
housewives, 16 in farmers, and the remainder in
butchers, knackers, etc.
There is no doubt that industrial anthrax is con-
tracted by handling infected hides, wool, etc., but
the reason for the dissemination among domestic
animals is much more obscure. Many believe such
animals contract the disease by feeding upon infected
pastures, but recently a considerable amount of evi-
dence has been collected which indicates that arti-
ficial foodstuffs or manures may carry infection.
With regard to the former possibility, Stockman
(1911) has noted, first, that S3 per cent, of the out-
breaks of anthrax, in the six worst infected counties
in Great Britain during five years, 1905-1909, occurred
upon new farms, that is to say farms in which there
had never been a previous case; consequently it was
unlikely that the animals contracted it from infected
pastures; and second, that in 6S per cent, of the
outbreaks the evidence pointed, after careful elimi-
nation of other causes, to infection with "artificial
feeding stuffs or manures." Again anthrax is least
common from July to October when the stock are on
grass, but there is a decided rise in the following
months when they may be "assumed to be running in
and receiving artificial food." B. anthracis has very
rarely been found in these artificial foods, though
M'l'adyean (1S95) once detected it in a linseed cake,
which caused the death of six shorthorns, and ampng
.some oats responsible for an outbreak in London
horses; similar cases have occurred in Germany
(Legge, 1905). We have recently detected anthrax
bacilli in a sample of pea meal, used for feeding
cattle, one of which died of anthrax; the investiga-
tion will be alluded to subsequently.
The importance of ascertaining the origin of agri-
cultural anthrax is seen from the second table, which
indicates that in spite of Government inspection the
disease appears to be spreading. In the last five
years the number of deaths among domestic animals
have increased from 306 to 406 per 100,000, i.e. by
59.3 per cent.; the number of outbreaks have in-
creased even more, i.e. 59.3 per cent.; and lastly, t he
number of cases amongst agricultural laborers and
others have also increased from 8 to 24 per annum.
Of course some of this increase may be due to more
systematic notification of the disease.
Anthrax spores have been demonstrated by the
inoculation method in 21.3 per cent, of 141 samples
of industrial material, supposed to have produced
anthrax in Liverpool amongst those who handled
them. Of these samples 286 per cent, were from
hides, 20.2 per cent, from wool, 20.6 per cent, from
hair, and 7.1 per cent, from bones. The largest
proportion of infected samples came from Singapore.
Anthrax appears to be steadily increasing among
domestic animals, and consequently a larger number
of agriculturists are becoming infected. The rea-
son for this dissemination amongst animals is still
obscure.
We have found B. anthracis in a sample of pea
meal used for feeding cattle confined to a shippon,
one of which died of anthrax. The meal was prob-
ably infected from the sack.
Anthrax is preventable among men and domestic
animals; and its ultimate suppression depends largely
upon the certainty with which bacteriologists can
demonstrate the presence or absence of bacilli in
suspected industrial food, or other materials. (Glynn
and Lewis, Journal of Hygiene June, 1912.)
Prophylaxis. — As the diseased or dead body of a
human being or an animal, and the substances emanat-
ing from the same, form the source of danger from
anthrax, it is evidently important that these sub-
stances should receive special attention. The excreta
or discharges of any kind from those sick with the
disease should be carefully disinfected and burned,
and the bodies of animals or human beings dying
from the disease should be immediately wrapped in
some efficient disinfectant and cremated. No post-
mortem examination should be allowed, as thereby
the opportunity for further infection is largely in-
creased. The physician should warn the attendants, in
cases of anthrax, of the danger of infection from the
discharges of the patient. No person having a wound
or abrasion on an exposed part of the body should take
any part in the care of the patient, or touch anything
which has been in contact with or near him. All band-
ages, dressings, etc., should be immediately burned.
Especial attention should be given to the exclusion of
flies and mosquitos, which have been proved to be the
active carriers of various contagia. Unneces
persons and all visitors should be rigorously excluded.
The prophylaxis of anthrax must at present be
regarded as unsatisfactory, until other and more
stringent precautions are adopted to effect efficient
sterilization of the commercial animal products deri
from countries in which anthrax is either prevalent as
a permanent infection, or at times appears in epidemic
form.
Osier states: "The ordinary processes of tanning
leather do no't affect the spores of anthrax; and the
writer has kept them immersed for 240 days in the
strongest tanning fluids — twice the usual time required
for the process — without any perceptible change in
their vitality or viruleney. Spores are not formed
in cultures "kept at temperatures below 18° C, nor
in those above 42° C. ; when grown at a temperature
above 42°, the bacillus loses the power of forming
466
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Anthrax
spores, ami becomes gradually attenuated, and ac-
quires' vaccinal properties. When brought to this
condition, the attenuated bacillus may be cultivated
at ordinary temperatures, without regaining virulence
or the spore-forming power. The vaccines of Pasteur
are prepared in this manner, the degrees of attenua-
tion depending upon the number of days the culture is
kept at 1-'° I" -13° C. The first or weakest vaccine is
grown for about twenty-four days, at I lie end of which
nine it has lost the power to kill larger aninals and
i guinea-pigs, bin will still kill white mice; the
,1 vaccine is grown for about twelve days, and
ild kill guinea-pigs, but not rabbits. In practice,
an interval of twelve to fifteen days is allowed to
elapse between the two inoculations, which are made
itaneously." ("Modern Medicine," vol. iii.,
p I'''.)
Warren-Gould in the last edition of the "Inter-
national Text-book of Surgery" (1902), p. 191, when
ussing human anthrax, add the following, which
M properly be regarded as belonging to the
n\ lactic considerations of this malady: "The
disease is transmitted to man from infected animals;
t he atrium of the microbe is usually an abrasion of the
skin, but the bacteria can enter by the lungs and the
intestines without the occurrence of wounds. Flies
are said to transmit the disease (Koch), and the
bristles from which brushes are made have conveyed
microbe." "Surgeons have repeatedh' con-
veyed the infection by using imperfectly sterilized
catgut from sheep suffering from splenic fever."
"Pathologists have frequently been infected while
making postmortems of experimental animals dead
of the disease."
The inoculation of the vaccines and toxins of an-
thrax is an efficient preventive of the disease in ani-
mals. The blood serum from an immune animal, if
injected subcutaneously into a susceptible animal,
will afford a certain degree of protection against sub-
gequent infection with anthrax. The following state-
ment is from Sajou's Annual for 1S9S: "A sheep was
immunized until it could bear the injection of seven
agar cultures with but slight elevation of temperature.
A lamb was immunized likewise to the highest degree,
and blood was taken from the carotid to obtain serum.
With the serum of the sheep it was actually possible
save from death a rabbit in which an extremely
virulent culture of anthrax was injected either after
or simultaneously with the serum. Evident thera-
peutic results were obtained with this serum in animals
that had received the anthrax bacilli previous to the
injection of serum. These results permit us to hope
that anthrax in man and the domestic animals may
sometime be treated by serotherapy." (Vaughan,
"Twentieth Century Practice," vol. xiii.) It is
further stated that "French skins, since Pasteurian
inoculation has been employed among the French
flocks, have been found rarely to cause anthrax."
Bell makes the following statement: "No efficient
system in relation to the spread of anthrax has been
yet possible. To accomplish this end there should be
a careful separation of the infected wools, hair, hides,
rags, etc., at their source, often in distant countries.
This is manifestly very difficult to accomplish." In
the subsequent handling of the materials during the
processes of preparation and manufacture, every
effort should be made to protect the workers from the
dust arising from such materials, which should be
removed by air draught and burned. Sterilization of
all suspected substances by steam under moderate
pressure has been found useful in the treatment of
other infected substances, and would doubtless pro-
vide efficient protection against this disease.
Page says (Journal of Hygiene, December, 1909)
that "we may conclude that disinfection of horsehair
by steam cannot absolutely be relied upon; but that
with due care the number of anthrax spores may be
diminished, and the vitality of the remainder lowered
without appreciable damage to the hair." That
steam is ever likely to be certainly effective in disin-
fecting horsehair is improbable, since the damper
the steam the better chance of destroying the spon ,
but the greater the damage to the hair; and the dryer
t he steam I lie less chance of destroying the spore- and
the less damage to the hair. These antagonistic
results produce a deadlock, [n Nuremberg, one of the
chief brush-making towns in Germany, regulal ions are
carried out, all raw materials being disinfected by
steam; yet cases of anthrax still occur, though less
in number.
The vapor of formalin would probably be destructive
to the germs of anthrax, and possesses the special
advantage thai the texture of the suspected materials
is not injured by I he process.
Fagge says: "The system of prophylaxis by inocu-
lation of anthrax virus attenuated by transmission
through suitable animals promises important results,
and its study indicates a close analogy to the
relation of eowpox to smallpox."
Tueatment. — From the earliest times, all writers
on the treatment of anthrax have recommended
destruction of the primary focus by causticsor
cauteries. The actual cautery is still the chief treat-
ment in many parts of Russia, Siberia, Persia and
other countries of Asia, where the disease is most
prevalent. In England, surgical interference in
cutaneous anthrax usually takes the form of free
excision, and swabbing the wound with pure carbolic
acid. At Guy's Hospital, in addition to this, powdered
ipecacuanha is commonly dusted on the wound,
and is given in ten-grain doses internally. The guide
in this treatment was Muskett in South Africa, who
regarded ipecacuanha as a specific for anthrax, and
by this means had treated fifty cases without a fatal
issue. Washbourn also found that ipecac destroyed
the bacilli of anthrax, but not the spores; these latter
however are not found in the animal body.
The usual treatment of external anthrax in the
past has therefore consisted in the application of
varied medication to the local lesion, or in excision of
the pustule: a glance at the mortality shows how
ineffectual these measures are. When excision is
performed early, it will in many cases be followed
by a diminution of the edema and a fall in the tem-
perature; but the mechanical injury done to the
tissues by the knife, and the opening of new paths of
infection through the lymph-sinuses and the blood-
vessels, and the resulting scarring and disfigurement,
especially about the face, must be regarded as ob-
jectionable features to this plan of treatment.
More recent observers have discountenanced
operative interference in anthrax. In the Muenchener
mi ilizinischer Wockenschrift, Dec. 26, 1911, is con-
tained a review by Wolff and Weiwioski. This
article presents an account of the cases of anthrax
observed in that Clinic since 1900, with a short
abstract of the clinical history and the course of each
case; with the treatment in each patient. There
were thirteen cases, of which six are classed as
" severe, " and seven as of a mild form. In estimating
the gravity of the several cases, the temperature was
considered less valuable as an indication than the
general appearance of the patient, the location of the
lesion, the extent of edema, and the degree of swelling
of the lymph glands.
In one of the severe cases, a physician had already
made an incision into the lesion, and in the Clinic
the patient was also treated by the Bier method
after operative treatment by another practitioner.
This ease was the only fatal one in the series of
thirteen; i.e. 7.7 per cent. In one other severe
case the primary lesion was on the right thumb: the
patient was a brush-maker, and was wounded by one
of the implements used in the manufacture of brushes.
Three days later, when admitted to the hospital, the
467
Anthrax
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
entire thumb as well as the corresponding matacarpal
region was of a livid color, and presented several
bulla? the size of a pea. The entire hand and the
forearm were much swollen and indurated. _ Two
very small incisions were made in the diseased tissues
near the root of the nail (not in the healthy tissues);
no pus was found; but anthrax bacilli were found in
the content of the blebs. The patient was discharged
on the eleventh day. with the wound nearly healed.
The treatment employed in ten of these cases was
absolutely conservative, and consisted with slight
variations, in dressings of boric acid, tincture of
iodine, etc., and light bandaging. The great, -I
reliance was placed upon absolute quiet on the part of
the patient, with repose of the seat of the disease.
The writers add: "In view of these results, we can
express ourselves in thorough approval of the con-
servative treatment of anthrax."
Strumpell ("Handbook of Medicine", 1912) ex-
presses his opinion as follows: The treatment of malig-
nant pustule is surgical. Cauterization with caustic
potash, nitric acid, or carbolic acid has been found
ineffective and even injurious. In mild cases moist
applications of aluminum subacetate, ice-bags, and
the like are sufficient. In severe cases experienced
surgeons advocate the division of the pustule, applica-
tion of the thermocautery to the circumference of its
base, and the injection of tincture of iodine in drops
into the border line between the inflamed and the
healthy skin.
Rigidly conservative measures of treatment have
been advocated by many writers. Among these,
Mnller treated thirteen cases, and Rammsted seven
cases, by rest, fixation, and the local application of
mercurial ointment: Strubel recommended applica-
tion of very hot cataplasms, supplemented by in-
jection of solution of carbolic acid: and Schultze
applies hot compresses of one-per-cent. mercuric
chloride solution in eighty-per-cent. alcohol. (Musser
and Kelly, "Handbook of Practical Medicine", 1911.)
The most important progress in recent years is the
introduction of the serum treatment for both local
and general anthrax infection. Previous to this, we
find in the literature the discussion of the following
methods of treatment: (1) Expectant, (2) antibacterial,
(3) complete excision of the local infection.
The expectant treatment is based on the fact that
man is not highly susceptible to the anthrax bacillus,
and that clinical observations have indicated that
manipulation of the local infection is apt to be followed
by death from general infection. Bacterial in-
vestigations have demonstrated that anthrax is fatal
to man only when the bacilli get into the general
circulation.
Injection of Carbolic Acid. — Strubell is the chief
advocate of this method of treatment. It consists
in the hypodermic injection of a three-per-cent.
solution of carbolic acid, in amounts of ten to fifteen
minims. These injections are sometimes given
thirty times in a day, and as many as 400 such in-
jections have been required in one case. They are
made around the area of infection. Combined with
this treatment, the infected area is covered with poulti-
ces at a temperature as high as 63° C. He reports two
cases, both of which recovered. (Musser). This
treatment as described by Strubell, on the whole,
seems popular. I find a successful case recorded by
Voigt; recovery took place after 300 injections of
carbolic acid, without symptoms of any toxic effect
therefrom. Caforio and Corseri advocate similar in-
jections of a one-per-cent. solution of corrosive
sublimate. Caforio reports eighteen cases, in some
of which the infection was very grave, associated
with edema and genera] symptoms. Cipriani advo-
cates injection of a one-per-cent. solution of chinosol.
His experience with carbolic acid and nitrate of
silver solutions indicated danger of intoxication
from thee substances. Musser adds: "The good
results in these various methods speak favorably for
the prognosis of anthrax in man. On the whole, I
should recommend the complete excision of the
pustule if possible, and the disinfection of the open
wound with pure carbolic acid. However in view of
the results after conservative treatment, or after
injection of carbolic acid, one would hesitate to per-
form a mutilating operation. In such an event, I
should recommend the injections of pure carbolic acid;
if properly performed, it is distinctly a stronger
antiseptic, and experience with carbolic acid has
cli -a rly demonstrated that there is less danger of
poisoning when the pure acid is used, than when
solutions are employed. The very hot poultices
recommended by Strubell should be used, whether
excision is practised or not."
Scharnowski treated fifty consecutive cases by
subcutaneous injection of carbolic acid with only one
death. In a remarkable case reported by Strubell
(Muenchener med. Wochenschrift, xlviii., p. 152G), the
nose was the seat of inoculation and of the primary
lesion: excision was impossible, and the face and neck
were extensively inflamed and edematous. The
patient received in eighteen days more than 400
hypodermic syringefuls of three-per-cent. solution of
carbolic acid in the vicinity of the affected parts, and
recovered without having at any time showed toxic
symptoms from the drug. In anthrax, there would
appear to be a special tolerance for carbolic acid.
When the primary lesion is recognizable, and its
size and location permit, most surgeons practise
exi ision, followed by the actual cautery, or by ninety-
five-per-cent. carbolic acid. This is the usual practice
in England, even when Sclavo's serum has been
employed. Where excision is not possible, free
multiple incision with cauterization has been recom-
mended. Objection has been raised by Mueller to
incision, on the ground that it may open the way for
the bacilli, up to that time successfully isolated by
nature, to enter the blood stream. Under this idea,
Mueller and Ramsted have reported twenty consecu-
tive cases of localized external anthrax treated ex-
pectantly by no other measures than rest, fixation
and elevation of the part, with local cleanliness or
antisepsis (in some cases with mercurial ointment),
good diet and stimulation. All recovered, though
several were severe cases, and in one the tongue was
involved in the disease. (See Milroy Lectures,
"Industrial Anthrax," T. M. Legge, Brit. Med.
Journal, 1905.)
If any operation is done in a case of anthrax, it
should not be done in the ordinary operating-room of
a hospital, but in a separate room. After the opera-
tion, the floor and walls should be thoroughly disin-
fected, and a bacteriological examination of the floor
should be made, in order to determine if disinfection
is effective. In Keen's case at the Jefferson .Medical
College Hospital, three disinfections were required,
with formaldehyde, pure carbolic acid, and strong
bichloride of mercury before the floor was germ-free.
In the closing sentences of the section on the treat-
ment of anthrax in the previous edition of this Hand-
book may be found the following: "From the results
obtained in the study of other specific organisms
affecting the human body, or that of animals, it,
would seem reasonable to hope and expect that
further research may furnish an efficient remedy in
the form of an antitoxin (or vaccine) in anthrax,
such as has been obtained in respect to some of the
other of the bacterial infections, particularly human
diphtheria." This prospective ami desired result has
been already realized, in keeping with the progress of
serum therapy in other diseases. An immunizing
agent has been developed which promises to be .as
effectual in the treatment of anthrax, as the antitoxin
has been in the treatment of diphtheria. Toussaint
in 1880, Pasteur in 1SS1, Marchoux in ISO"), Sobern-
heim in 1898 and again in 1902 and 1904, have con-
liis
REFERENCE HANDBOOK OF TIIK MEDICAL SCIENI ES
Anthrax
tributed important papers upon the subject of im-
munity to anthrax, based on their experimental work.
Bclavo in June, L897, began treatment of anthrax in
man by means of a serum prepared from animals
after combined active and passive immunization
treatment (simultaneous inoculations of serum and
virus), from which the most powerful serum is ob-
tained. In 1903 he collected a series of 104 cases
with two deaths, a mortality of three per cent.
The serum has no deleterious effects, and in the
hands of its originator and others, especially in Italy
England, the results substantiate the claims thai
have been made for it. It assists in the destruction of
the bacilli before they become so numerous that their
distribution increases the danger of fatal poisoning
by the toxins set free through the disintegration of
the bacilli. "Judging from the experience of those
who are best qualified to speak, the treatment of
anthrax should consist in the administration of
o's serum, in the excision of the pustule, and in
the application of certain bactericidal agents.''
Prof. Sclavo of Siena, after much experimentation
has produced a bacterial protective serum from the
a--, which he asserts to be harmless, and 'which he
subcutaneously in doses of 20 to 40 e.c. or, in
cases, of additional amounts of 10 c.c, intra-
venously, to be repeated if necessary. He does not
practise excision or cauterization of the local lesion.
He states that improvement almost immediately
follows the injection of the serum, and reports 16*0
3, with a mortality of six per cent. In two of
these cases that recovered, the bacilli had been
demonstrated in the urine, and in one of these, in the
blood as well. Recovery in a case of anthrax in which
the bacilli were found in the blood has never been
reported from any other form of treatment. Within
twenty-four hours after the treatment the bacilli
disappeared from the fluid of the vesicle.
In July, 1S97, Sclavo began to treat cutaneous
anthrax in man by the curative serum obtained by
his method from proper animals. Sclavo directs as
the initial treatment, that 30 or preferably 40 c.c.
should be injected in four doses of 10 c.e. each, in
four different places in the abdominal wall. On the
following day, if there be no improvement either in
the local or general symptoms, 30 or 40 c.c. should be
again injected in the same manner: and where the
symptoms are very grave, 10 c.c. additional may be
injected intravenously into one of the veins on the
back of the hand, and repeated if necessary. A rise
in temperature following the injection is regarded as
a favorable sign.
If kept cool and in a dark place, the serum remains
fully active for at least two years. Sclavo would
rely solely on the use of his serum. In England, the
inclination has decidedly been to employ it in all
cases in the doses recommended by him, but, in
addition, to excise the local lesion, or inject carbolic
acid in five-per-cent. solution into the tissues around
the local focus. Sclavo refers to a considerable
number of cases of cutaneous anthrax in Italy,
treated by his serum with a mortality of 6.09 per cent.
as compared with a mortality of 24.1 per cent, for all
cases in Italy.
Dr. T. M. Legge has published details of sixty-
seven cases, in fifty-six of which serum alone was
used: excluding one fatal case, and two, in which
there was loss of tissue, the duration of the illness
from commencement of the treatment until recovery,
appears to have been not more than fourteen days in
any of the fifty-three cases; and in forty-four of them,
the average duration was eight days. Among these
cases were none of the intestinal or the pulmonary
variety. Mendez of Buenos Ayres (1904) refers to
1,073 cases treated with serum from the horse, im-
munized by him in the same way as was done at first
by Marchoux and Sclavo, with a total of forty-four
deaths — 1.19 per cent. "Sclavo's (1903) claim as to
the effects of antianthrax serum may be summarized
as follows:
(1) Antianthrax serum even in very large doses is
inocuous and can be well borne even when introduced
into the veins.
(2) No case taken in an early stage or of moderate
Severity is fatal if treated with serum.
(3) With serum a ■ cases arc saved when the
condition is most critical, and the prognosis almost
hopeless.
I I ) When injected into the veins the serum quickly
arrest s the extension of the edematous process so a to
reduce notably the dancer of suffocal ion which exists
in many cases where the pustule is situated on the
face or neck.
(5) The serum, if used soon enough, reduces to a
minimum the destruction of the tissues where the
pustule is situated, and tints avoids deformity
(6) In some situations of the pustule, as the ej e-lid,
serum must be used in preference to any other treat-
ment, it being the only our which holds out hope of
success without permanent injury, and in cases of
internal anthrax the early injection of serum intra-
venously is the only remedy likely to be successful."
(From contribution to "Industrial Anthrax" in
Journal <ymp-
tom as in acute poisoning. The stools are at first
normal: later, there may be diarrhea, usually alternat-
ing with constipation. The time at which death
occurs depends chiefly upon the size of the doses and
the frequency of their administration. Taylor col-
lected five cases, four of which were fatal. In throe,
death took place in six, eight, and nine days respect-
ively; in the fourth, the poison was administered
over a period of three months preceding death.
In the treatment of chronic poisoning it is essential
to prevent the further administration of the poison.
Stimulants, tonics, and nutritious diet are required.
In chronic cases elimination can be assisted by ad-
ministration of the iodides.
Trichloride of Antimony. — Butter of antimony is a
transparent, fusible, crystalline substance, which, on
exposure to moist air, rapidly deliquesces to a clear
liquid. When pure it is colorless, but it frequently
contains more or less chloride of iron, which imparts
to it a color varying from yellow to dark brown.
It is decomposed by water, with the formation of
hydrochloric acid and an insoluble white basic chlo-
ride, which may be distinguished from the corre-
sponding basic chloride of bismuth by its solubility
in tartaric acid. A concentrated hydrochloric acid
solution of the chloride has some uses, and has given
rise to a few cases of accidental or suicidal poisoning.
It is a violent corrosive and irritant.
The symptoms resemble closely the symptoms
produced by the mineral acids. They come on very
rapidly, and consist of violent vomiting and severe
pain in the throat, stomach, and abdomen, soon fol-
lowed by symptoms of collapse. Death has taken
place in two hours, and has been delayed for ten and
one-half, eighteen, and twenty-four hours.
The smallest quantity required to destroy life is
unknown. Ninety cubic centimeters (three fluid-
ounces), approximately, of the solution has proved
fatal to adults in three cases. Recovery has taken
place after 30 c.c. (oj).
The lips, mouth, and throat have usually been
found more or less corroded. The interior of the
stomach and upper part of the small intestines are
intensely inflamed, corroded, and sometimes black,
as if charred. In a case related by Taylor, the whole
alimentary canal, from the mouth to the middle of
the small intestines, presented this black appearance.
The mucous membrane was entirely destroyed, and
the parts beneath were so soft that they were easily-
torn with the fingers. Fatty degeneration of the liver,
kidneys, heart, muscular tissue of the diaphragm,
and cells of the gastric glands was observed in rabbits
to which small doses of trichloride of antimony were
administered ( Salkowsky) .
Treatment consists in the administration of sodium
Vol. I.— 31
481
Antimony
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
carbonate, chalk, or magnesia, to neutralize the free
acid, and of preparations containing tannic acid.
Edward Curtis.
R. J. E. Scott.
Antiperiodics — The various malarial fevers are all
characterized by a more or less regular recurrence of
their characteristic symptoms, to wit: chill, fever, and
sweating; the period for such recurrence varying
according the the life cycle of the particular organism
which causes the special type of fever. These phe-
nomena are therefore spoken of as periodical, and the
remedies which are known to exert an inhibitive effect
upon them are called antiperiodics. This term, how-
ever, is a relic of the time when the nature of malarial
diseases was not understood and their distinguishing
symptom, periodicity, attracted an undue attention.
It is not as mere interrupters of a periodic morbid
phenomenon that the remedies hereunder mentioned
are to be regarded, but as inhibitory of the growth in
the red corpuscles of that organism whose successive
crops produce the periodic symptoms of chill and
fever.
The actual antagonisn of quinine in the circulating
blood to the development of the malarial plasmodium
has been abundantly demonstrated, and with the
.laying of stress upon this fact the weakness of the
term antiperiodic becomes apparent. It is retained
here out of deference to long established usage rather
than for its present appropriateness. The symptoms
against which antiperiodics are most commonly
employed are those constituting the seizure in the
estivo-autumnal, tertian, and quartan types of ague,
and consisting of the cold, the hot, and the sweating
stages. In the milder forms of intermittent and
remittent fever, the breaking up of the recurrent chills
as soon as possible is important for the comfort of the
patient, but in the so-called "pernicious" malarial
fevers, it may be a matter of life or death to stop at
once those congestive chills whose effects are so
alarming, and it is in such cases that the great value
of the antiperiodics is seen. Other chronic manifesta-
tions of the malarial cachexia, such as neuralgia, are
amenable to antiperiodic treatment, but it is notice-
able that the success of quinine in the relief of neural-
gia is in proportion to the regular periodicity of the
attacks, i.e. to the activity of the malarial organism,
rather than to its sequelse.
By far the most important antiperiodic — of more
value, in fact, than all the others taken together — is
cinchona, with its derivatives. Ever since the cure
of the Countess of Cinchon of an ague at Lima, in the
earlier half of the seventeenth century, first gave
name and fame to the drug, its value in intermittent
fever has been acknowledged. More than any other
remedy in the Pharmacopoeia it deserves to be con-
sidered a specific. Its direct action on the malarial
parasite in the blood has been abundantly shown.
Quinine, by reason of its more concentrated and
convenient form, is now used almost entirely to the
exclusion of cinchona as an antiperiodic. For this
purpose the dose must be large, corresponding in
quantity to the so-called antipyretic dose of the drug.
The quinine should be so administered as to produce
a saturation of the patient's system at the time w lien
the next seizure would occur. To attain this object
we may best give one full dose, one to two grams
(gr. xv. to xxx.) on the drop of temperature following
a given paroxysm in order to abort the following
paroxysm. Or it may be given in divided doses
through the twenty-four hours before an expected
chill, the last dose being six hours before the time
the chill is due. If the interval is much shorter than
this, the chance of aborting the very next seizure is
diminished. If a single administration of the drug
anticipates the chill by only four or five hours, the
chances are about equal for and against its success.
In no other form is quinine more effective than in that
of the crystals of the sulphate in an acid solution
(bisulphate) or dissolved in lemon juice. The
solubility is usually somewhat impaired in the pill
form, and the administration in coffee fails to give the
best effect because of the imperfect solubility of the
tannate. The manufacturing chemists have put upon
the market a "compound syrup of licorice," which
quite effectually disguises the bitter taste of the drug,
without, so far as the writer knows, interfering with
its solubility.
When the periodicity of the intermittent fever is
irregular, and in cases of remittent fever, cinchonism
should be produced as soon as possible after a seizure,
and maintained by moderate but sufficient doses for
several days. In the cases of pernicious malaria, if
there are not ten or twelve hours before the expected
time of attack in which to secure complete cinchonism
by the oral administration of the drug, it should be
given subcutaneously. In order to secure its com-
plete solution, acid must be added, one minim of
dilute sulphuric acid to each grain of quinine usually
sufficing. But this solution has the disadvantage of
being irritating, and there is some danger of abscess.
This risk, however, should be taken in preference to
that of a severe congestive chill. The hydrobromate
of quinine is especially adapted for subcutaneous
use. It may be prepared according to the following
formula:
T? Quininae sulph 10 (gr. clx.)
Acidi hydrobromici
(Squibb) 4 (5 i.)
Aqua? (vel spts. fru-
menti) ad 30 (3 i.)
The kinate and the disulphate of quinine are preferred
by some for hypodermic use. The dose of quinine
subcutaneously is less than by the mouth, and its
action is more prompt. When for any reason neither
of the foregoing methods is available, the drug may
be given by the rectum in doses somewhat larger than
by the mouth. For children and others with sensitive
stomachs, when haste is not an especial object,
quinine may be given by inunction. For this purpose
an eligible preparation is the following:
I? Quininae sulph. 5 (gr. lxxx.)
Acid, oleic, pur 30 (5 i.)
01. olivarum 30 (5 i.)
Dissolve the quinine in the acid with the aid of gentle
heat. Add the oil. The solution should be clear.
There is considerable choice among the various
salts of quinine both as to their strength and as to
their solubility. For example, the acetate contains
87 per cent, of quinine, the basic and neutral hydro-
chlorate each nearly S2 per cent., the basic lactate 78,
the basic hydrobromate 76, the basic sulphate 74,
the neutral sulphate less than 60 per cent., while the
tannate, much is favor for administration to children
in the form of "chocolate quinine tablets," has only
20 per cent.
The hydrochlorate is the most soluble salt, and as
it is one of the richest in quinine, it is. in spite of its
slightly greater cost than some others, the most
eligible. The neutral hydrobromate is soluble in
6 parts of water, while the basic sulphate is soluble
only in 5S1 parts of water.
In old malarial cases, in many of which the liver is
enlarged, we must, in order to get the full and prompt
effect of quinine, preface or accompany its exhibition
by the use of a mercurial, as calomel or blue pill,
followed by a saline.
The other alkaloids of cinchona, quinidine, chinoid-
ine, c'nehonidine, and cinchonine, have some an-
tiperiodic value, but are all inferior to quinine, and if
used should be given in larger doses. Regarding I lie
-IS J
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Antlpyrlne
,\,, f quinine, it should be said that it varies much
q I only with the individual, but with the place In
the tropics and in the habitat of malaria much larger
doses are tolerated and arc necessary to break up a
chill than in temperate climates and non-miasmatic
localities. The prophylactic value of quinine against
ague is even greater than its curative action. A
moderate amount— as, for instance, a grain three
times a .lay -may he taken constantly for years
without any ill effects. This precaution is one that
should he taken by every one compelled to live in a
malarious country. Even in non-malarious districts
persons who have contracted ague elsewhere should,
afi r breaking up the chills by the antiperiodic dosi
scribed above, continue with small quantities ol
quinine for a fortnight or more, or better, with a full
dose once a week.
Next to cinchona, the most useful antiperiodic
which we possess i- probably arsenic. It is to those
chronic cases which nave assumed a somewhat irregu-
lar type, and in which we hardly know at what time
to expect a chill, that arsenic i- particularly adap
It may he given in the form of Fowler's solution.
beginning with 0.3 gram (n\v.) three times a day,
i up to 0.5 or 0.7 or even one gram
times a dav. or the arsenousacid may be given in gran-
ule- of at first 0.0015 to 0.002 gram (gr ^ to^„) three
times a day. pushed till the physiological effects are
reached. \'\ itn arsenic we do not attempt to stop the
very next paroxysm; hence it is not adapted for perm-
eases. It should always be well diluted and
given on a full stomach.
When treatment has been delayed until the chill is
actually "on," quinine is useless for that seizure.
Nothing is so efficacious to check a chill actually in
progress as a full dose of morphine subcutaneouslv.
Chloroform is also recommended for this purpose in a
of from two to four grams ( 5 ss. to i.) in sweet-
ened water or mucilage. Good effects have been
claimed for the administration, during the chill, of
nitrite of amyl by inhalation, and nitrate or muriate
of pilocarpine hypodermically.
Nectandra, or bebeeru bark, has met with some
ess as an antiperiodic. The alkaloid, in the form
of the sulphate of beberine, contains whatever of
virtue the drug possesses, and may be given in the
same doses and at the same times as quinine.
Warburg's Tincture, formerly in much repute,
especially in India, as an antiperiodic, contains some
sixty-four ingredients, of which the most active is
quinine, in the proportion of ten grains to the ounce.
The eucalyptus seems to possess some antiperiodic
virtue. Among the peasantry of Southern Europe
it has quite a reputation. Careful observation shows
that in highly malarious localities it is often without
it. The oil of eucalyptus in doses of 0.1 to 0.3
grain (rn_ ij. to v.), may be given, or the tincture in
doses of one to two grams (nixv. to xxx.). That it is
of use in the milder cases is made probable by the
fact of its undoubted power as a prophylactic. Since
tree was introduced into Southern Europe in
1856, its growth has much improved the health-
fulness of many marshy regions. The Trappist
monks devoted themselves to cultivating this tree in
the most malarious regions of Italy, with the result of
making places habitable that were formerly highly
unhealthy. This result is now known, however,
to have been due merely to the effect which the trees
had in sucking up standing water, which had been a
breeding place for the malaria-bearing mosquito.
Charles F. Withixgton.
Antipyretics. — Antipyretics are therapeutic agents
or measures which are employed to lower the body
temperature when it is abnormally high. As a rule
they exert little or no influence upon the normal
body temperature. The temperature of the body
may be reduced in two way-: (1) By lessening the
production of heat; and (2) by increasing the dissi-
pation of leal.
The production of heal may bed !: (1) By
reducing the circulation; and (2) by a general
lessening of the metabolism of the body. Vgents
used to reduce the circulation, are; \uliinoi,\
preparations, colchicum, digitalis, trimethylamine,
and veratrine: also I he appli I lips,
and leeches. General lessening of the metabolism
may be brought about by: Act anilide. acetphenet-
idin. alcohol, antipyrine and the coal tar denvatj
in general), benzoic acid, berberine, camphor, eu-
calyptol, phenol, picric acid, quinine and it- alka-
loid-, resorcinol, salicin, salicylic acid and the sal-
icylates, salol, and thymol.
The dissipal i at may be I: (1) By
abstracting heat from the body; and (2) by pro-
ducing pcr-piration and increasing evaporation.
Heat is abstracted from the body by cold baths and
sprays, cold drinks, and the application of ice or cold
packs to the surface of the body. This method is the
readiest, the most rapid, and probably the safest
way to reduce the body temperature. Diaphoretics
used for this purpose are Dover's powder, spirit of
nitrous ether, acetanilide, and antipyrine.
Aconite will also reduce the body temperature;
so will chloral; but how many of these antipyretic-
act is not known. Antipyretics as a class (particu-
larly the coal-tar derivatives) are depressing, and
dangerous. As in other conditions, the cause of
the abnormally high temperature should be sought
and, if possible, removed. R. J. E. Scott.
Antipyrine. — Axtipyrixa (Y. S. P.). phenazonum
( B. P.), phenyldimethvl-isopvrazolone, C' HX.,0(CH,),.
C II, or (CH 3 )N.C (CH 3 ): CH.CO.N(C.H 5 ). This is
one of the earlier so-called coal-tar synthetic remedies,
obtained by the action of acetyl acetic ether upon
phenyl-hydrazine. It occurs in the form of a white
crystalline powder or scales, of a bitterish taste, readily
soluble in water (the only substance of its class except.
resinol having this property), alcohol, and chloroform,
and in forty parts of ether. When treated with a
solution of ferric chloride it gives a deep red color.
It is chemically incompatible with most substances,
with some of which indeed, such as amyl nitrite and
nitrous ether (when containing free nitrous acid), it
forms poisonous compounds, and should therefore
always be prescribed alone, or with caffeine, salicylic
acid, or potassium bromide. With some substances
it combines to form definite chemical compounds, such
as salipyrine (antipyrine salicylate), tussol (antipyrine
mandelate), hypnal (antipyrine chloral hydrate), etc.
Antipyrine is analgesic, antipyretic, hemostatic,
and antiseptic. It was introduced as a febrifuge, but,
like other remedies of its class, was seen to possess
the disadvantage of depressing the heart action and
causing profuse sweating, and its greatest value was
f. mud to reside in its anodyne and analgesic properties.
It may be given for the relief of headache, the crises
of tabes dorsalis, neuralgia, dysmenorrhea, and rheu-
matic pains, in doses of gr. iv.-x. (0.25-0.6), re-
peated with caution every two or four hours. In the
pyrexia of pneumonia and other sthenic fevers it is
sometimes useful in similar doses, but should not be
continued if depression or profuse sweating occurs.
Locally it is employed in four-per-cent. solution as an
antiseptic and local anesthetic in acute rhinitis, pharyn-
gitis, and other mucous-membrane inflammations of
the upper air passages. Its hemostatic properties
render it of service, applied in powder or strong
solution, in epista.xis and in bleeding following the
division of urethral stricture.
A rash of a purplish patchy character may follow
the administration of antipyrine in susceptible in-
dividuals. In large doses it causes marked depres-
483
Antipyrine
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
sion, cyanosis, sweating, vertigo, shallow respiration
and dyspnea, rapid heart action, and convulsions.
These symptoms are not common after therapeutic
doses, but may occur even after small doses, and
caution should always be observed in its adminis-
tration. The treatment of toxic symptoms caused by
antipyrine consists in the application of heat to the
extremities and body and in the administration of
stimulants, strychnine, or atropine; inhalation of
oxygen may be of service. T. L. S.
Antisepsis. — See Asepsis.
Antiseptics. — This term was originally applied to
those means whereby putrefactive decomposition
could be prevented, but has gradually acquired a
much broader meaning. We now consider as antisep-
tics only those agents which suppress certain functions
of microorganisms, inhibiting their development but
nut killing them. If the bacteria are removed from
the influence of an antiseptic they will be able to
resume the function of multiplication. In many
instances, substances in a certain dilution act as
antiseptics, but when employed in a stronger con-
centration have the power of killing bacteria, that is
to say, become germicides or disinfectants. There are,
however, notable exceptions to this rule. A detailed
discussion of the whole subject will be found under
the heading Disinfectants. Ralph G. Stillman.
Antiseptol is the trade name for a substance pre-
pared by mixing a solution of twenty-five parts of
cinchonine sulphate in 2,000 parts of water, with a
solution of ten parts each of iodine and potassium
iodide in 1,000 parts of water. The precipitate
formed is washed and dried and constitutes a reddish
or dark brown powder, without odor, almost insoluble
in water and freely soluble in alcohol and chloroform.
It is an odorless iodoform substitute containing fifty
per cent, of iodine, and when used internally is given
in dose of gr. i. to v. (0.06-0.3). Antiseptol is also
cinchonine iodogallate and cinchonine herapathite,
although its chemical formula is unknown.
W. A. Bastedo.
Antisera. — See Antitoxins.
Antispasmin is a double salt of sodium salicylate and
narceine-sodium, having the formula C, 3 H, 8 No s Na +
3C 6 H 4 OHCOONa. It is a reddish, slightly hygro-
scopic powder, which is readily soluble in water; fifty
per cent, of it consists of narceine. As an antispas-
modic and sedative it is given in whooping-cough,
laryngismus stridulus, chorea, asthma, etc., especially
in children, and is useful in allaying irritating cough or
intestinal colic in adults. On account of its affinity
for moisture it is preserved with difficulty in the dry
state, and therefore may well be kept in five-per-cent.
solution; of this, five to eight drops are given to a
child of six months, or forty drops to a child of five
years; an adult may take one or two drams.
W. A. Bastedo.
Antispasmodics — If we are to interpret the term
antispasmodic in its literal sense as a means of pre-
venting spasm, nothing so completely fills the
requirement as ether or chloroform, pushed to
complete anesthesia. In conducting a careful phys-
ical examination, especially in diseases of the abdomen
or pelvis, such relaxation of spasm is often secured
by anesthetizing the patient. But as ordinarily used
by therapeutists the word antispasmodic is given a
somewhat loose and unscientific application to a
class of drugs supposed to be of special service in
controlling at tacks of muscular spasm depending upon
functional nervous derangement. The inappropriate-
484
ness of the name is seen from the fact that it is not
alone convulsive phenomena which form indications
for their use, but that they are also useful in other of
the multiform manifestations of nervousness or of
hysteria. The theory of their mode of action — if,
indeed, any one method of action is common to all
the members usually included in the class — is not
sufficiently established to make any discussion of it
profitable in this place. Suffice it to say that it is not
impossible that at least one important action of these
drugs is a local one upon the intestinal tract, where
their warming and stimulating character may produce
a revulsive effect. For the detailed description of the
most important drugs included under this heading
the reader is referred to their proper titles.
To be mentioned in connection with atropine, which
is the alkaloid of belladonna, is homatropine, an
artificial tropeine which has been recommended as
a desirable substitute for atropine as a mydriatic on
the claim (not well substantiated) that it produces
no increase in the intraocular tension.
Belladonna has a considerable power of relaxing
spasm, as, for instance, in the unstriped muscular
tissue of the intestine. It and its congeners, stra-
monium and hyoscyamus, are also much used in
asthma, which is a disease attended by spasm of the
bronchi. In the same condition opium is at times
of the greatest value, the hypodermic injection of
morphine alone causing relief in some asthmatic
attacks. In "colic" (meaning spasm of the muscular
walls of the intestine) opium is also invaluable.
This drug, like the anesthetics already mentioned,
while distinctly antispasmodic, has other and more
important therapeutic qualities which lead to its
classification in another group (see Anodynes).
Scopolamine, identical with hyoscine, is of value.
It has been combined with morphine, in which com-
bination it must be used with care. It has also been
used instead of chloral in tedious first stage of labor.
It may be given hypodermically in doses of gr. -j-Jj
grain.
Apomorphine is sometimes employed as an anti-
spasmodic in delirium tremens. It is believed by
some to be efficient in quieting this mania in less than
emetic doses, but is usually employed in doses of gr. ^
to T V hypodermically which not only relieve the
excitement but empty the stomach as well.
Among other remedies traditionally called anti-
spasmodics, we have a group of animal origin, strongly
odorous, but of little therapeutic value. Moschus,
musk, an oily substance obtained from the preputial
glands of the Thibetan musk-deer, is the only one of
this class which is used to any extent. In the last
stages of adynamic diseases, as typhoid fever, it is
given, especially by German physicians, but rather
as a forlorn hope than with real confidence. Its
former use in hysteria is now quite superseded.
Castorcvm, a corresponding secretion from the
Castor fiber, or beaver; ambergris, a morbid product
obtained from the sperm whale, and the source of the
oleum suceini; and the oleum animate of Dippcl, a
substance of disgusting origin and nature, obtained
from "trying out" decomposing animal structures,
deserve mention only as having been at some time
used as antispasmodics.
Another group consists of drugs of generally feeble
action, but occasionally useful in infantile hysteria
and allied states. Among these are humulus, hops,
and its derivative, lupulin. The former, applied
locally in the form of poultices or embrocations, has
possibly some virtue, and the latter is somewhat
more active internally. Lactucarium, derived from
the garden lettuce, is even more feeble than hops,
but as some persons are made drowsy by eating let-
tuce, it is not impossible that lactucarium may have
in certain cases a useful medicinal effect. The claims
which have been made for celery as an antispasmodic
and anticephalalgic do not seem to rest on reliable
REFERENCE HANDBOOK OF TIIF. MEDICAL SCIENCES
A III i IK]. .Ill i.^
grounds. Cimicifuga, or black snakeroot, belongs in
this group. It has been chiefly used in chorea, and in
full doses it has seemed to have some effect Dra-
contium, the root of the "skunk cabbage," and gaU
..i ingredient with asafetida and myrrh in the
la Oalbani Comp., 1". S. I'. 1880, have also had
antispasmodic virtues ascribed to them, but with
little reason.
\\ ,■ n..u cm 1 1. ■ lo i In- group which contains the most
important drugs of this class. They are three in
number, viz., camphor, valerian, and asafetida. They
; ill produce a sensation of warmth in the stomach, and
probably stimulate the whole alimentary canal. Hut
that this is not their sole action is proved by their
rioritv in certain nervous states over the essential
oils and other so-called carminatives. The intestinal
action of camphor makes that drug a valuable aid in
the treatment of cholera and choleraic diarrhea. In
the delirium of adynamic fevers and as a sedative for
"nervousness" it is useful. An especially quieting
influence lias been claimed for it in sexual irritation
and excitement. For more distinctively hysterical
symptoms, camphor is often combined with bromine
in the form of bromated or monobromated camphor,
which, despite? its disagreeable taste, difficult solubil-
ity, and frequent tendency to cause irritation of the
stomach, is considerably used for chorea, reflex con-
vulsions, etc. Perhaps no drug is more generally used
to combat the true hysterical convulsive seizure than
valerian, and certainly in many cases it meets the
indication better than almost any other agent. The
fluid extract and the ammoniated tincture are among
the most eligible palliatives of the hysterical attacks,
sometimes a single dose serving to restore conscious-
ness. For more protracted use in the countless
nervous manifestations of hysteria, hypochondria,
and neurasthenia, the salts of valerianic acid, notably
the valerianates of zinc and of ammonium, are
especially adapted, serving to control at times even
i positive and conspicuous symptoms as neuralgia.
Asafetida, long the synonym for what is most
loathsome and offensive to the palate, acts very like
valerian in the hysterical attack. The flatus which
lias been rolling about in the intestine is expelled, and,
as has been intimated above, there is some reason to
believe that the stimulation of the intestinal mucous
membrane and the revulsion so caused may, with the
relief of the tympanites, play a prominent part in
the alleviation of the hysterical spasm. In cases in
which simulation seems to have any part in the
attack, the vile taste of the drug may become of
service in adding to its effectiveness. In other cases
we may give the drug by enema, and its action upon
the intestine and also its effect on the convulsions
will be nearly the same as if it were administered by
the mouth.
While the above-mentioned drugs constitute the
more distinctive antispasmodics, there yet remain two
groups to which the term is often applied, and of which
some part of the action is similar to that above
described. The compound spirit of ether, Hoffman's
anodyne, is very useful in controlling nervous dis-
turbances, as is also the spirit of chloroform, formerly
known as chloric ether. The substances from which
these are derived — sulphuric ether and chloroform —
may, administered internally in appropriate doses,
be employed for the same purpose, although, of
course, their more proper classification is among the
anesthetics. The bromides of potassium, ammonium,
and sodium and chloral, though in their most promi-
nent action depressomotors, are yet, in moderate doses,
used as antispasmodics.
Finally, we have the group which includes coffee,
tea. mat<5, and guarana, of all which the active
principle is practically identical with caffeine.
Leaving out of account the important action of this
substance upon the heart and circulatory system, and
limiting our attention entirely to functional nervous
phenomena, we find that in migraine, which in the
family of diseases is not distant of kin from hysteria,
of the mo i useful remedies are caffeine and
guarana.
The newer analgesics of the coal-tar series, such as
antipyrine, acetphenetidin, acetanilide, etc., are, many
of them, constituents of unethical proprietary remedies,
which as used by the public for headache and other
nervous symptoms are a distinct source of danger,
causing s etimes profound cyanosis with fatal re-
sult. I lematopot ■phyrinuria has thu been caused.
The employment of these drugs, especially as domestic
ret lies, should be forbidden.
Marked antispasmodic elfects, in many cases fur
superior to those obtained by the above mentioned
drugs, are to lie gained by the external use of water
in the form of the hot bath, the warm pack, and tin;
ni her devices of hydrotherapy. Moreover, the latter
agency is devoid of some of I he dangerous effects
nf the drugs above mentioned. Hydrotherapy is
destined to supersede many of the old-time anti-
spasmodics. Charles F. Withington.
Antisudorifics. — Synonym, antihidrotics. A group
of remedies employed to check excessive secretion
from the sudoriferous glands. It includes belladonna
and allied plants, agaricin, picrotoxin, mineral acids,
sulphate of copper, oxide of zinc, and many other
drugs which possess astringent properties. What
may be termed indirect antisudorifics are creosote,
sulphocarbolates, and other antiseptic remedies, also
strychnine, iron, and tonics generally, which act by
improving the tone of the system and overcom-
ing any debility which is often the predisposing
cause.
Excessive sweating may occur with a marked
degree of pyrexia or an entire absence of fever. It
may be general or local, affecting a paralyzed limb
only, or limited to the hands or feet during perfect
health. (See Hyperidrosis.) That form which is of
importance to the practitioner is the very profuse
sweating met with in phthisis and in all forms of
septic absorption. In these conditions the loss of
fluid is at times enormous, and as there is also present
a large amount of solids, it becomes a very exhaustive
drain upon the system. This secretion is not an
ordinary transudation of water in the form of serum.
It is a special secretion controlled by special nerves,
and any depression or paralysis of these nerves at
once lessens the secretion. This is well seen in the
effect of poisonous doses of belladonna, when the
vasomotors are paralyzed and the flow of blood in
the skin is increased, but notwithstanding this the
skin remains dry on account of the sudoriferous
glands being also paralyzed.
The antisudorifics are useful in all forms of hyperi-
drosis. Their action, however, is but the relieving
of a symptom and not the cure of a disease. For-
merly they were given very empirically, an immediate
effect being desired, whatever the cause. With our
increased knowledge of the action of toxins and the
production of sepsis, not so much is expected of the
drugs. More attention is given to the general health
of the patient and to removing the cause of the sweat-
ing. In tuberculous and septic conditions an effort is
made to lessen the formation of toxins; and we also
realize that the excessive sweating is an effort of
nature to cast off the poisons, and unless its production
is lessened much harm may arise if its excretion is
suddenly checked. The most valuable of antisudor-
ific drugs is belladonna and its alkaloid. One of its
earliest effects is to parah'ze the secreting glands of
the skin and mucous membranes, and, aside from its
interfering to a slight extent with the digestion, its
action is wholly favorable. The effect of belladonna
is secured by the administration of atropine by the
mouth, or preferably by hypodermic injection. It
485
Antisudorlfies
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
may be commenced in moderate doses of gr. yi^,
but its full physiological action must be secured and
as much as gr. .,'„ may be required. Too frequently
the dose employed is insufficient. The rapidity of
its action varies. Sometimes the system responds
almost immediately, at other times its effect is not
evident for three or four hours. Usually the effect
of a full dose will last for two or three days. Local
application of the ointment and liniment of bella-
donna will produce the same effect, but is less under
control.
Hyoscyamus and its alkaloids have also the same
action. Agaric acid has been used with much suc-
cess in doses of gr. -fo to J. Picrotoxin has also been
recommended in doses of gr. t^j to ^. Zinc oxide,
gr. ij. to iv. at bedtime, and sulphate of copper,
gr. ss. are very old remedies. One of the oldest
remedies, and, next to belladonna, one that is the
most generally employed, is the aromatic sulphuric
acid. This requires to be given more continuously
until it produces its astringent action. At first,
ni xx. three or four times a day, should be given for
two or three days, after which a single dose at bedtime
will continue "the effects of the drug. The dilute
phosphoric acid is also of service when administered
in the same way. These acid astringents have not
the same specific action as belladonna, but are
probably excreted in part by the sweat glands, and
during the excretion exercise their astringent action.
Camphoric acid, gr. vii. to xii., has been highly
recommended.
Bathing the surface of the body with weak acid
solutions assists in allaying perspiration and prevent-
ing the "night sweats," for it is known that all acid
solutions will lessen the secretion of acid-secreting
glands. Dilute acetic acid, or vinegar, one table-
spoonful to the pint, applied at bedtime, and in
severe cases repeated a short time before the ex-
pected "sweat," will allay the trouble and at the same
time prove most refreshing. For local sweating of
the hands or feet the general health of the patient
must be attended to, after which the above drugs
may be given in more moderate doses and extended
over a greater period. In addition dusting powders
and lotions may be used, salicylic acid five per cent,
with starch and talcum, oxide of zinc, tannin.
Solution of formalin ten to twenty per cent, in water
or alcohol is particularly beneficial.
Beaumont Small.
Antitoxins; Antitoxic Sera. — The word antitoxin is
at present usually restricted to substances found
in the blood of animals which neutralize the toxins
produced by bacterial or other cells. Other substances
exist which are slightly antitoxic. These are found
in old cultures, and Bolton developed them from
toxins by means of electricity. An antitoxin is, to
a large degree at least, specific in its effects on poisons;
that is, it acts only, or at least chiefly, upon the toxins
produced by" one species of organisms.
Thus, a given quantity of antitoxic serum from a
horse made immune to diphtheria will absolutely
neutralize a number of fatal doses of diphtheria toxin,
so t hat the mixture injected into an animal will prove
harmless.
The same antitoxic serum mixed with the toxin
from tetanus bacilli will have no appreciable neutral-
izing effect. In a few instances some have reported
an antitoxin to have an effect on more than one toxin,
but even here this effect is always much greater upon
some one than upon the others.
Antitoxins are present to some extent in the blood
of a certain percentage of animals which have not
passed through an infectious disease or been injected
with bacterial or other cell poisons. For instance,
li"i i usually have more or less of a substance an-
titoxic to the diphtheria toxin. Thus it will require
5 c.c. of the blood of one horse to protect a 250
gram guinea-pig from ten fatal doses of diphtheria
toxin, while in another j'j c.c. will suffice. The
blood of these same horses may have no neutralizing
effect upon tetanus toxin.
Whether these antitoxic substances present in small
amounts in normal blood are the same as those
present in larger amount in the blood of immunized
animals, we as yet do not know. Neither in their
chemical nor in their physiological properties can we
detect any difference.
The Nature op Antitoxins. — Up to the present
time we know only that they seem to have the prop-
erties of globulins. If it were not for the fact that
we have them present in normal blood, we might, in
order to account for their specific qualities, consider
them as partly satisfied combinations of globulins and
specific toxins, but as they occur without the pres-
ence of toxins this theory seems to be excluded.
Blood from either normal or immunized animalx
contains a number of globulins, and some of these,
when the blood is antitoxic, prove antitoxic also.
By no known method can we separate the antitoxin
from all the globulin so that if antitoxin be not a
globulin it is at least a substance very closely allied to
it. Exactly how the antitoxins are produced we do
not know, but we believe them to be cell products.
Different antitoxins may be produced by different cells.
A relation which exists between the amount of
antitoxin in the blood of an immunized animal and
the amount of globulins has been noted, in the tests of
the different horses under the care of the Department
of Health of the city of New York, by Atkinson.
He found that the globulin increased and decreased
roughly as the antitoxin increased and decreased.
Antitoxins are only fairly stable substances. In
sera antitoxins more or less slowly deteriorate,
largely according to the conditions under which they
are kept, but partly also in proportion to the abund-
ance of certain blood ferments. In sterile serum,
kept cold and free from access of air, antitoxins
deteriorate very slowly, diminishing from ten to
fifty per cent, in a year. Exposed to light, air, and
slightly elevated temperature, they quickly become
altered, and especially so if exposed to heat above 50°
C. Exposed to 70° C. for ten minutes, a portion of
the antitoxin in a solution i-< destroyed.
As the antitoxins of diphtheria and tetanus have
been the most studied and are by far the most im-
portant of the known antitoxins, they will be con-
sidered in detail as types of the others.
Both of these antitoxins have the power of neutral-
izing their corresponding toxins, so that when a
certain amount is injected into an animal before or
together with the toxin the poisonous effect of the
toxin is removed. There is still some difference of
opinion as to whether antitoxin acts by direct chemi-
cal neutralization of the toxin or indirectly on the
cells. The facts in favor of a direct action of antitox-
ins upon their corresponding toxins have been briefly
summarized by Cobbett as follows.
1. Certain reactions have been observed to take
place between these substances outside the animal
body (venom, ricin, crotin, tetanus toxin, diphtheria
toxin, and their corresponding antitoxins).
2. Various attempts by filtration, chemical means,
and heat to separate the toxins and antitoxins from
neutral mixtures have been failures. Partial successes
have, at least in some instances, been shown to de-
pend upon the fact that insufficient time for the com-
plete union of toxins and antitoxins was allowed,
separation being no longer possible if this were
granted.
.;. The accuracy of the titration of toxins and an-
titoxins to within one per cent, of error.
4. The fact that to save an animal from one
thousand fatal doses of toxin requires little more than
1st;
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
\ rilitin I.-
a hundred times as much antitoxin as is required to
fully protect for ten fatal doses, the resistance of the
animal itself accounting for the difference.
;,. Thefact |liat the potency of antitoxin is greatly
Increased if it is allowed I" remain for a sufficient
time in contact with the toxin at a suitable tempera-
ture to allow of chemical union.
On the other hand, the (■(inclusions which Buchner
Rous drew from their experiments have been
shown to have been based, partly at least, on a mis-
eption, for they ignored the capacity of an
animal to deal with a certain minimal quantity of
poison, and consequently made no distinction be-
tween what seemed to be a physiologically neutral
and a completely neutral mixture.
The facts now known, therefore, indicate clearly
that the antitoxins of tetanus, diphtheria, the plague,
and cholera, of snake poison, of ricin, etc., enter into
direct chemical combination with their respective
toxins — a combination which is, perhaps, not exactly
comparable to that of an acid with an alkali; for, as
we have seen, it is a much slower one, but one which
possibly as Ehrlich has suggested — more closely
resembles the formation of a double salt. Some facts
seem to indicate that the antitoxin has a stronger
affinity for toxin than the toxin has for the cells.
Many points, however, are still far from clear as to
the manner in which both toxins and antitoxins act.
The Persistence op Antitoxin in the Blood. —
About five days after the absorption of toxin has
Ceased, either after a natural disease or after an arti-
ficial infection, the production of antitoxin in the
body stops, and the amount in the blood gradually
ens, partly from its elimination by the urine, milk,
and partly, perhaps,by its destruction in the blood.
The blood of an animal highly immunized may
retain appreciable amounts of antitoxin for from
three to six months.
When animals are immunized with the antitoxic
sera of animals of other species, the antitoxin is much
more quickly eliminated than when sera from the
species are employed. For this reason the
immunizing effect of sera in man against diphtheria,
tetanus, and the few other infections for which we
have antitoxins, is of quite short duration, much less
than if antitoxins had been developed from toxins
injected. Thus, immunization of a child with 1,000
units of antitoxic horse serum insures immediate
safety, but only ten days of certain protection from
diphtheria or tetanus.
The diphtheria and tetanus antitoxins are the only
two used extensively in treatment. All the other
protective -era are largely bactericidal in their action
and owe what value they have to this characteristic.
The most important of them will be touched upon in
the article on immunity, under the bactericidal prop-
5 of the blood.
The use of antitoxins in the prevention and treat-
ment of diphtheria and tetanus is so important that
some details as to how to choose and administer the
sera may be of value. All antitoxic sera must be
injected subcutaneously, or intravenously, for they
are only very slightly absorbed by the stomach or
intestines. The sera should be clear and have no
odor except in cases in which an antiseptic has been
added, such as trikresol or carbolic acid. Let us now
sider in detail the diphtheria antitoxic serum.
The dosage is regulated by units of effect and not by
weight, for we have nofr as yet absolutely isolated
antitoxin. A unit is the amount of antitoxin which
protects a 250-gram guinea-pig from about 100 fatal
doses of diphtheria toxin. Toxins produced in differ-
ent ways are found to vary in their relative toxic and
neutralizing forms. In Hygienic Laboratory of the U.
S. Public Health and Marine-Hospital Service sup-
plies a standardized toxin to be used by the different
producers.
Diphtheria antitoxic serum is put up in dill, tent
"grades," the lower grades having 800 to 1,000 units
i n each cubic cen timet er(jf globulin solution, the higher
grades having 1,400 to 2,000 units. Other things
being equal, the higher grades are better and more
convenient than the lower ones. Thi concentration
should be of antitoxin and not of proteins, for thick
sera do not, absorb as quickly as when more diluted.
The Amount of Diphthebia Antitoxin to be
VdMINISTJ 10 D k.ND THI \ I MBEE OF [NJECTIONS IN A.
Single Case. Therei -till ome difference of opinion
a ng competent observers as to the answer to the B
questions. For immunization, 500 units in infants
and 1,000 in adults will suffice. In treatment, our
practice is the following: Cases seen early, in which
the onset is mild, 2,000 units. Cases seen early, in
which the onset is severe, shown either by local sign-,
such as swelling, hyperemia, or the extent of the
exudate, Or by constitutional symptoms, 10,000 to
20,000 units, according to severity. Cases -ecu after
the disease has progressed so far that its probable
local extent can be guessed, mild case-, 2,000 to 5,000
units, according to the size of the patient; moderate
cases, 3,000 to 5,000 units; severe cases, showing
necrotic membrane, swollen glands, or laryngeal sten-
osis, 10,000 to 20,000 units. For these severe cases
the antitoxin should be warmed to body heat and then
injected intravenously.
The effects to be expected from the antitoxin are,
that the local disease should not extend, that the
swelling and hyperemia should lessen and the constitu-
tional symptoms abate. If twenty-four hours after
the injection these changes have not begun clearly to
manifest themselves, the injection of antitoxin should
be repeated. The extent of the disease, rather than
the size of the patient, guides the dose; still size should
be considered, as the concentration in the blood is of
course in proportion to the size. When antitoxin is
injected subcutaneously it is absorbed very slowly.
At the end of twenty-four hours not more than one-
half has been absorbed. When given intravenously
the whole amount becomes immediately available.
Second injections are not usually required if the full
sized initial dose is given. Larger amounts of serum
are advised by some. There is no objection in giving
more except for the expense. With the serums as now
used, these large doses have produced in a small
percentage very disagreeable results, namely, rashes,
fever, and in a few joint inflammation.
Whether some samples of serum may or may not
cause, along with their beneficial effects, really serious
deleterious effects, is still undetermined; but we do
know that many samples of serum produce practically
not even disagreeable effects. Thus. I have seen
sixty cases treated, with only one rash. Serum as
such is rarely given, but instead a solution of globulins.
Banzhaf, Gibson and Atkinson finally succeeded in
eliminating from the antitoxin all the serum constitu-
ents except a portion of the globulins. Although
rashes occasionally follow the injection of the anti-
toxic globulins they are much less frequent than from
the whole serum.
The Production of Diphtheria Antitoxin for
Therapeutic Purposes. — As a result of the work
of years in the laboratories of the Health Department
of New York City the following may be laid down as a
practical method:
The strongest diphtheria toxin possible should be
obtained by taking a very virulent culture and grow-
ing it in slightly alkaline two-per-cent. peptone
bouillon. The culture, after a week's growth, is to
be removed, and, after it has been tested for purity by
microscopical and culture tests, is then to be rendered
sterile by the addition of ten per cent, of a five-per-
cent, solution of carbolic acid. On the following day
the sterile culture is filtered through ordinary sterile
filter paper and stored in full bottles in a cold place
4S7
Antitoxins
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
until needed. Its strength is then tested by giving a
series of guinea-pigs carefully measured amounts.
The horses used should be young, vigorous, of fair
size, and absolutely healthy. A number of such
horses are severally injected with an amount of toxin
sufficient to kill 1,000 guinea-pigs of 250 grams
weight. After from two to three days, so soon as
the fever reaction has subsided, a second subcutaneous
injection of a slightly larger dose is given. With the
first three injections of toxin about 1,000 units of
antitoxin are given. If antitoxin is not mixed with
the first doses of toxin, only one-tenth of the doses
advised is to be given. At intervals of from two to
three days increasing injections of pure toxin are
made, until, at the end of two months, from ten to
twenty times the original amount is given. There
is absolutely no way of judging which horses will
produce the highest grades of antitoxin. Upon a
very rough estimate I may say that those horses
which are extremely sensitive and those which react
hardly at all are the poorest, but even here there are
exceptions. The only way, therefore, is at the end
of six weeks or two months to bleed the horses and
test their serum. If only high-grade serum is
wanted, all horses that give less than 150 units per
cubic centimeter are discarded. If moderate grades
only are desired, all that yield 100 units may be
retained. The retained horses receive steadily
increasing doses, the rapidity of the increase and the
interval of time between the doses (three days to one
week) depending somewhat on the reaction following
the injection, an elevation of temperature of more
than 3° F. being undesirable. At the end of three
months the antitoxic serum of all the horses should
contain over 200 units, and, in about ten per cent.,
as much as 600 units, in each cubic centimeter.
Very few horses ever give above 1,000 units, and
none so far has given as much as 2,000 units per
cubic centimeter. The very best horses continue to
furnish blood containing a large amount of antitoxin
for several months, and then, in spite of increasing
doses of toxin, the amount of antitoxin gradually
decreases. If every nine months an interval of three
months' freedom from inoculations is given, the best
horses furnish high-grade serum for from two to four
years. The toxin injected at one time should be
divided into five or six portions so as to reach more
tissue and lessen the liability to abscess.
The Production of Tetanus Antitoxin. — The
tetanus antitoxin is developed in the same manner
as the diphtheria antitoxin — by inoculating the
tetanus toxin in increasing doses into horses. The
toxin is produced in bouillon cultures grown anaero-
bically. After ten or fifteen days the culture fluid
is filtered through porcelain, and the germ-free
filtrate is used for the inoculations. The horses
receive 0.5 c.c. as the initial dose of a toxin of which
1 c.c. kills 250.000 grams of guinea-pigs, and along
with this a sufficient amount of antitoxin to neu-
tralize it. The antitoxin is added to the first few-
doses. In five days this dose is doubled, and then
every five to seven days larger amounts are given.
The dose is increased as rapidly as the horses can
stand it, until they support 700 to S00 c.c. or more
at a single injection. After some months of this
treatment the blood of the horse contains the anti-
toxin in sufficient amount for therapeutic use.
When the animals' temperatures are normal and
they have recovered from the dose of toxin last-
given, they are bled into sterile flasks and the serum
collected.
Technique op Testing Tetanus Antitoxic
Serum for Value in Antitoxin. — Tetanus anti-
toxin is tested exactly in the same manner as diph-
theria antitoxin, except that the unit of measure is
different. A unit by the U. S. standard is the amount
of antitoxin which will neutralize 1,000 fatal doses
488
of a standard tetanus toxin. A 350-gram guinea-
pig is used as the test animal. A unit in the German
standard is the amount of antitoxin needed to neu-
tralize 4,500,000 fatal doses of toxin for 1 gram of
white mouse. In the French method the amount of
antitoxin which is required to protect a mouse from
a dose of toxin sufficient to kill in four days is deter-
mined, and the strength of the antitoxin is stated by
determining the amount of serum required to protect
1 gram of animal. If 0.001 c.c. protected a 10-gram
mouse, the strength of that serum would be 1 to
lo.ooo. Guinea-pigs are frequently used in place
of mice. Knorr's method of preserving toxin is by
precipitating it with saturated ammonium sulphate
and drying and preserving the precipitate in sealed
tubes. As required, it is dissolved in ten-per-cent.
salt solution, as above stated. For small testing
stations the best way is to obtain some freshly stand-
ardized antitoxin and compare serums with this.
The Dosage of Tetanus Antitoxin. — For im-
munization, one dose of 1,500 units U. S. standard
is given. This will suffice unless the danger seems-
great, when the injection is repeated at the end of a
week. For treatment, an intravenous injection of
15.000 to 20,000 units should be given, according to
the severity of the case. Not a moment's unneces-
sary delay should be allowed. In the gravest cases ao
curative effect will be noticed from the use of the
serum, but in many moderately severe cases it is
very beneficial. The symptoms cease to grow worse
and then gradually lessen. It is sometimes injected
into the spinal canal, the lateral ventricles, or even
into the brain substance. Both the theoretical rea-
sons for, and the actual results obtained from, this
method of treatment are open to criticism. The
first dose, in severe cases, should be given intra-
venously, but if for any reason the physician hesitates
to give it in this way it should be given subeutane-
ously, rather than allow of delay. It is well to give
5,000 to 10,000 units daily until the symptoms
markedly abate so as to keep up the antitoxin con-
tent of the blood. William H. Park.
Antitrypsin. — Blood serum contains a substance,
called antitrypsin, which is able to neutralize the
action of trypsin. The expression of the quantity of
antitrypsin thus contained is called the antitryptie
index or titer of the serum. There are two methods
for the determination of this index. One, that of
Jochmann and M tiller, depends upon the digestive
action of trypsin on serum albumin. Loefner's blood
serum plates are used and the time necessary is about
twenty-four hours. This method will give results of
only relative value. The incubation is carried out at
55° C, which is higher than the optimum tempera-
ture for tryptic action. The variability of the reac-
tion and composition of the serum, the method of
measurement by loopfuls, and the possibility of
bacterial contamination, all may prove sources of
error. The other method, introduced by Gross and
Fuld, is much more exact. It is based upon the diges-
tion of a clear casein solution and the precipitation
by acid of any casein remaining undigested at the
end of the period of incubation. Citron thus de-
scribes the performance of the test.
The casein solution is made up by dissolving one
gram of casein in 100 c.c. of A'/ 10(decinormal solution)
NaOH, neutralizing with A'/iO HC1, using litmus, and
diluting to 500 c.c. with physiological salt solution.
The trypsin solution is prepared by dissolving 0.5 gm.
of trypsin in 50 c.c. of NaCl and 0.05 c.c. of normal
sodium hydrate solution and diluting with physiolog-
ical salt solution up to 500 c.c. The acid solution
consists of 5 c.c. of acetic acid with 45 c.c of alcohol
and 50 c.c. of water.
The trypsin solution is first titrated. "Gradually
REFERENCE EANDBOOK "1 THE MEDICAL SCIENCES
increasing amounts of trypsin (from 0.1 to 0.6 c.c.
are placed into six test-tubes and to each 2.0 <■.<■. oi
casein solution is added. These tubes are placed
In an incubator at 37 c C. for one-half hour, and then
several drops of acid soution are placed into each
tube. The first tube, and all of those above it that
n't. iain absolutely clear, contain enough trypsin
fully i" digest the 2.0 c.c. of casein." For the test
Itself:
"Into each of eighl to ten test-tubes, are placed
2 c.c. of the casein solutionand 0.5 c.c. of a two-per-
cent, dilution of the serum for examination; to these is
next added the trypsin solution in successively increas-
ing amounts, beginning with the smallest quantity
which in the first part of the test was sufficient com-
pletely to digest the given amount of casein. Salt
solution is then added to each of the test-tubes so that
all con lain an equal quantity of fluid, and the mixtures
arc placed into an incubator at 37° C. for one-half
hour. At the end of this time, several drops of the
acid arc added to each tube. Those tubes which become
cloudy or -how a precipitate, designate the amounts
vpsin solution which have been neutralized by the
C. of diluted serum." The quantity of trypsin
solution in the first tube to remain clear is considered
the antitryptic titer of the serum. That is. if the tubes
containing 0.4, 0.5, and 0.6 c.c. of the trypsin solution
yield a precipitate with the acid and those with 0.7
and 0.8 c.o. remain clear, the antitryptic index of the
serum is 0.7.
The test has a certain amount of diagnostic value.
The antitryptic index is increased in from seventy
to ninety-five per cent, of patients suffering with
cancer, also frequently in acute infections, in chronic
Infections, as tuberculosis, in diabetes, severe anemias,
and in Graves' disease. It has also been noted in
infants on the inauguration of artificial feeding and
in pregnant women at the onset of labor. It evi-
dently occurs in too many conditions to have the
value of a specific symptom, but on the other hand
it has a distinct negative value. A low index, for
instance would be a good argument against the
diagnosis of cancer.
The nature of antitrypsin is but little understood.
It is probably not a highly .specific immune body, but
on the other hand it is almost certainly not a non-
ific antiferment. It will act only in the presence
of lipoids. Weil concludes that "the antitryptic
function is exercised by an albuminous substance,
thermolabile, indeed, like the true antibodies, but
differing essentially from these in the lack of speci-
ficity." The normal antitrypsin probably is entirely
distinct from that produced in the body following
the injection of trypsin. The theory of its origin is
that it is produced by the body, stimulated to that
effect by the presence in the blood of a certain amount
of trypsin, which latter is, in part at least, a secretion
of the polynuclear leucocytes. In fact, in infections
there is a definite relation between the antitryptic
index and the polynuclear leucocytosis. In cancer
this ferment may very conceivably be produced by
the cancer cells. At the present time, however, the
proved facts as to the chemical and biological nature
of antitrypsin are so few that no definite statements
can be made concerning them.
Ralph G. Stillman.
Anuria. — By this term (derived from a-privative
and oipon, urine) is understood a total suppression
of the secretion of urine. It is to be distinguished
from retention of urine, in which the kidneys are
performing their function, but through atony of the
bladder, spasm of the vesical sphincter, enlarged
prostate, or calculous impaction or stricture of the
ureters or urethra, no urine is passed; and from
oliguria (iklyos, little, and ofrpov, urine) in which
the secretion is greatly diminished, though not
entirely suppressed, the very -mall amount formed
being retained for a long time in the bladder until
this viscus is sufficiently distended to excite the
urinary reflex. Anuria occurs rarely in uremic
attacks accompanying acute nephritis, in conditions
in which there is extreme loss of' fluids through the
other emunctories, as in cholera, colliquative diarrhea,
profuse vomiting, etc.. and sometimes in hysteria.
ahus. Diseases of the. See R ' Anus,
!>.■■■
Anytin i- a derivative of ichthyol introduce, 1 by
TJnna in dermatological practice. It is a thirty-three-
per-cent. aqueous solution of sulphoichthyolic acid
and the aromatic oily sulpho-compound contained in
ichthyol. Dark brown in color, if contains l(i..j per
cent, of sulphur and 4.5 per cent, of ammonium. It
is decomposed by acids and strong alkalies, and
possesses the peculiar property of rendering such
sub-tances as phenol, guaiacol, cresol, camphor, etc.,
freely soluble in water. These solutions are called
"anytols" and promise to be valuable additions
to our antiseptic materia medica. Koelzer used a
7.5-per-cent. aqueous solution of metacresol anytol
(metacresol, forty per cent.) in erysipelas. By
painting it on frequently over an area extending some-
what beyond the inflammation he obtained a good
result in every case. These anytols, especially those
of phenol and cresol, may be used in five- to ten-per-
cent, dilution for disinfection of the hands or for
vaginal or intrauterine douches. They then have
much the same effect as creolin.
Anytin itself is capable of setting up an active
dermatitis, but diluted to ten per cent, it is very
useful in chronic eczema, sunburn, ami ivy poison-
ins. It is stated to be directly antagonistic to the
diphtheria bacillus. W. A. Bastedo.
Aorta. — From the Greek, aoprr/, from aeipeh, to lift, to
carry. Synonyms. — Arteria magna (Harvey); haemal
axis lOwen). French, aorte; German,; grosse Schlagarlcr.
Originally, in the plural, aortae iaoprai) signified the
bronchial tubes (Hippocrates).
Definition - .- — The main trunk (single in mammals
and birds, double in cephalopods and most reptiles,
triple in the crustaceans) of the systemic arterial
system, by means of which the oxygenized blood is
carried to all parts of the body.
Embryology. — According to Gibson, "the single
median tube," which is seen at one stage in the
development of the vascular apparatus, begins to
pulsate before the appearance of either muscular or
nervous elements. "The heart movements must be
due to some as yet unknown indwelling property of
the embryonic heart tissue." In the development
of the embryo there are two primitive aorta 1 . These
unite early, and to them four lateral pairs are succes-
sively added, and all develop into the artery seen at
birth — the aorta and its branches.
Anatomy. — The aorta, although the main arterial
trunk, is at its commencement generally a little smaller
than the pulmonary artery, but in the aged it is usually
slightly larger than that vessel. Its position, like that
of other arteries, is protected in proportion to its
importance. It takes its origin from the upper part
of the left ventricle, extending upward and to the
left for a short distance; then curving over the root
of the left lung, it descends in front of the spinal
column, passing through the aortic opening, hiatus
aorticus, which is in the middle line behind the
diaphragm, and which also transmits the vena azy-
gos major, the thoracic duct, and occasionally the left
sympathetic nerve. The vessel descends to the left
side of the fourth lumbar vertebra, where it termi-
nates, dividing into the right and left common iliac
4S9
Aorta
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
arteries. In its course it gradually decreases in size
from twenty-eight to seventeen millimeters, giving off
at different points branches of varying caliber.
Quain divides this artery into the ascending aorta, the
part within the pericardium; the arch, that part
extending backward from the pericardial limit to the
spine at the lower margin of the fourth thoracic verte-
bra; the descending thoracic aorta, from this point to the
diaphragm, and the abdominal aorta, the part below
the diaphragm. This method of division is founded
on the fact that the first part is intrapericardial and
has its origin from the fetal aortic bulb; while the
third part of that section, which was formerly known
as the arch, does not differ in relation, direction, or
origin from the rest of the descending portion. The
2 3 4 5 678 9 10 11 12 13
Fig. 257. — Anterior View of the Great Vessels of the Heart.
(From His's "Handatlas der Anatomie des Mensehen.") 1. First
rib; 2, subclavian vein; 3. subclavian artery; 4, internal jugular
vein; 5, right branch of pulmonary artery; 6, vena azygos; 7.
inferior thyroid vein; 8, left innominate vein; 9, trachea; 10, arch
of aorta; 11, ductus arteriosus; 12, left pulmonary artery; 13,
subclavian vein; 14, right lung; 15, right pulmonary veins; 1»>,
vena cava superior; 17, left atrium; IS, ascending aorta; 19,
pulmonary artery; 20, left pulmonary veins; 21, left lung.
older anatomists treated the arch as consisting of three
parts — the ascending, transverse, and descending, and
comprising that part of the artery found between its
ventricular origin and the lower border of the fifth
dorsal vertebra. This latter division seems far less
logical than the former according to the reasons ju-t
given. The first parts of both the aorta and the
pulmonary artery are regarded embryologieally as
parts of the heart.
Ascending Aorta. — The ascending aorta springs
from the upper and fore part of the left ventricle on a
level with the lower border of the third costal cartilage
behind the left half of the sternum. It passes up-
ward, forward, and to the right in a line with the
heart's axis till it reaches the upper border of the
sternum, at which point its direction changes and the
arch begins. The ascending aorta measures about
two inches or two inches and a quarter in length, and
it curves upward, backward, and to the left. Just
ab.,\ ,■ its origin this part of the aorta shows externally
three -mall dilatations of about the same size, known
490
as the sinuses of the aorta or sinusi s of Valsalva. ( fne
of these sinuses is anterior, the other two posterior.
The anterior and left posterior give origin to the two
coronary arteries of the heart. Opposite to these
three sinuses are the semilunar valves. A cross
section of the vessel at this point is rather triangular
in form, while below the valves it is circular. At the
commencement of the arch and along the right side of
the ascending aorta there is generally found another
bulging, the great sinus of the aorta. Now and then
this sinus is not present. It is seen more distinctly
in the aged. The fibrous pericardium embraces
the whole length of the ascending aorta, while a tube of
serous membrane extends up from the cardiac surface
to invest this vessel together with the pulmonary
artery, except where they are in contact with each
other.
Relations.- — At its commencement the ascending
aorta is covered anteriorly by the pulmonary artery
and the right auricular appendix. Higher up, the
directions of these vessels diverge, the aorta passing
forward and to the right and the pulmonary artery
backward and to the left. At this point the aorta
closely approaches the sternum, being separated
from it, however, by the pericardium, the right
pleura, the narrow part of the anterior mediastinum,
the anterior edge of the right lung, besides a little fat
and areolar tissue, as well as the remains of the thymus
gland. Posteriorly are the left cardiac auricle and the
right pulmonary artery. At its right are the right
auricle and the superior vena cava. On the left is the
main pulmonary artery.
Branches. — The ascending aorta has two branches
only, the right and left coronary arteries. These
vessels, relatively small, spring generally from that
part of the vessel which is just above the free margin
of the semilunar valves, in the upper part of the two sin-
uses of Valsalva, and they supply the heart. The
right coronary artery is about the size of a crow 's
quill, while the left is somewhat larger.
Variations. — The ascending aorta and pulmonary
artery may be transposed, i.e. the former may rise
from the right ventricle and the pulmonary artery
from the left. There may be a communication be-
t w cen these two arteries by abnormal openings. One
may be wholly or partly obliterated, while the other
selves as a passageway for the blood of both by
means of communications between them. There is
now and then seen one simple tube connected with a
simple heart like that in fishes. , Sometimes the coro-
nary vessels arise by a common trunk, or at times
from the same sinus of Valsalva. As many as four
arteries have been observed, in which case the sup-
plementary vessels are smaller than normal and play
the part of branches of the main coronary trunk,
near which they take their origin. An extra coro-
nary has even had its origin in the pulmonary artery.
When one of the arteries is unusually small, the other
is correspondingly large and supplies a greater area,
especially at the back of the heart.
Arch of the Aohta. — The arch or transverse
aorta begins at the upper margin of the second right
costal cartilage at the right border of the sternum
and arches around the trachea, in its course passing
upward, backward, and to the left of the fourth
thoracic vertebra. At this point it passes downward,
and at the inferior margin of this vertebra the tho-
racic aorta begins. The arch at its superior border
is generally about an inch below the upper margin
of the sterum in the median plane.
Relations. — The arch of the aorta is situated in the
superior mediastinum, and is covered in front by
the pleurae and lungs, and the fatty remnant of the
thymus gland. ()n the left it is crossed by the left
pneumogastric and phrenic and the superior cardiac
branches of the left symphathetic nerve and by the left
superior intercostal vein, while the left recurrent
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Aorta
laryngeal benda upward beneath it. Posteriorly and
to the right lie the trachea, the deep cardiac plexus,
the lefl recurrent laryngeal, the esophagus, the tho-
racic duct, and the body of the fourth dorsal verte-
bra. The anterior part of the upper margin of the arch
is in contact with the left innominate vein, and gives
a to the large arteries— innominate, left caro-
tid, and left subclavian —which supply the head and
upper limbs. The border is just above the left bron-
chus and the bifurcation of the pulmonary artery.
and is joined with the left branch of that vessel
a fibrous cord, representing the remains of the
ductus arteriosus, which is connected with the aorta
just beyond the origin of the left subclavian. Be-
tween the arch and i lie bifurcation of the pulmonary
artery are found the superficial cardiac plexus and a
few large bronchial lymphatic glands. To its infe-
rior, anterior surface the fibrous pericardium is at-
tached. After giving off its branches, the arch is re-
i i i : e to some extent (23 mm.). There is
12
.11
—10
8
Fig. 258. — Arch of the Aorta with its Branches (anterior and
from the left). After a plaster-of-Paris cast. (From His 's " Hand-
ler Anatomie des Menschen," Band ii., S. 387.) 1, Right
subclavian artery; 2, right common carotid; 3, innominate artery;
4, arch of aorta; 5, ascending aorta; 6, bulbus aorta-; 7, right
coronary artery; s. sinuses of the ai irta ( Valsalva); 9, left coronary
artery; 10, thoracic aorta; 11, aortic spindle; 12, aortic isthmus;
13, left common carotid; 14, left subclavian artery.
often seen at that point where the ductus arteriosus
is attached, a constricted part, which is called the
aortic isthmus. The isthmus is far more marked
in the fetus from the expan-ion caused by the open-
ing of the ductus arteriosus. Beyond comes a fusi-
form dilatation reaching to the thoracic and called
the aortic spindle of His.
Branches. — The aortic arch has three branches
springing from its upper surface — the innominate or
brachiocephalic artery, the left common carotid, and
the left subclavian. The left carotid and the in-
nominate arteries are generally nearer together than
the left carotid and the left subclavian. These ves-
sels supply the head, neck, upper extremities, and
part of the thorax.
I arialions. — The upper limit of the aorta may be
found in some subjects as high as the third thoracic
bra, at the level of the top of the sternum, while
in others it is as low as the fifth thoracic. Sometimes
there is complete lateral transposition of the aortic
arch and pulmonary artery together with the great
veins and the divisions of the heart (dextrocardia).
This abnormality may be confined to these parts or
may embrace all the viscera (situs inversus). The
aortic arch has been observed to be completely
double. It has also been seen to pass to the right of
the trachea and esophagus instead of t.. the left, and
to continue its downward ci 'he riL'ln 9ide
mI' the pine.. I" 'his case the three branches h
an arrangement the reverse of the usual
Variations in the number ami position of the
branches of the arch are frequent. There may be only
one trunk, or there may be fj i i\ inclu
Descending Thoracic Unn. - At the termina-
tion of the arch, at the lower border of the fourth
thoracic vertebra, the d< cending aorta begins at d
continues down along the -pine to the fourth lumbar
vertebra, where it divides into the two common
iliac arteries. Its direction is not vertical, for as it
rests against the spine ii rily follows the spi-
nal curve . being concave forward in the dorsal region
and convex forward in the lumbar, As it- com-
mencement is to the left of the spine and its termina-
tion nearly in the median line, its general direction
throughout its whole length is inward, this being
more marked in its upper part. The lower limit of
the thoracic aorta is the hiatus aorticus at the level
of the diaphragm. This part of the aorta is from
seven to eight inches long and is contained in the back
part of the posterior mediastinum, where it rests
against the spine. Its branches are small, and
equently its diameter is little diminished (from
23 to 21 mm.).
Branches. — The branches of the descending
thoracic aorta, though numerous, are small. They
arc the pericardial, bronchial, esophageal, posterior
mediastinal, and intercostal.
Variations. — Now and then an obliteration of the
aorta at the point of junction of the arch and
thoracic portion is observed just below the connection
between the ductus arteriosus and the arch. This
condition, known as coarctation of the thoracic aorta,
results in the establishment of an interesting collat-
eral circulation. Xot infrequently variations in the
number and position of the branches of this section
of the aorta are observed.
Abdominal Aorta. — This name is given to the
vessel between the diaphragm and its bifurcation
into the two common iliac arteries. In relation to
the spinal column it begins about the lower margin
of the last thoracic vertebra and ends at a point about
the middle of the fourth lumbar vertebra, most
g inerally slightly to the left, sometimes almost
exactly in the median line, at other times slightly
to the right. This point almost corresponds to the
level of a line drawn between the two iliac crests or
to a point just below and to the left of the umbilicus.
In length it is about five inches. As its branches
are both numerous and large, its size rapidly di-
minishes. As mentioned before, its curve as it
rests against the vertebrae has its convexity forward,
being most prominent at the third lumbar vertebra,
slightly above and to the left of the umbilicus.
Relations. — Anterior to the abdominal aorta are
the lesser omentum and stomach, the solar plexus,
splenic vein, pancreas, left renal vein, transverse
duodenum, mesentery, aortic plexus, peritoneum,
lymphatic vessels and glands, and dense areolar tissue;
posterior to it are the bodies of the vertebrae and
the left lumbar veins, the thoracic duct, and the
cisterna (receptaculum) chyli. On the right are the
inferior vena cava, right crus of the diaphragm, vena
azygos (major), thoracic duct, and right semilunar
ganglion. On the left are the sympathetic nerve and
the left semilunar ganglion.
Branches. — These may be classified under two
heads: (1) Visceral — celiac axis (gastric, hepatic,
splenic), superior mesenteric, inferior mesenteric,
suprarenal, renal, and spermatic or ovarian. i2)
Parietal — phrenic, lumbar, and sacra media. The
branches of the aorta mostly pass off at right angles.
Variations. — Instances are known in which the aorta
491
Aorta
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
| — -16
— 15
is divided by a septum for either a part or the whole
of its course, so that two closely united tubes are the
resull. Sometimes this condition has a pathological
foundation, at other times
M#>| a . 21 it is due to an embryological
defect in the fusion of the
' 20 double fetal aorta. The
19 vessel has been known, as
i S in certain quadrupeds, to
1 7 divide into an ascending and
a descending branch, the
former subdividing into
three trunks to supply the
head and upper extremities.
The abdominal aorta may
vary in position and extent.
Its lower limit may vary to
the depth of a lumbar verte-
14 bra, so that its bifurcation
may take place at the third,
or even lower, at the fifth.
13 Its deviation from the
normal position with refer-
ence to the vertebral column
is generally due to patho-
logical changes rather than
to congenital causes. Quain
speaks of two cases of a
large pulmonary branch
springing from the aorta
very near the celiac axis,
which, after having passed
upward through the esoph-
ageal foramen in the dia-
Chragm, separated into two
ranches and entered the
lungs near their bases. Bal-
four, in writing of the simu-
lation of aneurysm by mal-
position of the aorta due to
rickets, says: "In rickety
chests the aorta may be so
deflected, without any
marked dila.tation, as to
make its pulsation visible
either to the right or left of
the sternum, and so to sim-
ulate an aneurysm. It is of
even greater consequence
to have proof that in certain
comparatively rare cases a
similar abnormal pulsation
may be due to a trifling
divergence from the normal
course of the vessel itself,
apart from any marked
change in the bony skeleton.
But we must never forget
that aortic aneurysm may
coexist with malformation
of the thorax with or with-
out scoliosis, and whatever
may be the condition of
the skeleton, any abnor-
mal pulsation must be care-
fully considered from every
point of view before we
are able to give any defi-
nite opinion as to what it
really is." Virchow has pointed out the relation
of the reduction in size of the aorta to chlorosis,
and he named the condition aorta chlorotica. Con-
genital stenosis of the aorta is seldom seen. Rosen-
Bach Iris noted this condition found together with
hypert rophy of the heart. It may cause sudden death,
and when it is present, otherwise unimportant
affections may assume a grave aspect, from sudden
untoward cardiac symptoms. In congenital stenosis
Fig. 259. — View of the
Thoracic and Abdominal
Aorta. (From Joessel-
Waldeyer: " Lehrbuch der
Topographiseh - Chirurgi-
schen Anatomic ") 1. Right
common carotid; 2, innomi-
nate artery; 3, right sub-
clavian artery; 4, right
lymphatic duct; 5, right
innominate artery; 6, su-
perior vena cava; 7, pos-
terior intercostal glands;
8, vena azygos; 9, inferior
vena cava; 10, right lumbar
lymphatic duct; 11, left
lumbar lymphatic duct; 12,
receptaculum chyli; 13,
thoracic duct; 14, posterior
intercostal glands; 15, aorta;
1G, left innominate vein; 17,
left subclavian vein; IS, left
■subclavian artery; 19, mouth
of thoracic duct; 20, internal
jugular vein; 21, left common
carotid.
of the aortic system, a striking characteristic is the
continuous subnormal temperature present in infec-
tious diseases which normally show a high temper-
ature. In women this condition is generally asso-
ciated with infantile uterus and other signs of ar-
rested development.
Structure. — The aorta is very strong and elastic
and is enclosed, like most other arteries, in a sheath,
which has more connective than yellow elastic tissue,
so that, when cut, the vessel shrinks within the
sheath. It is composed of three coats — (1) tunica
Ultima; (2) tunica media; (3) tunica adventitia,
The internal coat, smooth and offering but little, if
any, resistance to the blood, consists of three layers
(a) Epithelial layer or arterial endothelium. This
is made up chiefly of irregular, flat, polygonal cells
with round or oval nuclei with nucleoli. (6) Sub-
epithelial layer, which is well marked and consists of
numerous anastomosing cells resting in a delicately
fibrillated ground work of connective tissue. There
are, besides, elastic fibers which are in connection
with the next layer, (c) Elastic layer, which forms
the principal part of this inner coat. Sometimes this
network assumes characteristics which have caused
it to be designated as the "perforated" or "fenes-
trated" membrane of Henle. At times it is rep-
resented by a longitudinal network of fibers. The
middle coat is muscular, consisting of bundles of
plain muscle fibers, which are disposed circularly
around the vessel, although not forming a complete
ring. These fibers contract and relax, thus changing
the caliber of the vessel. Elastic fibers are also
found well developed in this tunic, and there is also
considerable connective tissue. This coat is thicker
than the corresponding coat in other arteries. It has
also relatively more elastic tissue and less muscular
tissue than is found in other arteries. The external
coat consists of white connective tissue and elastic
fibers. The connective-tissue bundles run chiefly
diagonally around the vessel and connect it with its
sheath. This is the strongest and densest coat.
Vessels and Nerves. — Both small arteries and veins
(xmsa vasorum) ramify in the external coat of the aorta.
They serve as nutrient vessels. Ranvier states that
in health in the human subject they never penetrate
to the middle coat. The inner coat is thought
to be nourished by the blood circulating through it.
Alt hough the aorta is supplied by nerves, it is insensi-
ble when in a healthy condition. These nerves are
chiefly non-medullated. The finer branches are dis-
tributed chiefly to the muscular tissue of the middle
coat. The aorta is supplied by both vasoconstrictor
and vasodilator fibers. Nerve plexuses are formed
around the vessel.
Physiology.- — The second heart sound, short and
sharp, occurs just at the closure of the two semilunar
valves, that is, immediately after the end of ventric-
ular systole. This sound is best heard over the
second right costal cartilage close by its junction
with the sternum. At this point the aortic arch is
nearest to the surface, and here sounds generated
at the aortic orifice are best transmitted. The sound
is due to the vibrations of the semilunar valves which
are made tense by their sudden closure.
The sound is not exclusively of aortic origin as is
instanced in those cases in which the action of the
semilunar valves on the two sides of the heart is
not absolutely simultaneous. For then the sound is
double ("reduplicated second sound"), one due to
the aorta, the other to the pulmonary artery. A
murmur may replace the normal sound when the
semilunar veins are diseased.
If the closure of pulmonary and aortic valves were
absolutely synchronous the second sound would be
shorter and sharper. But due doubtless to local
pressure variations that sometimes occur in the
aorta and pulmonary arteries, the closure of one
492
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Aorta, Diseases <»f
valve may lake place just a trifle earlier than thai
df the others. The sound is increased by the trem-
bling of the blood column set in vibration by the ven-
tricular systole and by the closure of the valves on
the sudden passive recoil of the arterial walls.
Sudden relaxation follows contraction of the ven-
tricles, intraventricular pressure falls. The pres-
sure of the blood column as it tries to regurgitate
closes the semilunar valves, the central orifice is
closed by the corpora Arantii, and both aorta and
pulmonary artery are cut oil from the heart.
By means of a pair of elastic manometers or by
the differential manometer the pressure-curve oi
the aorta may !»■ compared with thai of the left
ventricle and thus may be determined the instant at
which the .semilunar valves open and close. Tin
closure of these valves is estimated to occur at a
period corresponding to a point on the upper portion
of the descending limb of the intraventricular curve.
Clinically speaking, the semilunar valves may be
said to close "0.03 second before the bottom of the
aortic notch in sphygmographic tracings from (he
carotid, this being approximately the average time
taken by the pulse-wave in traveling from the aorta
in the carotid." At the abrupt end of systole when
the ventricular outflow ceases, the aortic blood col-
umn continues to move on in accordance with the
law of inertia. As the pressure diminishes there is a
recoil of the aortic walls behind this blood column
• just as a negative wave is set up in the central end
of the elastic tube when the stroke of the pump is
over." Now before the semilunar valves are com-
pletely closed the blood is forced back against them
under the combined influence of lower pressure from
relaxation of the ventricular muscle and diminished
pressure in the beginning of the aorta. The valves are
ton I'd slightly into the ventricular cavity and a neg-
ative wave — "a wave of diminished pressure, rep-
resented in the pulse-curve by the 'aortic notch' —
travels out toward the periphery." A rebound
quickly follows in this elastic system and "the re-
coiling blood meets the closed semilunar valves."
Again the aorta expands; this expansion spreads
throughout the arteries and is known as the dicrotic
elevation.
When the blood pressure within the contracting
ventricles exceeds that in the aorta and pulmonary
artery respectively, the closed semilunar valves are
burst open and the oncoming blood torrent is forced
from the ventricles into these arteries. In other
words, the valves open when the pressure below
becomes greater than that in the arteries. With the
distention of the great arteries the sinuses of Val-
salva become filled. At the completion of ventricular
systole when intraventricular pressure ceases to in-
crease, the passive recoil of the distended walls of the
arteries forces more blood into the sinuses, thus
pushing together the cusps of the semilunar valves,
and aided by the corpora Arantii they entirely ob-
literate the openings.
In regard to the relation between respiration and
blood pressure, it may be said briefly that unless
the respiratory movements are very shallow a record
of blood pressure gives a tracing showing waves
that are synchronous with the respiratory move-
ments. During inspiration the aortic pressure rises.
This is due to the larger output of blood from the
heart. During expiration, on the other hand, the
reverse occurs.
The arteries are always somewhat distended with
blood but with each cardiac systole from two to four
ounces of additional blood are suddenly forced into
the already distended aorta. With ventricular
diastole the aorta recoils, so forcing the blood for-
wardin a steady stream. But this arterial contrac-
tion is no more powerful than the force exerted by
the heart in distending the artery. Consequently
the force propelling the blood must be referred to the
heart. The extra aortic distention due to ventric-
ular systole gives rise lo a v\ a \ e in the blood which
is transmitted throughout the arterial tubes. This
wave as felt in uperficial arteries is known a- the
pulse. The pulse is merely a wave in the steady
stream of blood, for tl (foci of an ela tie tube on
an intermittent Bow of Quid is to converi it practi-
cally into a continuous stream. The average bio. id
pressure in the aorta is about l"'ii millimetei
Emma K. Wai k i r
Aorta. Diseases of the. — Congenital Am
tions: (1) Defects «./' Me Aortic Septum. — These
result from failure in the division of the primitive
aorta, into its two daughter vessels, the aorta and
I he pulmonary artery.
In both its complete and incomplete forms, this
a i aly is rare.
The complete defect known as persistent truncus
arteriosus may be associated with absence ..I I he cardiac
sept uin, but in all cases this sepi urn is deficient.
The truncus may in Hie latter case override the
septum, receiving blood from the two ventricles, or
may spring entirely from the right side, in which
case the blood from the left enters through the
septal delect.
The pulmonary blood-supply may arise 'near the
origin of the main trunk or may come off at the site
of the ductus arteriosus.
Partial Defect of the Aortic Septum. — This may
take the form of an opening between the aorta and
pulmonary artery just beyond the origins of the
two vessels, or a communication may occur between
the aorta and the conus arteriosus.
(2) Transposition of Aorta and Pulmonary Artery. —
This, according to Abbott after Rokitansky, may
result from alteration in the direction of the aortic
septum, which alteration may give rise to a number
of varieties of transposition.
In the complete form the aorta arises from the
right and the pulmonary artery from the left ventricle.
Both vessels may also arise from one ventricle,
right or left, or again both may arise transposed
from a common ventricle.
In the complete form of transposition, the cir-
culatory embarrassment may be understood when
it is seen that venous blood from the right heart
passes to the body by the aorta and the aerated
blood passes from the left heart to the lungs by the
pulmonary artery. Fortunately there is nearly
always an associated defect such as a patent foramen
ovale or ductus arteriosus which allows of mixing
of the bloods.
Cyanosis appears usually within a few weeks of
birth. Clubbing of the fingers is usual.
The cardiac signs are inconstant and the majority
of cases die before the second year, though some
have reached adult life.
(3) Congenital Narrowing of the Aorta. — This may
be (a) Subaortic, in which a ring-like thickening occurs
just below the valves which becomes the seat of a
chronic inflammation which results in still greater
constriction.
(6) Stenosis of the orifice is very rare and is ascribed
to fetal endocarditis.
(r) Coarctation, occurring at the isthmus near the
opening of the ductus arteriosus, may be in one form
developmental, in the other or adult type an abrupt
strangling of the aorta by the presence in its wall of
fibers similar to those in the ductus itself, which
tends to contract after its function has ceased.
In this type is seen the excessive development of
the cephalic vessels and atrophy of those in the lower
part of the body with a consequent extensive collat-
eral circulation between them.
(4) Hypoplasia of the Aorta. — This affection, in
which the vessel and its branches are small of caliber
493
Aorta, Diseases of
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
and thin of wall, was connected by Virchow with
chlorosis and by others with a tendency toward tu-
berculosis and poor resistance to other infections.
Cases of death from cardiac disease with this lesion
as a cause have also been reported.
On the other hand, Suter, from measurements of
2,719 cases, considers that hypoplasia as such has no
causal relation to these affections.
(5) Double Aortic Arch. — This rare anomaly con-
sists of the division of the main aortic trunk into two
branches which surround the trachea.
The posterior branch is regarded as the fourth
right arch and the anterior as the fourth left arch,
which join to form the descending aorta in the am-
phibia (Abbott).
Aortitis. — That such a condition as aortitis does ex-
ist is nut debatable, but concerning the place it should
hold as a clinical entity there is wide difference of
opinion, English and German writers looking upon
it witli distant politeness, while the French embrace it
as an old friend. A natural conclusion is that on the
one hand a real condition may often be overlooked, or
its symptoms attributed to some other cause, while on
the other hand the early stages of a purely regressive
process may be classed as an inflammation.
French writers divide aortitis into three groups:
(a) with gelatiniform plaques; (b) the ulcerovegeta-
tive form; (c) suppurative form.
Concerning group (a) with gelatiniform plaques,
it is difficult to consider this as other than an early
manifestation of the intimal proliferation of arterial
sclerosis and not a true inflammatory process.
(6) The vegetative form may occur alone or with
valvular vegetations. Its usual seat is in the first
part of the ascending aorta, and it may be the source
of embolus or the seat of a rupture of the vessel.
(c) Suppurative aortitis is practically always
associated with ulcerative endocarditis; the inflam-
mation commences between the outer and middle
coat and may extend like a dissecting aneurysm or
may rupture into the lumen of the vessel.
Aortitis, acute or subacute, is always of infectious
origin and though it may occur in the previously
healthy vessel it more readily attacks one already
atheromatous.
Etiology. — It may occur by extension from tumors
or abscess of the mediastinum or from tracheal
ulceration or in the course of the infectious fevers.
Typhoid fever, chiefly during the third week, may
initiate it, and in syphilis in the secondary stage
an acute form may arise.
The symptoms of aortitis are vague, though an elab-
orate symptomatology has been formulated by some.
Dj'sphagia from pressure of the food bolus, epigas-
tric pain, and vomiting have been described and J.
Tessier mentions crises of pain in the abdomen and
diarrhea in inflammation of the abdominal aorta.
Fever is absent.
Though the symptoms may be obscure or even
absent there are some which are rather characteristic.
Dyspnea is most important. It may be of the
ordinary type or be severe and paroxysmal even in
the absence of effort. Inspiration is prolonged,
painful, and difficult, expiration is free and short.
It resembles respiratory obstruction without its
signs and has been attributed to bronchial spasm
from reflex vagus irritation. Such intensity of
symptoms in the absence of physical signs is diag-
nostically important.
Cough when it occurs is dry and sometimes strident.
Pain. — At first this is a sensation of substernal
constriction which later may appear as a burning
or tearing at the base of the neck spreading to both
shoulders and down the back.
The ]iain is anginal in character but persists
between the paroxysms and may appear during rest
as (veil as on exertion.
The physical signs consist in the aortic pallor with
usually a quick and often dicrotic pulse and in cases
of some standing the signs of dilatation of the aorta
described below.
Prognosis. — The outlook in aortitis is not good.
After from two to six months of symptoms, as a rule
death ensues. The fatal ending may result from an
anginal attack or acute edema of the lungs or more
slowly from progressive cardiac failure. Recovery
may take place chiefly in the typhoidal form.
Other cases may drift into a condition of chronic
aortitis.
Diagnosis. — From its constant association with
other diseases the recognition of an acute aortitis is
no easy matter, its sign^ and symptoms being usually
attributed to the coincident malady. In the words
of Barie whose description of the condition I have
largely followed — "IV aortite aigue demande a etre
cherchee.'"
With dyspnea and pain of the character mentioned,
in association with a bounding and dicrotic pulse and
the signs of aortic dilatation, increase of aortic dulness
and elevation of the subclavian artery, the diagnosis
is fairly well assured.
Treatment, aside from that of the primary disease,
is symptomatic — morphine and belladonna for pain,
ire or dry cupping to the sternal region, amyl nitrite
for the anginal attacks, and when the acute attack
has passed, iodides given over long periods.
Chronic Retrogressive Conditions.- — Though
some of these are primarily inflammatory and may be
spoken of as chronic aortitis, the majority are
degenerative rather, and by the seat and the type of
the degeneration are to be classified.
The investigations of recent years by Jares, Klotz,
and others have done much to classify this group of
diseases. They found that the injection of such drugs
as adrenalin, barium chloride, and digitalin, as well as
diphtheria toxin into rabbits resulted in destruction
of the muscle cells of the media which later under-
went calcification, while injection of cultures of B.
typhi and streptococci of low virulence gave rise to
proliferative intimal changes without degeneration of
the media. Klotz points out the similarity between
the first or adrenalin type with the common or
Monckberg type of nodular arteriosclerosis in man,
The second or "infective" group is represented in
man by a true inflammatory endarteritis.
So far then as the aorta is concerned, the following
groups may be recognized:
1. Chronic Aortitis. — An inflammatory endarteritis
following typhoid fever and other infections.
2. Syphilitic Aortitis. — This is primarily a peri-
arteritis and mesarteritis, the destructive changes
being found in the muscular and elastic tissue with
infiltration about the vasa vasorum running in from
the adventitia, Thickening of the intima follows
as a reactive change, but when the process is acute,
aneurysm results. The site of election of this type
is at the root of the vessel, in the lower part of the
thoracic and lower part of the abdominal aorta.
The patches may be of small size and separated.
Irregularly radiating grooves or puckerings are
seen on the intimal surface.
Such a condition has also been reported by Klotz
in an infant with congenital syphilis.
3. Atheroma. — Intimal proliferation, non-inflam-
matory. Following weakening of the media _ there
develops a proliferation of the cells of the intima
and subendothelial connective tissue. These patches
occur in order of frequency in the ascending aorta,
anh, thoracic and abdominal portions.
In time they undergo hyaline and fatty degenera-
tion and calcareous deposition forming atheromatous
plaques which are most marked over the curves,
1« in lings, and divisions into branches of the vessel.
The aorta may be markedly atheromatous with
494
REFERENCE IIWHH00K OF THE MEDICAL SCIENCES
Aphasia
but little sign of thickening of the peripheral arteries
and via vi a.
I. Medial Degeneration. — 11ns, the Monckberg
type, has been mentioned above as analogous to
lie "adrenalin" type of experimental arteriosclerosis.
[n the aorta it is this type which is chiefly associated
with thinning of the walls and diffuse dilatation and
in the peripheral vessels with the nodular form of
gdero i I, EClotz makes mention of a group of eases in
which the aorta is macroscopically healthy but in
ch microscopical examination shows a marked
deposit of calcium in the degenerated muscle cells of
the middle layer of the media.
The outer layer nourished from tin' vasa vasorum
ami the inner from the blood stream being little
affected. This form was found in patients in the
latter half of life.
\tion or thi: Aorta. — This condition is
in which tln> vessel, instead of giving away at one
point with the gradual development of an aneurysmal
tun, or. becomes uniformly enlarged and this enlarge-
ment may be present in the first part only or may
Oi i upy the whole vessel as far as the opening in the
diaphragm.
As distinguished from aneurysm again, dilatation
of the aorta is not a sequence of syphilis which causes
calized weakening of the aorta, but rather of an
acute aortitis or of tin/ Monckberg type of arterio-
sclerosis, in both of which the aortic weakening is,
uniform and diffuse.
[t is commoner in males than in females in the
proportion of 9 to 1.
I'd, iw the age of thirty and over that of sixty years
it is relatively rare, the three intervening decades con-
tributing most of the cases in equal numbers.
Alcohol, tobacco, and hard work, especially
periodical exertion, are figures in the etiology, but as
mentioned above syphilis appears in the minority of
as against the majority in aneurysm.
Causation. — Granted a diffuse weakening of the
aortic wall, the impact of the blood column causes not
only a widening but a lengthening of the artery and as
it is fixed at the heart end, it N pushed sidewise and
upward as well as having its caliber increased and
its walls thinned.
Symptoms are sometimes absent but usually the
two complaints are made of dyspnea and pain under
the sternum. The pain may be referred to one or
the other shoulder or the root of the neck.
The physical signs correspond with the anatomical
condition. They are (a) visible pulsation in the
ud space with some lifting of the manubrium.
McCrae points out the contrast between the marked
visible and the slight palpable lift of the sternum.
(b) Increased dulness over the sternum. The
following figures are given of the dulness in the second
space transversely.
Average
Mliii 5 cm.
Woman 3 cm.
If the figures are greater than these, dilatation is
suggested.
A^ a matter of fact measurements of 7 to 10 cm.
or more are found in dilatation. The dulness is
Usually greater to the left than to the right.
(c) Elevation of the subclavian artery so that its
pulsation is felt above the sternal notch and above
the inner end of the clavicle.
The aortic second sound has usually not only
the high pitch of increased tension but a clinking
amphoric character, and this may be made out by
auscultation in the suprasternal notch more readily
than in the second interspace. Contrary to what
might be expected, the blood pressure is raised little,
if any, above the normal.
(e) The fluoroscope shows a shadow to the left and
sometimes to the right of the usual aortic area.
laximum
Minimum
5.5 cm.
4 cm.
3.5 cm.
2.5 cm.
Diagnosis. — from trui oi the pp ence of
the above sign-, the absence of localized pre
signs and of expansile pul ation, and the r-ray picture
b ill usually m:ii e the destine! ton.
Hodgson's D ■••■ i thi name given to dilatation
of the aorta which involves the aortic ring, cat
coincident aortic insufficiency.
Thrombosis of the Aorta. — 'this is rare. It
oeriiis in atheromatous arteries nearly always in the
abdominal aorta a short distance above the bifurca-
tion. In Barth's case it extended up to the renal
arteries. The thrombus is stratified, with a soft
center, the periphery showing primary clotting at
the intiina.
If the thrombosis is complete ii results in severe
jiaiu, paraplegia, later gangrene and death.
If incomplete, p;iin and 1 1 1 1 111 1 mess in the legs ap-
pear, followed by weakness amounting to paresis.
In one case the patient is reported to have lived
two years when paraplegia became complete.
Embolism results from endocarditis, simple or
malignant, or from atheroma.
The onset is sudden with severe abdominal or leg
pains, sometimes with rigidity or convulsive move-
ments. The legs become cold and blue and gangrene
later develops.
Rupture of the Aorta. — This is usually an
accident of later life and with but few exceptions
oceius in vessels previously diseased. Acute aortitis,
atheroma, and tuberculosis have been found, while
invasion of the aorta by cancer of the esophagus
has also occurred.
The rupture is usually intrapericardial and the
tear is usually single, but occasionally multiple.
The rupture is nearly always in two stages, through
the intima first, with the formation of a dissecting
aneurysm and from minutes to days later and at
another level through the other coats.
The symptoms are sudden, severe, thoracic pain
with syncope and death.
The rupture may occur into any of the neighbor-
ing organs. A. H. Gordon.
Aphasia. — See Speech, Disorders of.
Aphonia signifies loss of the voice. It may result
from disease or injury of the vocal apparatus, particu-
larly the larynx, maybe a congenital affair (see Deaf-
mutism), may result from paralysis of one or more
of the laryngeal muscles, or be purely ideogenic in
origin, forming a constituent part of a neurosis,
psychoneurosis, or psychosis, as, for instance, in
anxiety neuroses, hysteria, compulsion neuroses, or
dementia pra?cox respectively. Only the neurological
types of aphonia are discussed here. These result.
from paralysis of the laryngeal muscles, either from
definite pressure or from inflammation of the motor
nerves or from psychic causes. The superior laryn-
geal nerve sends motor filaments to the cricothyroid
muscle only, the recurrent laryngeal supplies the
greater motor innervation to the larynx, and disease
of this nerve is responsible for most of the aphonias,
partial or complete.
Complete aphonia usually results from bilateral
lesions; unilateral recurrens palsy may cause an
initial aphonia, but later the voice can be used,
although it is much modified. Central laryngeal
paNies resulting in aphonia are most frequent in tabes.
Aphonia is often then associated with Iaryngea,
crises, excessive coughing, huskiness, loss of voicel
and pain. A few rare instances are due to syringo-
myelia. Rethi, in his monograph on laryngeal
symptoms in multiple sclerosis, has collected a
comparatively large number of palsies in this disease.
Other syphilitic disorders than tabes may account
for recurrent laryngeal palsies. Among the rarer
495
Aphasia
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
causes are various growths of the neck and mediasti-
num pressing on the nerve — carcinoma, enlarged
lymph nodes in the posterior mediastinum, foreign
bodies, aneurysm, esophageal growths. Occasionally
overuse may cause fatigue palsy. Acute toxemias,
diphtheria, measles, typhoid fever, lead, alcohol,
copper, antimony, arsenic, etc., may occasionally be
the etiological factor.
Hysterical aphonias vary considerably. Here the
mechanism causing the conversion may be very
.superficial, in which case almost any hocus pocus,
from a faradic spark to making a few hypnotic passes
may. for a time at least, efface the symptom. Many
of "these aphonias have owed their origin to acute
psychical shock: they do not represent the conversion
of long suppressed complexes. Many of the so-called
cures, however, prove to be fallacious. In dispensary
as well as in private practice such patients go the
rounds.
Those patients, whose aphonia represents a definite
psychic conversion, either as a defense or a retention
mechanism, are rarely cured by the superficial
psychotherapy of suggestion, no matter what its
particular form may be. Such patients are usually
cured only by a complete psychoanalysis.
Smith Ely Jelliffe.
Aphrodisiacs. — These are agents, medicinal, physical,
psychic, or hygienic, which increase sexual desire or
ability. Some act by increasing desire, others by
increasing or restoring the ability to perform the
sexual act.
Loss of sexual power may have origin in various
■ways and is frequently divided into organic, psychic,
irritable, and paralytic. A distinction is also to be
made between anaphrodisia, or absence of desire, and
impotence, or inability to perform the sexual act.
Organic impotence is dependent upon structural
change, either congenital or acquired, such as anoma-
lies, malformations, new growths, etc., for which
relief must be sought by surgical or other special
treatment.
For nervous or irritable impotence, which is due
generally to weakness of the genital organs and ab-
normal excitement of the reflex centers causing pre-
irature ejaculations, or due to irritations caused by
some morbid condition of the urine or by the presence
ot strictures, recourse must be had to measures such
as the passage of a cold sound and other local treat-
ment, which will relieve the causative factor. In
paralytic impotence, caused by disease of the central
nervous system, syphilis, anemia, systemic poisoning
from lead, tobacco, etc., the indication is to remove
the cause, when possible, to build up the patient by
general tonic treatment, and to restore sexual
tone by electricity, mix vomica, and other aphrodis-
iac drugs. Psychical loss of sexual power is best
treated by suggestion combined with the exhibition of
strychnine or mix vomica. Most cases are due to
nervousness, overwrought desire, indifference, grief,
fright, and mental preoccupation.
If the case has its origin in nervousness caused by
fear of the consequences of early abuse, psychotherapy
is the most effective measure. Tin' patient must be
told to abstain from any attempt at sexual intercourse
for one or two weeks and at the same time be given
strychnine in small doses or cannabis indica. Those
cases depending upon overwrought desire, frequently
seen in newly married men after long engagements or
sexual abstinence, are best treated by tin- temporary
use of the bromides, together with suggestion. For
these and for the remaining class of cases indications
will be found for prescribing such general measures as
hydrotherapy with massage, tonics, such as mix
vomica, a diet consisting of highly seasoned food, red
meats, and freedom from exhausting mental or
physical work. Among the aphrodisiac drugs, mix
496
vomica (strychnine) and phosphorus enjoy the most
repute. Ergot is said to be of value in those case-, of
impotence which depend upon lack of erectile power
and among drugs of use in pure anaphrodisia as
distinguished from impotence, damiana, caffeine, and
cannabis indica are recommended. Alcohol in small
il(i1 ii 'resins cause irritation of the urinary tract and may
indirectly stimulate the sexual appetite, but their use is
to be condemmed as unscientific and dangerous.
Other agents used are alternate applications of hot
and cold water locally, electricity applied to the
urethra or to the rectum, and the passage of a sound
reinforced either by electric stimulation or by cold.
In general more can be accomplished by hygienic and
moral measures, tonics, rest, long hours of sleep,
and the avoidance of worry than by the use of any
of the so-called aphrodisiac drugs.
Charles Adams Holder.
Aphthae. — See Mouth, Diseases of the.
Aphthae Tropica. — See Sprue.
Aplasia. — See Agenesia.
Apnea. — See Asphyxia.
Apocodeine. — A grayish-yellow amorphous powder,
C ls H 19 N0 7 , soluble in water and alcohol. It bears
the same relation to codeine as apomorphine does to
morphine. The hydrochloride which is readily
soluble in water is the salt employed. Physiologically
it has the remarkable property of depressing or
paralyzing the sympathetic nerve-endings, and for
this has come into extensive use in experimental
work. It is directly antagonistic to adrenalin.
Therapeutically its only use is as a purgative that
can be administered hypodermatically, its action
being to cut off the splanchnic impulses which are
the normal inhibitory stimuli of the bowel. It has
not proven to be of very great value, and its use is
not without the danger of arterial relaxation with
fall in blood-pressure. The hypodermic dose for
cathartic purposes is half a grain (0.03).
W. A. Bastedo.
Apocynacese. — (The Dogbane, Oleander or Stro-
phanthus family.) A great family of 130 genera
and more than 1,000 species, very abundant in the
tropics of both hemispheres, a few extending into
the temperate zones. The plants are almost
all trees or erect or climbing shrubs, with milky
juice, and are highly ornamental and frequently
cultivated for decorative purposes. The juices of
Landolphia, Hancornia, and some others are utilized
in the production of rubber. Valuable timbers are
yielded by several species. The most noteworthy
characteristic of the family is its poisonous nature,
few other families being able to compare with it in
this respect. Many of the species have been utilized
as arrow poisons, and a number of these have been in-
troduced into the materia medica. The active consti-
tuents are mostly glucosidal, uncommonly alkaloiihil.
The action is chiefly upon the heart, stimulant in
small doses, ultimately paralyzant, and thus fre-
quently powerfully diuretic. Often, also, they are
irritant emetico-cathartics. Their action is so
powerful that even minute differences between them
are of importance, and new remedies introduced
from this family are always worthy of careful atten-
tion. The important medicinal genera are strophan-
tus, aspidosperma, apocynum, and alstonia.
The poisonous principles are widely distributed
through the plant bodies. H. H. Rusby.
REFERENCE HAXDROOK OF THE MEDICAL SCIENCES
Ippendlcostom;
Apocynum. — Canadian Hemp, Dogbane. The root
of Apocynum cannabinum L. (Fam. Apocynaceai)
l . S. P. Up to a comparatively recent period the
fenus Ipoeynum was supposed to contain, in the
Astern United States, bul two species, A. canna-
binum L. and A. andro&amifolium L. As the latter
was known to have but a weak physiological action,
it was supposed to 1"' necessary to exclude only this
well-known species from the drug in order to insure
it- full properties. It is now known that the several
supposed varieties of A. cannabinum are perfectly
distinct species. A. cannabinum, then-fun', as it has
been understood and collected, is in reality several
ibably four, at least) distinct species. That some
one Or more Of these species is a powerful and im-
int medicine is indubitable, in view of the evi-
dence presented; hut in view of the aumerous recorded
failures, it is equally certain that not all of them are SO.
Wo are at present quite ignorant as to which is the ac-
tive species, all statements of manufacturers, as well as
tlie Pharmacopoeia, to the contrary notwithstanding.
The entire comparative study of these species is still
before us. Under these circumstances any specific
pharmacological account of the drug is out of the
question.
The plants are erect, perennial herbs, growing by
preference along railroads and roadsides. They
propagate by long, horizontal underground struc-
tures, which appear to combine the characters of
both root and rhizome. The latter is the part used.
The aerial portion may be smooth or pubescent, and
is usually purple or purplish. The leaves are oppo-
site, oblong, or oval-ovate, thickish, mucronate.
The stem is branched above and bears very small
white or greenish-white flowers in close cymes. The
fruit is a pair of long slender follicles, filled with
small plumose seeds. The entire plant exudes an
abundant milky juice.
The drug occurs in long, rather straight pieces, of
about the thickness of a lead pencil and sparingly
branched. It is of a brown color, having an orange
shade if not old and stale. The very thick bark
exhibits few coarse wrinkles, finer nerves, and coarse
circular fissures, and is pinkish-white internally.
The wood is yellowish, very soft and brittle, its pores
large enough to be visible to the naked eye. It
contains resin, tannin, starch, an amaroid, and the
peculiar crystalline body apocynin, soluble in alcohol,
and the glucoside apocynein, soluble in water and of
feeble action. The chief activity is believed to reside
in the crystalline bitter principle cynotoxin, which
occurs in white rhombic pyramids, insoluble in water
and melting and decomposing at 165° C. Quinemore
assigns to it the formula C\, H 2S O . Apocynum is a
cardiac stimulant and a diuretic, as well as a nauseat-
ing expectorant. The most important use of the
drug is in causing the removal of dropsical effusions.
Y fluid extract is official, the dose of which is irt; v.
to xxx.(0.o to.'.O). H. H. Rusbt.
Apomorphine fC,,H n NO,). — Apomorphine is an
alkaloid derived from morphine by abstracting from
the latter a molecule of water. This is done by
heating it in sealed tubes with zinc chloride or hydro-
chloric acid. It may also be derived from codeine.
Jt is commonly used in the form of the hydrochlorate,
which is official. The Pharmacopoeia describes it as
in minute, grayish-white shining, acicular crystal-,
without odor, having a faintly bitter taste, and
acquiring a greenish tint upon exposure to light and
air. Soluble in 39.5 parts of water, or in sixteen
parts at Su° C, in 38.2 parts of alcohol, or in thirty
parts at f.o° C: verv little soluble in ether or chloro-
form. When heated to near 100° C. (212° F.), the salt
is decomposed, rapidly if in solution, slowly when dry.
The properties of apomorphine are totally distinct
from those of morphine. It is primarily an emetic,
Vol. I.— 32
acting altogether centrally, and with great prompt-
ness and power. It is secondarily an expectorant,
increasing and greatly thinning the bronchial mucus.
In poisoning, there is intoxication or delirium and
paralysis of the motor nerves, with failure of respira-
tion and especially of t he heart .
In use, apomorphine i- probably our most prompt
and energetic emetic, it special value being the
promptness and certainty with which vomiting can
be induced by hypodermic injection when, for any
reason, the stomach cannot be acted upon to produce
it. As an expectorant, it is perhaps our most useful
agent for relieving a "dry ''cough. [f given early, it
will do much to avert bronchitis, and it is also e
eially useful in the hacking cough of tuberculosis. In
infants, or in the aged, it is possible for large doses to
suffocate by the excessive transudation into the
bronchioles. The emetic dose for an adult is gr.
,'„ to J (0.006 to O.01); as an expectorant, gr. f to
..'„ (0.0015 to 0.003).
II. II. Rusbt.
Aponomma. — A genus of parasitic ticks usually
found on reptiles. The body is ornate as a rule, and
broad-oval in shape. See Arachnida. A.S.P.
i
Apoplexy. — See Cerebral Hemorrhage.
Apoplexy, Spinal. — See Spinal Hemorrhage.
Appendicitis. — See Cecum and Appendix, Diseases
of the.
Appendicostomy. — The operation termed "appendi-
costomy" is done with the purpose of utilizing
the appendix as a means of irrigation as well as for
the introduction of medicaments through its lumen
into the large intestine. The operation was named
appendicostomy, according to our usual rules of
nomenclature, by the present writer.
History. — The operation was conceived and first
carried out in 1902 by Dr. Robert F. Weir of New
York City. He was to operate on a greatly reduced
man thirty-one years of age, who had been suffering
for three years from frequent bloody, thin stools,
due to obstinate colitis. Dr. Weir entered the
abdomen with the intention of doing a cecostomy,
according to the Kader-Gibson method; however,
"as the cecum was exposed, the appendix rose so
suggestively into view" that he "determined to
employ it to make a fistula." It was accordingly
fastened to the skin and the rest of the wound closed;
soon after it was used for irrigating the large bowel.
The final result proved very satisfactory.
Indications. — As stated above, the operation was
originally designed for the surgical treatment of
chronic colitis and sigmoiditis after internal medica-
tion and high irrigation had proved ineffectual (Weir,
Willy Meyer, Tut tie). Within a few years it was
tested with success in all subdivisions of this trouble,
i.e. the mucous, membranous, ulcerative, dysenteric,
tuberculous, syphilitic, and amebic types. It has
steadily grown in favor with surgeons all over the
world and its indications have been gradually widened.
It was but natural that soon its application was
extended also to chronic intractable constipation. •
Splendid results were seen. It was further found
useful in the following diseases and conditions: Acute
appendicitis (stump not to be tied, amputated, and
inverted, but stitched into the abdominal wall for
saline infusion in place of rectoclysis) ; acute septic
general peritonitis with meteorism; in the treatment
of enteric ulceration in cases of typhoid fever; for the
more effectual introduction of nourishment, as a
substitute for rectal feeding; to prevent recurrence
in cases of intussusception of the ileocecal variety; as
497
Apdenplcostomy
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
appendico-enterostomy in order to reach for irrigation
also the lower end of the ileum. (See below.)
Technique. — Examination of the appendix in a
hundred autopsies selected at random, showed that
appendicostomy could have been done in ninety-six
per cent. The operation (as carried out by the writer)
can be done under general, regional, or local an-
esthesia. McBurney's intermuscular abdominal in-
cision is used; the cecum is pulled forward, or, in the
presence of adhesions, loosened, so that the base of the
appendix corresponds to the level of the parietal
peritoneum. Careful palpation of the appendix is
made to determine the presence or absence of foreign
bodies or fecal concretions. If any are present, an
attempt is made to press them gently into the cecum
or tip of the appendix; if this be impossible, careful
tamponade, incision, removal of the body, and suture
of the opening are called for. The further steps of the
operations are: ligation of the distal half of the
mesenteriolum; continuous catgut suture of the
peritoneal wound, allowing the appendix to emerge
at about its middle, one to two stitches to catch the
caput coli near the base of the appendix (care must
be taken not to injure or constrict the blood-vessels
of the mesenteriolum) ; layer suture of the abdominal
wall; one stitch to fix the mesenteriolum; (care
must be taken that fascia does not strangulate the
appendix); one subcuticular suture to penetrate the
appendicular wall superficially, for proper outside
anchoring; layer of sterile gauze dressing on sutured
skin wound, divided to surround the appendix; gauze
mops on top near base of organ; amputation about
one-third to one-fourth inch above the level of the
skin, secretion caught on mops, latter exchanged;
introduction of small flexible bougie to ascertain the
permeability of the appendicular lumen; (slight
strictures can be immediately stretched, in which
event a small Nelaton catheter remains in place) ; if
no strictures are found removal of bougie; gentle
bow-knot closure of the stump with catgut; final
dressing; removal of the bow-knot after twenty-four
hours; beginning irrigations.
Varieties of Technique. — 1. Sharp muscular and
peritoneal division in the same direction as the skin and
fascia, exit of the base of the appendix at the lower
angle of the peritoneal wound, the organ being then
run up to the upper angle of the skin wound — or
reversed, the base of the appendix emerging at the
upper angle of the peritoneal wound, the organ being
run obliquely downward through the abdominal
parietes. The oblique course of the appendix
can also be arranged for, when using the inter-
muscular incision; the organ would then run sub-
fascially above the muscles for some distance.
Neither modification is recommended, as the re-
quired frequent introduction of catheters or rubber
tubes may cause traumatic irritation or even ulcera-
ton at the kink (base of the appendix). The straight
outward way appears to be the best.
2. Total ligation of the mesenteriolum. This is not
advisable as a rule, since it may cause necrosis, especi-
ally in diabetics. It may be indicated in cases of acute
appendicitis in order to produce gangrene and more
rapid closure of the hole in the cecal wall later on.
However, this appears unsafe; complications may
occur in the healing of the wound in the abdominal
.wall. It is undoubtedly best to preserve the mesen-
teriolum either entire or at least up to the place where
amputation is comtemplated. This can be well
determined by putting the appendix on the stretch
when closing tin- wound.
3. Suture of the appendix in place, without
fastening the caput coli to the parietal peritoneum.
This is dangerous, as the intraabdominal part of the
appendix would present a band that might, cause
intestinal obstruction. The intraabdominal portion
might also become perforated if the use of stiff bougies
or catheters (silver) became necessary in order to pass
the narrow lumen of the appendix. One such
case has been observed in which perforation resulted,
followed by general peritonitis and death.
4. Amputation of the appendix twenty-four to
forty-eight hours after operation. This certainly
guards best against possible infection. However,
if the lumen be found absolutely impermeable,
cecostomy would become necessary at a second
operation; whereas, if it were so found at the comple-
tion of the appendicostomy, the sutured abdominal
wound could be quickly opened and cecostomy
added at once. This is an important point. With
ordinary precaution, soiling of the freshly sutured
wound can be well prevented. It is self-understood
that, if the appendix as such appears large, and its
walls show no infiltration suggestive of strictures,
it will always be safer for the patient if the amputa-
tion be performed twenty-four hours later.
5. Appendico-enterostomy (Pringle). Anastomo-
sis of the tip of the appendix with the lower end of
the ileum. The appendix is fastened in the abdom-
inal wound in such a manner that its middle projects;
it is fixed to the abdominal wall; after forty-eight
hours, an incision is made and a catheter is introduced
to either side, thus reaching the large intestine as
well as the ileum above the ileocecal valve.
Choice between Appendicostomy and Cecos-
tomy. — Appendicostomy appears to be the operation
of choice in all cases in which the appendix is per-
meable. It is simple, safe, and effective, and is also
better as regards the after treatment. It does not
necessitate the continuous wearing of a rubber tube
within the canal.
Possible Late Complications. — Aside from the
one case of perforation of the intraabdominal portion
of the appendix mentioned above, prolapse of the
cecum through a large appendicular stump has once
been observed by the writer. (Amebic dysentery;
appendix led out straight; gradual prolapse; cured by
operation. See Annals of Surgery, 1908, vol. xlvii.,
p. 808.)
In one case the catheter left in place slipped into
the gut and was later passed per rectum (Dawson).
The catheter or drainage tube should always be
secured with a safety pin outside, better still, be
introduced for each irrigation and removed again
after this procedure.
After Treatment. — There is usually no leakage;
a small dry gauze or ointment dressing is all that is
required. If there should be some slight leakage
from the stump of a large-sized appendix, a gently
pressing truss with rubber pad, filled with water or
glycerin, might be worn on top of the piece of gauze
covering the opening during the time of utilization of
the appendicostomy.
Once or twice a day a rubber catheter or small
rubber tube is introduced through the appendicular
stump into the cecum, and the colon is flushed.
Quinine solution 1:1500 alternating with nitrate of
silver 1:2000, or a solution of sodium bicarbonate
two per cent, and one of thymol 1:1000, alternating
ice cold or hot, according to subjective prefer
may be used for amebic dysentery; bichloride solution
1:2000, or thymol 1:1000, with antispecific general
regime for chronic syphilitic ulcerative colitis; saline
solution for cleansing, to be followed by pure balsam
of Peru and iodoform emulsion injections in tubercu-
lous ulcerative colitis, giving creosote or guaiacol
internally, with a carefully selected diet, and, of
course, the observance in addition of a general
hvuienic regime; weak solution of epsom salts and
cascara, etc. in small doses, even plain warm water,
in cases of chronic constipation.
Two quarts of fluid introduced through a tube
Nos. 12 to 14 (French scale), can be made to pass the
■His
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
\ !•■•■- 1 i I .-
entire large intestine within ten or fifteen minutes.
During this time l lie patient had best lie on a Kelly
Eits apron hanging into a pail, or on an ordinary
ed-pan.
Patients easily learn to flush the colon themselves;
they certainly are not in need of hospital treatment
during this period.
In view of the obstinacy of chronic affections of the
lame intestine and the tendency of the trouble to
t. it is unwise to bring about definite closure of
appendicular opening at too early a date. It
represents a safetv valve in the true sense of the
I. and may persist, just covered with a crust,
oticed by the patient (writer's observation).
If t!i g is to be kept patent and more secre-
tion than usually seen is present, the serous cover
of the projecting portion of the appendix above the
skin may be removed and the remaining portion
inverted into the lumen of the proximal portion.
If, after a time, reopening of the appendicular lumen
be desired, this is a simple matter, inasmuch as only
the most distal (intracutaneous) part contracts; the
rest of tlie canal remains patent ( Keatley).
Definite Closure of the Appendicular Opening. —
erization with nitrate of silver stick, or some
kind of acid, better still, with a pointed Paquelin
cautery, will be found effective.
Results. — The mortality of the operation is
practically nil. The few deaths that have been
reported were not due to the operation as such.
Immediate as well as late results have been very
gratifying, especially in cases of amebic dysentery
and .he various forms of chronic ulcerative colitis,
that had baffled internal medication and irrigation
and colonic flushing from below. The great majority
of patients were cured, gaining many pounds in a
short time.
It has also been very gratifying to see cases of
chronic syphilitic ulcerative affections of the colon,
but particularly those of tuberculous character yield
to irrigation and medication through the appendic-
ular stump in a way that one might rightly call the
patients cured (Pringle, Willy Meyer).
There can be no doubt that the operation of appen-
dieostomy represents a most effective addition to
our surgical means of treating diseases of the large
intestine. Affections that proved extremely obstin-
ate, if not incurable by former methods, have been
Been to yield nicely to the treatment made possible by
appendicostomy. The operation has also proved
useful in a number of other intraabdominal troubles
and as an operative preventive against recurrence
in cases of intussusception of the ileocecal variety.
Willy Meyer.
Appetite. — While frequently used to include sexual
desire, the craving for various narcotics and stimu-
lants, and while it might appropriately include the
appreciation of a need for water, oxygen, etc., the
term appetite is commonly limited to the desire to
ingest more or less solid and nutritious material.
Hunger indicates an actual deficiency of nutriment,
with or without the realization of such deficiency.
Appetite implies a mild degree of hunger, but em-
phasizes the subjective sensation and implies, also, a
greater or lesser anticipation or realization of gustatory
pleasures. The more closely we approch natural con-
ditions, the more nearly synonymous do appetite
and hunger become; that is to say, appetite consists
more of an actual desire for food, without much re-
gard to its taste and flavor, while the more artificial
the conditions and the less genuine hunger exists, the
more appetite involves social, esthetic, and gustatory
pleasures. But, even in a state of nature, most ani-
mals exhibit certain preferences for food, not en-
tirely explicable on metabolic grounds, and are liable
to overeat if opportunity presents itself. However,
in general, the rat me of appetite indicated by the
herbivorous, graminivorous, carnivorous, omnivi u
corresponds quite clo ely to the digestive and metab-
olic capacities of the organism Vn artificial appetite
i nut, as is sometimes imagined, confined to human
beings, but is displayed by many lower animals in
captivity or actually domesticated. Cattle are said
to be fed to some extent on salt fish in arctic region
cats, dogs, and horses usually develop a taste for
sugar, and in the la-t feu years it ha- become quite
common for eats kept in drug stores to eat ice , i ea Da,
while dogs not belonging on the premises often hang
about soda fountains on the chance of having this
appetite gratified. < hie of the strangest appetites
among the lower animals that has come to the at ten-
don of the writer was instanced by a cat for musk
melons.
Appetite is commonly regarded as a pneumogastric
reflex and properly, in so far as it is appeased by the
distention of the rugs with even innutritious material
and brought into play by the emptiness of the stom-
ach. Except in this transitory sense, appetite cor-
responds fairly well, both quantitatively and qualita-
tively, to the actual needs of the body, for caloric
energy, protein, carbohydrate, salines, antiscorbutics,
etc. No adequate explanation of this can be offered.
In diabetics, the use of saccharin temporarily cloys
the appetite for sweets but does not satisfy the
ultimate desire for carbohydrates. In certain in-
dividuals, the carbohydrate appetite is mainly for
sugars, in others for starches, but free indulgence in
cither satisfies the appetite for both, though not
necessarily changing the general personal appetite;
which indeed is usually persistent. There is also a
qualitative appetite for protein, especially for meat
protein which is not appeased by food in general,
though obviously habit has much to do with such
appetites and a mera preference for an excess of
meat may be controlled by an abundance of other food.
It is doubtful whether an appetite for iron, iodine,
and various salines can be demonstrated, but there is
a distinct appetite for salt, seen in both man and the
lower animals; and, on account of the formation of
HC1 from NaCl and the special need of HC1 in pro-
teolysis, the craving for salt is especially marked in
persons with relatively carnivorous tastes and ten-
dencies to hyperchlorhydria. There is also a dis-
tinct appetite for antiscorbutics. For instance, dur-
ing the Civil War, a company of soldiers who had
subsisted largely on hardtack and salt meat for some
weeks and among whom cases of camp diarrhea and
mild scurvy had developed, entered a field of half frozen
and decayed cabbages. Some of the sick men were
so ravenous for fresh vegetable food that, despite the
protests of their comrades, they ate large quantities of
cabbage — and were cured of their prostration, skin
lesions, and diarrhea. The antiscorbutic appetite is
sometimes depressed by overindulgence in candy, etc.,
or, more frequently, in alcoholics. The writer has
had two marked cases of scurvy develop in persons
with no other reason for deprivation and cured by
diet of fruits.
Occasionally, although the hunger is assuaged by
meals and the appetite is small, there is a vague
hankering after something which the patient cannot
identify. Finally, usually quite accidentally, some
particular viand is encountered which "hits the spot,"
satisfies the craving, and improves the appetite and
the nutrition.
There is considerable dispute as to the degree to
which a natural appetite is protective against actually
toxic or harmful substances. Barring actual adultera-
tion or tainting of food, many persons can eat with
impunity anything for which they have an appetite,
however unwholesome it may seem, while, owing to
some idiosyncrasy, even very slight amounts of theo-
retically wholesome food which is distasteful will cause
nausea, diarrhea, etc. The lower animals are often
499
Appetite
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
supposed to be protected by instinct against toxic and
harmful foods. This is not, however, the case.
It is also contended that a perfectly natural appetite
corresponds quantitatively to the demands of the
system, and that ingestion in excess of metabolic
demands is an artificially acquired vice. Observa-
tion, however, shows that, on the one hand, the
average appetite of civilized persons is not much
beyond the theoretical demand in calories, not far-
ther beyond this limit, indeed, than a fair margin of
safety requires. On the other hand, among both
human savages and the lower animals, we find that
periods of enforced abstinence alternate with periods
of excessive ingestion.
The relation of the appetite curve to fasting periods
is another interesting problem. The herbivorous
animals spend most of their time when awake in eat-
ing. Carnivorous animals, including omnivorous
and primitive man, eat at irregular intervals, but it is
not far from the truth to say that they eat whenever
and as much as they can. In a state of civilization,
most individuals and races or social groups have
established customs regarding the frequency and
relative amounts of different meals. To some degree,
these customs depend upon occupation, wealth, etc.,
but only approximately so. The change in meal
hours, in the relative importance of different meals,
etc., which has occurred in this country within the
last one or two generations, is largely due to diminu-
tion of physical exercise and the impossibility of
reaching home in the middle of the day.
The relation of appetite to physiological conserva-
tion of nutriment is an interesting corollary. Not
to mention the various problems in regard to storage
and utilization of fats, it is commonly held that the
body has extremely limited capacity for storage of
protein and carbohydrate. Yet we are developing
on a large scale an appetite for a very small breakfast,
a moderate luncheon, and a hearty dinner, the last,
representing at least half the caloric energy of the
total ration, being taken at the close of one day's
work and about fourteen hours before the next begins.
With so marked a discrepancy between empiricism
and theory, the whole question of conservation of
protein and carbohydrate needs further study.
Appetite is well known to depend upon a great
variety of sensory impressions and mental concep-
tions. Taste, smell, and to a scarcely less degree
sight, may either stimulate or inhibit appetite.
Sensations of temperature and touch have a similar
action, according to rather arbitrary customs that
certain foods shall be hot, others cold, and that
homogeneity and softness are a desideratum in some,
while in others, as crackers, bread, mousse, etc., the
opposite qualities are desired. The sense of equi-
librium has an important negative bearing on appe-
tite, as illustrated in seasickness. Sound can scarcely
be said to have any influence on appetite except in
the general way that any agreeable or disagreeable
sensation may act upon the mind. Excessively
loud noises, however, if continued, may affect the
appetite on account of the simultaneous vibrations of
the semicircular canals. Any conception, however
suggested, as directly through any of the special
senses or indirectly through memory, may affect the
appetite in either way. Thus there is a germ of
truth in the old story of the man who tied his com-
panion before taking poison but whose life was
nevertheless saved by the latter's presence of mind
in narrating a disgusting tale. Pawlow's investiga-
tions have verified and extended what has long been
known: That smell, taste, and sight of food produce
appetite by stimulating digestive secretions which,
on the contrary, are inhibited by fear, anger, and
excitement.
Disturbances op Appetite. — Anorexia, lack of
appetite, though usually a symptom of disease,
500
locally digestive or general, is often conservative.
Even when there is interference with the special
senses of taste and smell, appetite commonly remains,
indeed in a purer type than usual because these two
special senses are eliminated. Occasionally, howe\ er.
there is no true appetite and the individual eats
merely on account of a feeling of weakness or as an
intelligent act to furnish nutrition. Such cases seem
to.be due mainly to stoicism and habitual repression
of self-indulgence, but they are also found in mild
cases of melancholia among which may perhaps be
included nostalgia.
Hi/pcrorexia or Bulimia. — As the limitation of
appetite depends mainly on a reflex from the disten-
tion of the gastric rugae, bulimia is not so much the
cause as the result of dilatation of the stomach,
without marked pyloric obstruction. It is also
encountered in various conditions in which excito-
reflex stimuli are obtunded; as in general paresis,
various forms of insanity, often in old age. Some-
times, the enormous appetite is merely an expression
of a delusion of grandeur. Bulimia is popularly
regarded as a symptom of tape-worm and ascribed
to the demands of the parasite. This explanation is,
of course, absurd, as even the development of the
fetus, whose size and metabolism are very much
greater, causes no marked bulimia. The more
accepted explanation is that the craving is due to the
toxic or mechanical irritation of the parasite but, in
the writer's experience, it is very seldom that an
explanation is required, as the bulimia does not
exist except in a small minority of cases. It should
not be forgotten that the diagnosis of bulimia, like
that of gastric dilatation, requires a weighing of
conditions and not merely a measurement of ingesta.
An ox-appetite is normal for one doing ox work.
The excessive mental and physical activity and
actual building of tissues by growing boys, require
an amount of food that the larger adult, repeating
the same mental tasks instead of passing constantly
to new ones, exercising gently, and merely making
good the waste of fully formed tissues, is inclined to
regard as excessive. In young adults, an excessive
ingestion is often due not to a genuine appetite but
to the notion that physical and mental strength can
be increased by depositing nutriment as one would
deposit money in a bank. Idle persons also eat as a
means of diversion and it is probable that, in addition
to mild pathological failures of digestion and absorp-
tion, the physiological economy of utilization really
relaxes so that more food is needed. It is said that
under the Roman empire it was quite a common
practice to prolong the pleasure of eating by thrusting
the finger down the throat after the stomach had been
filled, so as to allow a repetition of the process without
delay. The writer has encountered one such ease, in
an otherwise dainty and refined old maid. This
patient is thin. Indeed, bulimia is very apt to be
attended by poor nutrition and slight deposition of
fat and, conversely, fat persons are usually light
eaters.
Perverted Appetites and Cravings. — It is extremely
difficult to draw hard and fast lines between natural
and artificial appetites and between the latter and
perverted cravings. At one time or another, nearly
every plant and animal has been used as a food, and
the esthetic notions with regard to what substances
are proper and what improper foods, are difficult to
explain. Many persons would no more eat frogs'
legs than snakes; or horse meat than dog or cat flesh.
In the eighteenth century, tea leaves were eaten like
greens. Until about the middle of the nineteenth,
tomatoes were called love apples — the term persists
in some sections — and were used only as table orna-
ments. Urodipsia may be merely suggested by
olives but has a close analogue in the use of kidney.
Coprophagia, at first thought not merely a perversion
but an insane perversion of appetite, is duplicated by
REFERENCE HANDBOOK 0] THE MEDICAL SCIENCES
A|ir;i \la
(he routine and inevitable use of deer intestine with
oontents by the Indians, as affording the only avail-
; ,i,;. anti scorbutic food in winter; also by the practice
of serving with game the " trail" which is the intestine
and usually infested with parasites. We may also
pause to reflect thai the hulrs in Swiss cheese are
§ue to the colon bacillus and that, in cheeses, high
meal, sour milk delicacies, liqueurs of various kinds,
etc., nearly every possible method of decomposition
is duplicated in food stuffs.
Pica, the eating of gravel, clay, plaster, magnesia,
tale, slate, etc., is often seen in very small children,
nt puberty, especially in girls, sometimes in pregnant
v, , wnen. Among savages and sometimes among the
poorer classes of civilized nations, clay eating is a
re-ort in famine. The clay habil favors the entrance
of the hook worm. When we consider the custom of
Qg children, of putting all sorts of articles in the
mouth, and the pleasure which many adults derive
from "dry smoking," holding a tooth-pick, straw, etc.,
in the mouth, and the commercial importance of
chewing, we must analyze each case carefully,
to distinguish between a genuine perverted appetite
and a men' habit. It is also worth while to remember
that a good many vegetables consisting of leaves,
stalks etc., are only slightly richer in nutriment than
the mineral matters discussed under the head of pica.
Peculiar and often highly individualized cravings
are quite often encountered in pregnant women,
sometimes in fever patients, often in invalids, espe-
cially in the neurotic. It should not be forgotten
that some such cravings, as for pickles, salt, etc., may
possibly represent a genuine need of the body. At
any rate, if the craving can be gratified with a flavor,
without introducing any appreciable quantity of a
deleterious substance, it is much better to gratify it.
For instance, a few whiffs of a cigarette after an
operation, or during typhoid fever, may cause greater
subjective relief than three centigrams of morphine,
the actual amount of toxic substances introduced
being infinitcssimal. In other instances, the craving
may be for something not deleterious at all except
that it is not ordinarily given in the particular condi-
tion and that it should not be given in any consider-
able amount — for example, a very little sugar or soft
fruit, weak coffee, chocolate, or the like, may be
introduced into almost any dietary.
A. L. Benedict.
Apraxia. — This term was first used by Gogol in
is;:; in a Breslau thesis on Aphasia. His patient
ate his soap, urinated in his water pitcher, and was de-
BCribed as having lost his understanding for objects.
Such defects had been noted before, and it is worthy of
note that Hughlings Jackson in 1866 called atten-
tion to a similar type of phenomenon, and attached
much importance to it. Quaglino in 1S67 described
a case, Finkelnburg in 1S70 another, in which recog-
nition of tilings and people was lost, and he created
the term asymbolia. Wernicke in 1S74 expanded
the term asymbolia, while Freud finally utilized the
term agnosia to cover all types of loss of sensory or
motor object images, apraxia then being arranged
as a form of loss of knowledge of objects, really a
form of visual agnosia.
From this early use of the term apraxia there has
been a distinct variation, brought prominently into
the foreground by Liepmann in 1900. He defined
the disturbance as a lack of knowledge of the use of
objects, although there was no true agnosia or loss
of recognition of what they were. Out of the later
studies of Liepmann, Pick, von Monakow, D'Hollander
and others has come the following general definition
of apraxia:
It consists in an inability to perform certain sub-
jectively purposeful movements, or movement com-
plexes, the motor power, sensation, and coordina-
tion being intact. Such an inability will naturally
depend upon at least three factors; one may be
unable to recognize the object which is to be u ed, in
which case we can speak of a sensmv apraxia. in the
sense as one speaks of a sensory aphasia, or a
visual agnosia. Should the patient recognize the
object, call it perhaps by name, slate its use, and yet
in attempting to use it totally fail in proper motor
act, one speaks of a motor apraxia. It being under-
stood here that, there is no necessary change in the
motor tire, with either incoming sensory or outgoing
motor side. Thus one can speak, as \\ ilsmi has done,
of a motor aphasic as having an apraxia of his speech
musculature. In grave intracerebral changes the
knowledge of the proper kinetic images to carry out
purposeful actions in the arms and legs may be com-
plexly involved. Hen' one speaks of an intrapsychic
•da. Clinically it is usually overlaid in the gen-
eral psychic loss, often spoken of loosely as dementia.
Apraxia may be then either sensory or motor; it
may be unilateral or bilateral, it may be extensive,
involving many muscular groups or may be limited
to a few, such as an inability to protrude the tongue
on demand with perfect power in other movements,
or closure of the eyelids, etc.
A certain patient with motor apraxia on being
given a cigarette holder and cigarette recognized
the objects, said they were for smoking, but on being
told to put them together was unable to make the
correct movements, and finally gave up. Another
patient was given a candle and a match-box. She
took out a match, made rubbing movements with
it in the air above the candle, and then reinserted it
in the box.
In Liepmann's celebrated case the patient was able
to do things with his left hand, but failed entirely
with Iris right. When told to brush the examiner's
coat, he picked up a corner of it carefully in his left
hand, then picked up the brush in his right hand,
with which he made movements as if to brush his
hair. Asked to pour water into a glass from a carafe,
he grasped the carafe with his left hand to pour
water into the glass held in the right hand, after
which the glass was brought to the mouth without
any water in it. These patients fail to carry out the
simple commands to blow a kiss, make a threatening
fist, soldier's salute, etc.
In ideomotor apraxia the situation is more compli-
cated. One patient given a tooth brush recognized
it, then began to brush his beard with it clumsily;
another being given a pistol which he named cor-
rectly, on being told to shoot it grasped the barrel,
blinked and put the muzzle into his left eye. Another
patient, being given a cigar and a match-box opened
the latter, stuck the cigar in it, and tried to shut
the box as though it were a cigar cutter. Then
taking the cigar out rubbed it on the side of the box
as though it were a match. The entire order of pro-
cedure was badly devised.
Like aphasia, apraxia is largely implicated in left
hemisphere lesions. It is usually due to a supra-
capsular lesion.
In left hemisphere disease, the apraxia may be
homo-or heterolateral, and in homolateral apraxias
the corpus callosum is usually involved. In left
frontal disease apraxia has been found especially
with lesions of the first and second frontal convolu-
tions. Anything that brings about an isolation,
diaschisis of the left frontal area from the right,
frontal area will seem to bring about an apraxia, or
when there is any isolation of the left frontal from
other parts of the cortex.
Naturally a great diversity of pathological condi-
tions may happen to bring such associations to pass.
Thus an apraxia is to be looked for in tumors, paresis,
multiple sclerosis, hemorrhages, etc.
The subject of apraxia is well discussed bv Wilson,
Brain, vol. xxxi., 1908, p. 164; by D'Hollander, Bull.
501
Apraxia
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
delaSoc.de med. mentale de Belgique, 1907; by Liep-
mann, Drei Aufsatze, Berlin, 190S; Pick, Studien
iiber motorische Apraxie, 1905; and Glascock,
Journal of Nervous and Mental Disease, 1903.
Smith Ely Jelliffe.
Aquas. — Waters, or medicated waters, are clear,
aqueous solutions of volatile substances; these latter
may be solid, liquid, or gaseous. They are prepared
in various ways: By simple solution in cold or hot
water, by nitration through an absorbent powder, by
percolation through cotton saturated with the
substance, and by distillation. As a class the aquffi
have but slight medicinal value, and deteriorate if
kept for a long time. They are mainly used as
vehicles and solvents. In the U. S. P. there are
nineteen official waters:
V. S. P. Latin Title.
Aqua
Aqua ammonue
Aqua ammonia fortior. . -
Aqua amygdalae amane...
Aqua anisi
Aqua aurantii florum
Aqua aurantii florum
fortior.
Aqua camphora 1
Aqua chloroformi
Aqua cinnamomi
Aqua creosoti
Aqua destillata
Aqua fcrniculi
Aqua hamamelidis
Aqua hydrogenii dioxidi. .
Aqua menthre piperita?. . .
Aqua mentha? viridis
Aqua rosse
Aqua rosa? fortior
Water.
Ammonia water
Stronger ammonia water.
Bitter almond water
Anise water.
Orange flower water
.Stronger orange flower
water.
Camphor water
Chloroform water
Cinnamon water
Creosote water
Distilled water.
Fennel water
Witch hazel water
Solution of hydrogen di-
oxide.
Peppermint water
Spearmint water
Rose water
Stronger rose water
HJxv.
5i
5ss.
5«s.
oij-
3>.i-
5ss.
oss.
3u-
5ss.
5i.i.
5i.
Sss.
3ss.
5ss.
3ij.
R. J. E. Scott.
Aquifoliaceae. — Ilicineoe (the Ilex or Holly family.)
A family of three genera and some 200 species,
chiefly of North and South America. It is chiefly
notable for the presence of an appreciable amount
of caffeine in the leaves of at least two species,
on account of which they have been used as bever-
ages (see Mate and Cassine). Other species have
been used as bitter tonics and alteratives (see Alder,
Black, and Holly). H. H. Rusby.
Araceae. — Aroidere (the Arum family.) A largo
family, of more than 100 genera, growing mostly in
the tropics of both hemispheres. Many species, as
the cultivated calla, are highly ornamental. Calocasia
produces an important starch-yielding corm, and
monstera, an edible fruit. Many of the tropical
species are known as poisons, but their constituents
and actions are little known. It is remarkable that
a few northern species in the genera Spathyema,
Acorus, Arum, and Ariswma, should represent about
all the medicinal contributions of the family, and
more active agents may be expected to be made
known in it in future. H. H. Rusby.
Arachnida. — In the branch or phylum Arthropoda,
characterized by bilateral symmetry, by meta-
meric segmentation of a heteronomous type, and by
the possession of jointed appendages, typically a
single p.'iir for each mctamere of the body, may be
distinguished five great groups: the Crustacea, includ-
ing crabs, lobsters, water fleas, etc.; the Onychophora
including but a single genus, Peripatus; the Myria-
poda, including millipeds, centipeds, etc.; the Insecta,
including the true insects; and the Arachnidaor Arach-
noidea. The latter may be defined as air-breathing
arthropods, characterized by the fusion of head
and thorax into a single region, the cephalothorax,
which is without antennae, but bears two pairs of
appendages more or less closely connected with the
mouth, and four pairs of walking legs. The abdo-
men, which may or may not be segmented, is usually
distinct from the cephalothorax, though in the mites
it is fused with it.
The class Arachnida is subdivided by various au-
thorities into from seven to nine orders, among which
are the Scorpionida or true scorpions, the Pseudo-
scorpionida or book-scorpions, the Phalangida or
"Daddy Long-legs," the Araneida or true spiders,
the Acarida or mites, and the Linguatulida.
The true scorpions have the power to inflict a pain-
ful wound by the sting located at the tip of the abdo-
men. In the case of large tropical species the effect,
of the sting may even cause the death of small
children, but only in the most exceptional cases does
it seriously affect an adult. There is injected at the
time a quantity of poison from a gland in the last
joint of the abdomen; its action is in general to irri-
tate nerve centers while at the same time producing
paralysis of motor nerves. The sting of the smaller
species found in the United States is harmless, giving
rise to a slight irritation, which lasts at most seven or
eight days. Mr. Herbert H. Smith, the well-known col-
lector in South and Central America and the West
Indies, after enumerating symptoms and results in a
number of carefully observed instances, says: "Prob-
ably death might result in some cases, as (if reports are
true) it does, rarely, from bee stings My
wife was stung by a small one; the wound was exceed-
ingly painful. By the advice of a servant, she held
the finger for an hour in hot sweet oil, mixed with an
equal measure of laudanum. There was no swelling
and three hours after all pain had left her."
In Africa scorpion sting is not regarded so lightly
and the occurrence of gangrene as a result is on record
while a brawny swelling and more or less collapse are
the usual sequels for adults save in natives who seem
to have developed some immunity. In children
under twelve the sting produces an effect not unlike
tetanus. An antiserum for scorpion venom has been
prepared and used by Todd at Cairo and in upper
Egypt. It appears to have a marked palliative
effect on the intense pain following the sting, but in
spite of its use some young children have not survived
the effects of the scorpion poison.
Among the spiders also there are those that are
able to pierce the human skin by the action of the
jaws or chclicerce which also contain the orifices of a
pair of poison glands. The effect of a spider's bite on
an adult has, however, been much exaggerated; of
itself the bite produces at most a slight dermal swell-
ing which soon disappears. The large hairy thera-
phosids, popularly known as tarantulas, are not to be
called dangerous. Their bite is painful, but the
inflammation, though often violent, subsides rapidly.
On the other hand, several cases on record of death
from spider's bite have been traced to a small spider
(Latrodectus viactans) which is related to supposedly
poisonous species in other countries of the world, and
it is not unlikely that the spiders of this genus secrete
a more powerful fluid than others. The condition of
the patient, his susceptibility to poison, and other
important facts are not on record in these cases, and
it may happen that the chance introduction of extra-
neous matter through the bite has given rise to the
more serious and rarely to the fatal results noted.
There are no spiders in this country of which it may
positively be affirmed that they are venomous, though
certain South American species enjoy an evil reputa-
tion which is undoubtedly well founded.
502
REFERENCE HANDBOOK OF THE MEDICAL Si'IKVKS
Arachnlrla
I.i\i;i!.\tulida. — The highly modified forma in-
cluded in this group have a certain superficial resem-
blance to tapeworms, From which, however, they
differ radically in structure. Their closest affinities
are doubtless to be found among the arachnids of
which they arc here considered as an order. Accord-
ing to Sambon their structure, their
blood-sucking habit, and the pari
they play in fostering the sporogonic
cycle of the haunogregarines peculiar
to their respective reptilian hosts,
suggest relationship to the ectopara-
site Ixodidse.
The body (Fig. 260) is elongate,
cylindrical or flattened; the anterior
end (cephalothorax) is more or less
clearly marked off from the rest
(abdomen), which is subdivided by
ambulations variable in number and
distinctness. At the blunter, ante-
rior end the mouth is located on the
ventral surface and provided on either
side with two protractile hooks, con-
tained in sheaths or pockets. These
hooks represent the mouth parts of
other arachnids, while other append-
ages are entirely lacking. There is
no special respiratory apparatus, and
the so-called stigmata are but the
orifices of dermal glands. At the
posterior end may be found the anal
opening.
The linguatules are of separate
sexes, the males being much the
smaller. The female genital pore is
located near the anus, the male on
the ventral surface near the anterior
end of the abdomen. The adults
live in the nasal cavities and lungs
of mammals or reptiles, and the eggs,
produced here in large numbers, must
be imported by chance into a suitable
guatula rhinaria, secondary host in which they give
female. Natural rise to tetrapod, acariform embryos
size. (After (Fig. 261, b) that metamorphose into
Br»un.) a second stage (nymph, Fig. 261, c),
manifesting the main features of the
adult. By a migration usually semi-passive, this
form reaches the primary host and attains full de-
velopment in it.
Linguatula Frohlich. — Body flattened, with arched
dorsum and crenated margins. Body cavity extend-
ing into the lateral regions of the rings (pectinate).
Fig. 261. — Linguatula rhinaria, Stages of Development.
( After Leuckart.) a,_ Egg with embryo; 6, free embryo; c, nymph
or pupa. Magnified."
Linguatula rhinaria Pilger = Pentastoma tmnioides
Rud. — Larva = P. denticulatum Rud. and P. ser-
ratum Frohlich. — Body lanceolate, attenuated pos-
teriad; head rounded, annuli circa 90, hooks acumi-
nate, enlarged toward the base, with basal joint
elongated proximad. Female S0-100 mm. long, 8-10
nun. broad anteriorly, 2 mm. posteriorly. Male 1 8-20
mm. long by '■'> mm. broad, decreasing to 0.5 mm.
The adult inhabits the nasal cavities of many
mammals, particularly the carnivora, among which
the dog is perhaps most- commonly infested. The
larva occurs in the viscera of the herbivorous mam-
mals. The masses of eggs containing well-de-
veloped embryos are deposited by the adult female
n the nasal mucus and distributed over grass, etc.,
with which they are swallowed chiefly by rabbits,
but even, as on salads, by man himself. Hatched
in the stomach the larva; penetrate the intestinal
wall and encyst in liver or mesentery, where after
nine eedyses covering a period of from five to six
months, they reach the second
stage, characterized by the rows
of retrorse spines on each an-
nulus. From the liver they
may, as some maintain, wander
out actively and if eaten by a
dog reach the nasal cavities di-
rectly; or they may await the
consumption of the flesh by
some carnivorous form, in
which case they are set free in
the stomach and wander through
the tissue to the lungand thence
by the air passages to their
final location. Some authorities
deny the possibility of the larva
deserting its cyst and wander-
ing out, and maintain that the
transmission is always passive.
In man older cysts regularly
become calcified.
Rare instances of the occur-
rence of the adult in man are
on record, probably due to tin 1
consumption of poorly cooked
flesh (mutton) containing the
larva3. The larva (Fig. 262) has
been reported frequently as a
human parasite, chiefly from
Germany and Austria. Most
commonly found in the liver, it
has also been met with in other
viscera. Here it occurs in
sharply defined yellow tumors, embedded in the sub-
stance of the liver or protruding somewhat from its
surface. The tough capsule contains caseous or cal-
careous contents, and varies in diameter from about
1 cm. to the size of a pea. The capsules are less fre-
quently found scattered irregularly over the surface of
the peritoneum. The parasite is probably innocuous,
as its presence has not been suspected previous to
autopsies, at which Virchow reported the parasite in
Wurzburg and Berlin and Wagner in Leipsig. Frerichs
found it in Breslau five times in forty-seven autopsies,
Zenker found it in Dresden nine times in 168 cases,
Heschl at Vienna five times in twenty; Klebs at
Basel, however only twice in 1,914 cases. Laengner
recently records fifteen in 500 autopsies in Berlin;
the larva? were found seven times in the liver, seven
t imes in the intestinal wall and once in the mesentery.
He believes this parasite is frequent and often over-
looked. The adult occurs in seven per cent, of the
dogs examined in Berlin. I have one record of its
presence in man in this country, although it has been
reported rarely from other hosts (rabbit and cattle).
This case of infection with Linguatula serrata, the
larval form of L. rhinaria, has been reported by
Darling and Clark from the Canal Zone. At the
autopsy of a Nicaraguan, a larval linguatulid was
found crawling over the cut surface of the lung and
along the pleura. It was the only specimen present
and its exact location during the life of the host could
not be determined in spite of careful search. This is
the first instance on record cf the occurrence of this
Fig. 262.— Lingua-
tula denticulata, Larva
of L. rhinaria. (After
Leuckart.) Magnified.
503
Arachnida
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Fig. 263. — Nymphal Stage
of Porocephalus arinillatus in
the liver. (After Sambon.)
parasite in a native of the American continent.
Two cases have been observed at Ancon Hospital
during the past six years. The other, a larva also,
having been taken from the feces of a resident. _ The
adult parasite has never been found in that territory.
Porocephalus. — Body cylindrical; body cavity con-
tinuous.
Porocephalus arniillatus (Wyman) = Linguatula
armillata Wyman. — Larva = L. diesingii van Ben.;
Pentastomum constrictuin v. Siebold; Nematoideum
hominis (viscerum) Diesing. Color in life lemon
yellow; in preserved specimens ivory white. Elon-
gate, vermiform; female 9 to 13 mm. long by
5 to 9 mm. broad, with
eighteen to twenty-two
rings in body; male 3 to
4.5 mm. long by 3 to 4
mm. broad, with sixteen to
seventeen rings, cylindrical
anteriorly, tapering poste-
riorly, end bluntly conical.
Eggs double shelled, 0.10S
by 0.08 mm. Embryo 0.092
by 0.072 mm. Nymph
when encysted coiled in a
more or less complete circle
with ventral surface convex
(Fig. 263) occurring in a great variety of hosts.
Sambon lists sixteen positive cases from man; the
list would doubtless be greatly extended by full
records from Africa where the parasite certainly
is common. It may be looked for in travelers,
missionaries, and others who have visited the in-
fected region. Discovered in a West African python
by Dr. Savage and described by Dr. Wyman of
Boston, it has been found since then in other pythons
and puff adders throughout the Ethiopean region.
It is the larval form which occurs in man, encysted
in the liver, lungs and mesenteric glands. This
species is frequently reported in Africa and once from
Jamaica in a recently introduced slave. Other
records, such as those of Flint from Missouri, Sanchez
from Mexico, and Osier from Johns Hopkins Hospital,
are at least in fault in diagnosing the species pre-
sent ; in some of these cases it is clear that the para-
site did not belong to this group at all. Successful
artificial infection experiments were carried out in
Africa on natives suffering from sleeping sickness.
Porocephalus moniliformis (Diesing) Adult = Pen-
tastomum moniliforme Leuckart. Much like the
former species but slenderer, tapering more caudad.
Male 2o mm. long, 2.5 mm. broad, with twenty-six
rings; female with twenty-eight to thirty-one, 70 to
90 mm. long, 4 to 7 mm. broad in maximum.
This species belongs to the Oriental region: India,
China, Philippines, East Indies, etc., where the adult
occurs in the pythons and the nymph encysted in
many hosts, including man. Of the two human
cases on record, that of Herzog and Hare concerns a
native Filipino who died in Manila of tuberculosis.
A single parasite was found in the liver at necropsy.
Acarida. — The mites are throughout of small
size, even the largest ticks attaining a length of only
half an inch and the majority being but a fraction of
this. The body is circular or oval in outline, with
flattened ventral surface and arched dorsal. Ordina-
rily it manifests no separation into parts, though in
some forms a distinct groove makes two regions distin-
guishable. While the skin is commonly marked by
transverse striations or folds, traces of metameric
segmentation are only rarely to be found. The
chitinous covering is frequently provided with plates
or shields, and bristles are characteristically pres-
ent. A small projection (rostrum or capitulum)
carries the mouth parts, which are often more or less
fused into a beak and modified for biting, piercing, or
sucking. As mouth parts are distinguished (1) the
mandibles or chelicerae; (2) maxillipeds or pedipalpi,
the most prominent part of which are the maxillary
palps, jointed, highly mobile structures, located at
the sides of the mandibles. The lower lip (hypos-
toine), anterior and inferior to the maxilke, is ordina-
rily fused to their bases.
The four pairs of legs, composed of from three to
eight joints each, are terminated by claws, bristles,
or suckers of various sorts. They may be attached
directly to the skin or reinforced by a chitinous
framework (epimeres) which may join to form a
median ventral ridge (sternum). A special respira-
tory (tracheal) system is lacking in most parasites,
though present in some; it opens by paired stigmata
with sieve-plate coverings (peritremes) the location
of which is characteristic for various groups. Eyes
are also usually wanting in the parasitic forms.
The separate sexes may be distinguished generally
by difference in size; in some forms a marked sexual
dimorphism exists. The genital orifice is surrounded
by a system of chitinous thickenings known in the male
as the epiandrium and in the female as the epigynium.
The vulva serves as birth opening, whereas a special
copulatory orifice occurs at the posterior end of the
abdomen. The acarida are usually oviparous, and
from the egg emerges a hexapod larva which metamor-
phoses into an octopod nymph, and finally by the
development of the sexual organs becomes adult.
This metamorphosis is accompanied by a variable
number of moults, and in the SarcopticUe by histoly-
sis and complete regeneration of the animal at each
ecdysis.
The following table, taken -from Railliet, will be
convenient in recognizing the various sub-orders and
families:
o>
No tracheae.
Legs with
epimeres.
No trachea?.
Astigmata.
Legs with epimeres.
Trachea? opening in
the anterior portion
of the body, atro-
phied in the aqua-
tic forms.
Prostigmata.
Legs with epimeres.
Two pairs of legs.
Palpi unarmed.
Mandibles styliform. J
Four pairs of legs. ]
Palpi uncinate. [
Mandibles styliform. J
Palpi joined at base, i
unarmed.
Mandibles chelate. J
Palpi free, unarmed, i
antenniform.
M ri in li 1 ill--- chelate
Palpi free, armed
(rapaci).
M andibles with,
hooks, or styliform.
Trachea? opening in
the posterior por-
tion of the body, at
the base of the legs,
sometimes atro-
phied.
Metastigmata.
Legs without epi-
meres.
Palpi free fusiform,
mandil ilea chelate.
Palpi free, filiform or
valvate.
Mandibles, pseudo-
chelate.
Palpi free, filiform.
Mandibles chelate.
Phytopticke.
Demodicida?.
Sarcoptidae.
Bdellidfe.
Murine:
Halicaridae.
Freshwater:
Hydrachnidse
Terrestrial:
Trombidiidffl.
Oribatidse.
Ixodidx:
Argasidse.
Gamasidae.
DemodicidcB (the Follicle Mites). — Small, elongated
mites; anterior region undivided, in adult with rostrum
and four pairs of short legs; the posterior transversely
striated, without appendages. Tracheae, stigmata,
and eyes wanting. No marked sexual dimorphism.
Oviparous. Larva without legs or with three pairs of
tubercles, nymph with four pairs of. rudimentary legs.
Parasites of hair follicles and sebaceous glands of
mammalia. Only a single genus with several
Species.
Demodex folliculorum (G. Simon) =D. foil. var.
hominis auct.; Steatozoon foil, E. Wilson. Rostrum
short, anterior region of body approximately one-
third of total length. Egg eordiform, 0.06 to 0.0S by
504
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Arachnida
Fig. 264.— Dem-
odex canis. Ven-
tral view of female
and of egg. X 100
diameters. (After
Megnio.)
nil I to 0.05 mm. Male 0.3 mm. long; female 0.38 mm.
to 0.045 nun. long.
This form, which presents a characteristic appear-
ance ( Fig. 264), is a common parasite of the sebaceous
elands of the human skin. It is easily discovered in
the sebum from the glands of the
nose, lips and forehead; also in the
ceruminous and Meibomian gland .
and from the abdominal and pubic
regions. Normally the mites resf in
the gland, head inward (Fig. 265),
and but a few arc presenl m each
V gland; occasional increase in numbers
is said tn give rise to stoppage of the
dud and from five to twenty may be
found in a comedo plug. The state-
ments of some authors, according to
which these parasites occur in two-
thirds of the persons examined, are
held by other investigators to be far
beyond the usual percentage of in-
fection. Precise data are lacking.
Henle, who discovered this species in
1841, obtained living specimens of
the mite from a cadaver six days after
death. In spite of the fact that this
species is difficult to distinguish from
related forms of the dog, cat, and
other domestic animals, with a single
doubtful exception, no case of infec-
tion transmitted in either direction
is on record, and all efforts to accomplish this experi-
mentally have failed.
Although D. cants gives rise in the dog to a serious
dermal disease (Fig. 265) which is rather difficult to
handle, no similar difficulty is reported for man with
D. folliculorum, even in the case of those individuals
habitually regardless of personal cleanliness; and an
etiological relation between these mites and acne, as
maintained by various observers, has not been satis-
factorily demonstrated.
Sarcoplidce. — Small, pale mites, w r ith soft body, not
elongated, separated into two regions by a more or
less distinct transverse groove. Mandibles chelate,
maxillary palpi styliform. Four pairs of five-jointed
legs with epimera,. in two groups corresponding to the
regions of the body, terminal joints (tarsi) with one
or two claws, a sucker, or both, or with long bristle.
Trachea? wanting. Sexual dimorphism general. Met-
amorphosis with hexapod larva and two nymphs,
oft i'n complicated by the appearance of a h\ r popial
nymph.
Of the seven sub-families only the Sarcoptinae or
itch mites, and the Tyroglyphinae or cheese mites, are
of importance here.
Sarcopiince (the Itch Mites). — Parasitic mites with
transversely striated integument, with campanulate
pedunculate tarsal sucker, often atrophied and re-
placed by bristles on the third and fourth pairs of legs.
Vulva transverse. Found in the skin of mammals
and birds, where they produce the various forms of
scab and itch.
Sarcoptes (the Itch Mite of Mammals). — Body
round or slightly oval. Rostrum short, and thick;
posterior feet entirely or nearly hidden by the body.
Tarsal suckers with long, simple peduncle; in female
on the first and second pairs of legs, in the male also on
the fourth pair. Anus terminal.
Some authors distinguish but a single species with
numerous varieties; it seems better, however, in spite
of the often insignificant and in part inconstant specific
differences thus far known, to follow the later authori-
ties in regarding these forms as different species, even
though physiological characters must still be used in
part for their distinction. They apparently do not
interbreed, and certainly are permanent only on the
appropriate host from which in some cases they can-
not be transferred to any other, even for a short time,
A earns scabici de
though usually such transfer results in temporary
existence without the di ea e reaching a serious si i
and often disappearing spontaneou lv .
Sarcoptes scabiei (de Geer) (the Human Itch)
Acarus siro, .1. exulcerans, Linn.
Geer; Sarcoptes
hominis Hering;
S. se.var. /mini n is
Megnin. Dorsal
scales pointed,
longer t ha n
broad. Anterior
projections of
e p i a n d r i u m
short , scarcely
reaching the epi-
meres. Posterior
spines long,
pointed. Male
(Fig. 267) 0.2-
0.24 mm. long,
0.1.5-0.2 mm.
broad: female
(Fig. 266) 0.3 to
0.45 mm. long,
0.25 to 0.35 mm.
broad.
The history of
the disease
caused by t he
itch mite is con-
nect e d with
some of the most
momentous dis-
putes in medi-
cine. The com-
plaint is recorded
in the earliest
writings, ami the
mite may have
been known to
Aristotle; but the
Arabian physi-
cians in the
twelfth century
were the first to
state clearly the
existence of a
minute charac-
teristic animal
which could be
removed from
the skin and
"cracked" on
the finger nail. FlG o 63 ._ Transectioll of skin o( Dog ,
Ine galleries Showing Demodex canis in Position in Hair
bored in the skin Follicle and also in Sebaceous Gland. (After
were discovered Laulanie, from Neumann.) e. Epidermis;
in the fourteenth /"• hair follicle containing two hairs, p, the
centurv and the hulbs of which can be dislinquished at 6
'(--> Hn nrilinrl a "d &' I at the points, a, ai, aii, aiii and a&,
H " escrlDe J? the follicle has undergone dilatation, by
and figured reas0 n of the accumulation of the follicle
clearly in the mites, d\ sb, sebaceous glands one of which
s e v e n t e e n t h , («&i) contains the mites^ sd, sudoriferous
while in a letter glands. X 40 diameters,
to the famous
Italian anatomist Redi, in 16S7, Bonomo and Cestoni
gave a precise description and figures of the mites and
their eggs, inferring correctly that the animals were
of separate sexes and were the actual cause of the
disease, so that a cure depended upon their complete
destruction. Others of prominence in dermatology,
however, attributed the trouble rather to "destructive
juices," either denying the existence of the mites or
their relation to the itch, or holding that a poison was
inoculated into the blood by their bite. Early in this
century the French Academy offered a prize for the
rediscovery of the mite, whereupon a certain Dr. Gales
505
Araclinlda
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Fig. 266. — Sar copies seab-
iei, female, in Dorsal Aspect.
X 100. (After Fiirsten-
berg.)
E aimed off cheese mites on a learned jury, pocketing
oth the medals and the prize! Finally, in 1834,
Renucci demonstrated in Paris the method by which
Corsican women were accustomed to remove the mite
on the point of a needle from the end of its tunnel,
and thus established its actual presence in the disease.
The male was discovered by Kramer in 1S45, and the
pathology of the disease established upon unimpeach-
able experimental and clinical evidence particularly
by Hebra.
The mite appears to the
naked eye white and glisten-
ing, and was aptly described
by Bonimo as like a little
bladder of water. Viewed
under the microscope there
is seen a tortoise-shaped head
with a pair of short, heavy
legs on either side, which
have a framework of chitin-
ous bands like the garters of
an Italian bandit. The third
and fourth pairs of legs are
concealed under the posterior
margin of the body. The
male is much smaller than
the female and has the fourth
pair of legs terminated by a
sucker instead of the bristle
which is on the fourth pair in
the female. There is also on
the ventral surface of the male a complicated chitinous
frame-work wanting in the female.
The human itch mite lives in the skin in which the
female tunnels an irregular winding passage, where
she passes her entire existence (Fig. 268). These
burrows vary in length from a few millimeters to two
or more centimeters and are excavated preferably
where the skin is thin, as between the fingers, in
elbow or knee joint, on mamma? or penis. The gal-
lery, directed first downward through the stratum
corneum, is extended through the softer cells of the
Malpighian layer just above the papilla?. Eggs and
fecal matter fill the most of this tunnel, at the inner
end of which may be found the female. The male is
much rarer; its existence is passed on the surface of
the skin, hiding under scales and in furrows. After
an incubation of only a few days there emerges from
the egg a hexapod larva,
which bores through the roof
of the tunnel and gains the
surface of the skin, where
after three or four moults and
the acquirement of a fourth
pair of legs the development
of the sexual organs is com-
f)leted. Copulation is fol-
owed by the last moult on
the part of the female. The
latter now pregnant, begins
the construction of a gallery
in the epidermis (Fig. 2i>9)
and once buried in the skin,
the recurved dorsal spines
prevent her escape.
This species is probably
distributed over the entire
world; it is very common on
the Continent and among the poor in England where
it constitutes eight per cent, of dermatologieal cases
in hospital practice and three per cent, in private
practice. It is much rarer in the United States and
is inn I frequent in the East; in New York Bulkley
had two per cent, in the hospital and one-fourth of
one p«-r cent, in private practice. In Boston White
noted an increase from nine cases in 1880 to 16.5 in
L888. Of 318,500 cases recorded by the United
States Dermatologieal Association within a period of
Fig. 267. — Sarcoptes
scabiei, male, in Ventral
Aspect. X 100. (After
Fiirstenberg.)
a little over twenty-one years (from July, 1877, to
January, 1898), it was found in 3.66 per cent, of the
total number. Although rare under ordinary circum-
stances, it increases rapidly under conditions of crowd-
ing; thus in 1S93, the year of the Chicago Exposition,
901 cases were reported in the United States, while in
1895 the total was only 3S3 cases. Where such crowd-
ing is combined with faulty sanitary conditions, it
becomes epidemic in a severe form. Thus during the
Civil War, the "army itch," "Jackson's itch," and
Fig. 268. — Sarcoptes scabiei. Impregnated female (s) in cunic
ulus. i Ain-r Ilaillu-t; somi-diagrammatic figure adapted from Ger
lach.) oe, oe', oe", Eggs, those farther away from the mite being
older; c, an empty egg shell; o, orifice through which a larva has
escaped; e, excrementa.
"seven years' itch," which are merely aggravated
forms of the disease, followed the movements of the
troops.
The disease is produced by the transfer of the
parasite by actual contact from an infected person
to one not infected. Such infection must transport
both sexes, or at least pregnant females, and under
such conditions that they can successfully form bur-
rows. In spite of the fact that in large continental
hospitals and clinics, yearly thousands of cases are
treated and handled by nurses and students without
any precautions whatever in the way of disinfection,
no trouble is experienced from the disease.
Infection is easily and most commonly brought
about by long-continued and intimate contact, and
the nocturnal habits assigned by some to these mites
506
REFERENCE BANDBOOK OF THK MEDICAL SCIENCES
\r.n hnlil:i
arc due to their increased activity under the influei
of the warmth of the bed. The disease is also mo I
imon among men and of such classes and occu-
pation- as arc wont to sleep together. A transient
infection may be induced by the transfer of this
species to the horse, dog, or ape, but the cat is ap-
ently immune toward it.
The itch mite excites at first only a moderate
irritation, which gradually grows in intensity and
becomes an extensive pruritus, accompanied by ecze-
niaiic inflammation with the formation of papules and
vesicles. The malady increases in severity with dura-
tion, and especially as the result of scratching, until
%faJ\S
vv
\y^<
i^AA/J 8
c g^
Fig.269. — Acarian Furrows, a, Position of mho; A, themitehas
gone down beneath the epidermis; B, the mite has commenced to
dig a longitudinal burrow, and the place (/) where it was in A, has
by the growth of cells come up nearer to the surface; C, the point (/)
pecies, which normally attack- the swallow,
has been known to pass from the nests under the eaves
into sleeping-rooms and to attack the occupants of
the r i giving rise to severe itching.
Holothyrus coccinella, which is found on the island of
Mauritius, is a serious pest of the ducks and g( I e.
It attacks man frequently and incites an acute derma-
titis. H often migrates into the buccal cavity with
great danger to children especially. Several other
Gama ids have been reported in Isolated cases from
the human host.
Trombidiidce (The Harvest Mites). Soft-skinned,
velvety, often highly colored mites, with tracheae
opening at the base of the rostrum or on the cephalo-
thorax, and usually with eyes. Sucking rostrum with
styliform mandibles and uncinate palpi. Legs six-
jointed, terminated by a double hook together with
a .small sucker.
Of the large number of terrestrial mites included
in this family only a few species are parasitic, but
some of these, though only occasionally at lacking
man, are yet among his most disagreeable chance par-
asites. Doubtless many other species than these
noted here may be found
to attack him in one
place or another; it is
desirable that accurate
data regarding all such
species be on record.
According to Joly and
others, these mites are
the passive carriers of
infectious agents, but
Nuttall doubts this and
thinks the cutaneous
affections produced by
their presence on the
skin are due to irritating
secretions of the mites.
The effect Megnin pro-
duced by binding on the
skin the dead bodies of
one of the most toxic
species tends to support
this view. To secondary
bacterial infection
brought about by
scratching the skin and to reduced vitality of the
latter referable to the mites, are to be attributed the
extreme effects manifested in the formation in some
cases of ulcerous and running sores.
Pediculoides ventricosus (Newport) = Hcteropus
Vi ntricosus Newport. Male 0.12 by 0.0S mm., oval,
with six pairs of bristles and a pyriform plate on the
dorsal surface. Female cylindrical, 0.2 by 0.07 mm.,
with four pairs of bristles. When gravid with poste-
rior region inflated to a sphere filled with developing
eggs, nearly 2 mm. in diameter, viviparous.
This form lives parasitic on insect larva?, particularly
those of grain. Numerous cases of accidental para-
sitism on grain shovellers, or those otherwise engaged
in handling it, are reported from different parts of
France and Germany. The bite of the mite produces
insufferable itching and excites a considerable cutane-
ous inflammation.
Similar troubles have been produced by Tarsonemus
intectus Karpelles from Bulgarian grain and Pi/ymc-
phorus uncinatus (Flemming) from Russian wheat.
Chelytus eruditus (Schrank). Pale, rarely reddish
in color, with bifid hook on the palpi. Length, 0.S
mm.
This mite occurs at times in old books, or among
dusty rags, but more commonly in stables, chicken or
pigeon houses, in old feed bins and in tobacco store-
houses, or wherever mites are abundant. In spite of
509
Arachnida
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
its predacious habits, it has not been known to attack
man, and its presence in fecal mailer and in pus
collected from the ear, as reported in various medical
works, was undoubtedly due to accidental intro-
duction. When St. Peter's in London was restored,
this form swarmed in myriads over workmen engaged
in repairing the ancient tombs.
Nephrophages sanguinarius Miyake et Scriba is a
related species which two Japanese physicians found
daily in the bladder of a patient afflicted inter alia
with hematuria. Although its presence was noted for
a week, its relation to the disease was by no means
established. They showed that it was living in the
bladder, but had to leave undetermined how it reached
that location. This may have been due to contamina-
tion of instruments and such contamination in one
way or other serves to explain most similar cases.
The mites which van der Harst discovered in urine
he showed had really come from the cork of the bottle
in which the sample had been sent to him, and similar
confusion has arisen in other cases.
Yet such mites may be, if rarely, still sometimes
actually, endoparasites of man. Miyake and Sciba
in Japan found one species in a cyst of the wall of the
vena cava; and Castellani in Uganda discovered
another in a cyst of the omentum of a negro. New-
stead and Todd described mites of this family as
endoparasites in apes, and among birds such an occur-
rence is very common.
Leptus irritans Riley. Color brick or blood red; legs
terminating in two stiff hairs. Mandibles tridentate
at end. Length, 0.24 mm. (Fig. 273, C). Adult
unknown.
This is the larval form of some unknown adult, not a
plant-feeding species, as formerly believed but of a
form parasitic in the adult condition on grasshoppers
and other insects. The allied European species are
found on mammals, birds, and Arthropods. The
latter, especially the Insecta, appear to be the normal
hosts. The American larva under consideration
occurs in enormous numbers on grass and herbage and
its normal habits are unknown. But under temptation
it adopts a habit as fatal for itself as it is uncomforta-
ble for man. Brushed from grass or shrubbery on to
human clothing, it finds its way to the skin into which
it burrows until entirely buried, following usually the
duct of a sebaceous gland. The skin forms a fibrous
sheath about the proboscis of the larva in the midst of
a dermal swelling the size of a pin-head. The re-
sultant irritation varies considerably with the indi-
vidual and in some cases produces extreme torture.
The inflammation gives rise to a large red blotch with
paler spots and spreads rapidly when the body is
scratched in consequence of the itching.
This mite occurs over much of the eastern, central,
and southern portion of this country, extending in the
Mississippi valley as far north as central Iowa and
being very abundant in parts of Indiana, Illinois, and
Ohio, even as far north as the islands in Lake Erie.
In Washington it is abundant from June throughout
the summer, and farther south the season is longer.
Osborn speaks of the same species as annoying in
Southern Mexico in January. Those who are sus-
ceptible to the pest are accustomed, on returning from
field excursions, to resort at once to a hot bath with
strong soap, or to the use of a wash of dilute carbolic
acid to kill the mites before they become embedded in
the skin. Dilute alcohol is also recommended. At
this time it is also possible by close scrutiny to
recognize the mites in the center of the inflamed area
and to remove them individually, doing away thus
with the subsequent discomfort to a large extent.
It is interesting to note that the invasion of the
human skin causes the death of the mite and prevents
it- reaching maturity, a perverted habit being thus
fatal to the species. As a result the adult form is not
known, but assumed as possibly one of the genus
7 otnbidium.
510
Leptus americanus Riley (Fig. 273, B) is an associ-
ated form, the effects of which are very similar. The
Continental species is L. autumnalis Shaw. Similar
forms are known from all regions: among these the
one known as Tlalsahuate in Mexico, and the Colorado
of Cuba deserve mention.
Fig. 273. — B, Leptus americanus. Greatly enlarged. (After
Riley.) C, Leptus irritans. Greatly enlarged. (Alter Riley.)
(In B and C the dots underneath indicate the natural size.)
The Kedani mite of Japan also known as Tsutsuga-
mushi or Akamushi, is a small hairy mite with two red
eyes; it measures 0.1(3 to 0.38 mm. long by 0.1 to 0.2-1
mm. broad. When the mite is torn in removing it
from the skin or by accident, a small blister with
a painful swelling is formed at the site of the bite.
This is accompanied by enlargement of neighboring
lymph glands, with fever and general prostration,
which in extreme cases leads to sudden death.
Tanaka has isolated from the body of the mite a
toxic substance to which he attributes the effects
described. The mite occurs in widely separated
provinces of Japan and is greatly feared by the
populace.
Telranychus moleslissimus Weyenberg from Uru-
guay and Argentine, which lives normally on an aster,
is of like evil repute.
The case of Tydeus molestus Moniez, a blind, rose-
colored mite of the family Bdellidaj or snouted mites,
which was discovered on a large estate in Belgium
where it first made its appearance in 1S64 after an
importation of Peruvian guano, illustrates the chance
introduction of an undesirable species. Each year
it appears at mid-summer and remains until frost,
so abundant that it constitutes a veritable pest. It
throws itself on man passing through the grass or
shrubbery and produces an insupportable itching,
lasting several days.
Ixodoidca (Ticks). — Among the ticks, which con-
stitute technically speaking the superfamily Ixodoi-
dea of Banks, two families are recognized: the
Argasida; and the Ixodidre. The former are covered
by a uniform leathery integument without a hardened
shield or scutum. The Ixodicke possess such a scutum
covering the entire body of the male t hough on the back
of the female it forms only a small patch at the ante-
rior end while the distensible posterior region pro-
jects to a variable extent behind it. In the Arga-
sicke the sexes are much alike, whereas the Ixodidse
showed marked sexual dimorphism. Moreover the
former feed moderately and both sexes change
thereby only slightly in thickness when gorged. The
replete females of the Ixodida? are enormously in-
creased in size and changed to a shapeless round
mass. Numerous other minor features in structure
and habits serve to justify further the separation of
the two families but may be omited here. The work
(if recent years has disclosed the hygienic importance
of this group since at least two important human and
REFERENCE HANDBOOK OF THE MEDICAL SCIENI ES
\ i.ii liin'i.i
many animal diseases are transmitted specifically
by tin' ticks.
The Argasidse are mostly found in warm dry
regions and attack primarily birds and bats, but sev-
eral species seek out man when occasion offers and
from their nocturnal habits as well as their flattened
form when fasting they arc mistaken for bedb
Two genera only arc recognized: Argas and
thodoros; both of them attack man and both serve at
times as transmitters of human as well as animal
diseases. Mos( if not all of these species are noted for
their powers of endurance, specimens having withstood
absence of food and water for months and even for
two to three years. This characteristic accounts for
the sudden appearance of diseases transmitted by
such ticks in houses or shelters that arc rarely used or
been abandoned for a long period.
The genus Argas is defined by Xultall as follows:
y flattened, oval or rounded, with a distinct
flattened margin differing in structure from the
ral integument; this margin gives the body a
sharp edge which is not entirely obliterated even when
Hi,' tick is fully fed. Capitulum (in adult sand nymphs)
entirely invisible dorsally, distant in adults by about
its own length from the anterior border. On both
dorsum and venter there are numerous symmetrically
arranged disks, generally round or oval, more or less
disposed in radial lines. Elsewhere the integument
is minutely wrinkled into irregular zig-zag folds.
Eyes absent. This same author recognizes six valid
species and four that are doubtful among w'hich the
following onlv are of importance here:
Argas persicus (Oken) 1818 (Fig. 274) = Rhyn-
ekoprion perscium Oken; Argas persicus Fischer de
Waldheim; Argas mauritianus Guerin-Meneville; Argas
miniatus C. L. Koch; Argas americanus Packard;
s sanchezi Alf. Duges; Argas chinche Goudet;
radiatus Railliet.
Fie. L'74. — Argas persicus; Dorsal and Ventral Aspects. En-
larged. (After Marx.)
Body oval, widest posteriad. Margin striate with
quadrangular cells. Spiracle half as wide as anal
ring. Male 4 by 2.5 to 5 bj' 3 mm. or rarely S by 5 mm.
Gravid female 7 by 5 to 10 by 6 mm.; when gored
11 by S.5 mm. Nymph 4 to 4.5 mm. long in first
stage; 5.5 to 6.7 mm. in second stage. Larva 0.7
to 0.8 mm. in length. Egg spherical, 0.6 to 0.S mm.
in diameter. Host: primarily a parasite on domestic
fowl; this species has been reported also from duck.
-e, turkey, quail, canary, ostrich, and once from
cattle in Texas, as well as from man. After leaving
the host it hides in cracks in floors or walls, or under
the bark of trees.
Though originally described from the East and sepa-
rated from our native species this form is truly the same.
It is cosmopolitan in its distribution even though
it is most abundant in Persia where its frequence and
bad reputation are historic. It occurs widely on the
North American continent and in the United States
has been recorded often from Texas and also from
New Mexico, Arizona, California, and Florida. In
many places it is a serious fowl pest.
Arga / IS is popularly known in this country
as the fowl tick, or adobe tick it, Arizona and New
Mexico. In Persia it is called the Miana bug and is said
to behave like the bedbug, being at times so numerous
as to drive out the inhabitants from infested villages.
The early reports regarding the fatal re ult attending
its bites are probably exaggerated and il has not
been shown that this | Veys to man any
specific infectious disease as it does to fowls to whi< h
it transmits Spirochceta < thi cau e of a fatal
malady capable of destroying all fowls within a
in the course of a few day-. 'J here is, however.
evidence that in man also its bite ] lui il effect .
Mans, m states that miana fever is certainly trans-
mitted to man by this tick and this view is generally
found in scientific literature, but Nuttall questions
the truth of the statement. In cases, especially
a 1 1 mug infants and children, or individual 3U Ceptible
to urticaria fact it ia. the bite causes edema of the part,
or even of the entire body, together with intense
pruritus lasting several days.
Argus reflexus, the common European species,
regularly infests pigeon coops, from which it enters
dwellings, and has been found in large numbers in
house lofts, and even in old churches in which pigeons
had been kept. It seems to have grown rarer in
recent years. This tick has been shown capable of
transmitting pyogenic bacteria to healthy persons
when it has previously had access to the skin of per-
sons suffering from furuneulosis.
Argas brumpti infests the burrows of the porcupine
in Africa and attacks men sleeping on the ground;
it hides in the dust during the daytime.
Argas chinche, troublesome to man in Columbia, is
probably identical with Argas persicus, described
above.
Ornithodoros Koch, 1S44, is difficult to distinguish
from Argas and is regarded by some authors as hardly
more than of subgeneric rank. It includes eleven
well established and several doubtful species: O.
savignyi, the type species, occurs in Africa where it
attacks man as well as various domestic animals.
Ornithodoros moubata (Murray) = Argas moubata
Murray, Ixodes ?noubata Ornithodoros savignyi, var.
cazca Neumann.
Adult 8 by 6 or 7 mm.; gorged females up to 11
mm. long. Nymph in first stage, 1 by 0.87 mm.
Egg 0.9 by 0.S mm. Much like 0. savignyi, but less
hairy and easily distinguished by absence of eyes and
details in the structure of the appendages (Fig. 275).
Hosts: Domestic animals generally, also monkey
and man. Man appears to be the chief host. The
species is widely distributed in Africa south of the
Sahara. It hides in the dust or sand and attacks
animals at their resting places. Ticks are found
particularly along much traveled highways and less
frequently if at all in isolated native villages. This
may be due to the temporary character of native
huts and their frequent abandonment. Along the
Congo the rest houses of native travelers are badly
infected. The species is known as the papaze and is
evey where plentiful in the Arab houses, where they
hide in cracks and crevices of the walls, or even in
thatched roofs.
Livingston noted that its bite is painful and that
the sensation persists and he also referred to the well-
known fever that follows the bite. This disease is
the African relapsing fever or human tick fever
found through Eastern and Central Africa, the Congo,
and Angola. It is caused by Spirochceta duttoni
which is transmitted by bite of the tick and multiplies
in the human blood where maximum numbers are
found during the febrile attacks. These follow
five to ten days after a non-immune has been
bitten.
When a female tick sucks blood containing Sp.
duttoni, the organism migrates into the ovaries of the
ticks and infects the undeveloped eggs. Thus the
511
Arachnlda
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
next generation of ticks is infected and the parasites
are transmitted when the new nymph in the first
stage feeds on the blood of a new host. It has been
shown that the spirochete is even transmitted
through the ova to the third generation of ticks,
although the second generation had been fed on non-
infected blood. Such infected ticks will naturally
transmit the disease by their bites. So-called
coccoid bodies or granules demonstrated in the tick
Fig. 275. — Ornithodoros moubata, female, X3; dorsum and
venter; specimen from British Central Africa. (After Nuttall.)
ovary constitute the infective agents; their nature and
biology have not been fully elucidated.
0. moubata has also been considered capable of
transmitting Filaria perstans to man, and Wellman
was able to follow in part the development of such
filaria embryos in this tick.
0. coriaceus from California and Mexico is feared
by natives because its bites are severe and heal very
slowly. 0. turicata from New Mexico, Arizona, and
California, as well as further south, attacks pigs,
cattle, and man. It may cause serious injury by its
bite ami Duges says people are reported to have died
therefrom. 0. talaje is another species in the same
region that at times attacks man; it infests normally
old houses and like other species comes out at night
to bite. 0. thalozani is the sheep bug of Persia,
Fig. 276. — Rostrum of Ixodes hexajronus, female, from below.
X50 diameters. (After Delafoud, from Railliet.)
■which also attacks man and may transmit disease.
It is locally said to be very dangerous to man.
0. megnini occurs chiefly on the ears of the horse,
OX, and ass, and has been recorded from the human
cur in Mexico. The species has been reported from
the Gulf Stales, and as far north as Nevada, Idaho,
and Iowa. It has been found as a chance parasite
in the human car in New Mexico and Arizona but
was readily removed by introducing a pledget of
cotton moistened with chloroform. Most of the
cases on record are among children in infected
regions. Intense pain is caused by their presence in
the human ear but so far as known no more serious
consequences.
The Ixodidae are most easily recognized by the fact
that the beak, technically designated the rostrum or
capitulum, is not hidden below the anterior margin
of the body as in the Argasidae but projects con-
spicuously beyond it. The capitulum (Fig. 27G)
consists of (a) the flattened maxiUo-labial hypostome,
ib) two maxillary palps, (c) two elongated mandibles
inflated at the base but flattened toward the tip. The
hypostome and the terminal joint of the mandibles are
armed with retrorse spines or teeth. The two spiracles
lie just posterior to the coxae of the fourth pair of legs
The Ixodidae. are highly specialized parasites.
Most of them are parasitic on wandering hosts and all
stages are found on the same host. When the males
occur alongside of the females, both sexes are
characterized by the possession of hypostomes
similarly well armed with prominent teeth. Species
that are parasitic on hosts with more or less fixed
habitats display less highly specialized parasitism iu
that the males do not occur on the hosts and do not
possess armed hypostomes. The male feeds sparingly
Fig. 277. — Ixodes ricinus, L., male, in Ventral Aspect.
(After a drawing by A. Dampf.)
X 16.
on the host but the female gorges itself with blood
until the leathery distensible hind body has swollen
to the size of a castor bean which it resembles strongly.
Such engorged females drop to the ground and after
a quiescent period spent in hiding, the huge masses of
eggs are laid. The hexapod larvae, which emerge
after a variable time depending on temperature,
climb to the tips of blades of grass, bushes, and other
vegetation, and attach themselves to hosts from
which a meal of blood is taken. Once satiated such
a larva falls to the ground and undergoes a
metamorphosis.
The octopod nymph repeats this history on a new
host and then metamorphoses into the adult which
again seeks out a host and completes the life cycle.
The duration of this cycle s about six months under
most favorable conditions but may require two or
three years.
These ticks, naturally abundant in woods and
underbrush, or in high rank grass, select their hosts
largely by chance. .Many of them may occur on man
and the frequence of this depends chiefly on the
abundance of the tick; secondarily, its special habits
govern its appearance on the human host. The
512
REFERENCE HANDBOOK OF TIIK MEDICAL SCIENCES
Araclinlda
species occurring cm 1 1 1; :n i have iml been recorded with
desirable accuracy. They arc fre< |ucnt ly found Oil
travelers as well as cm workers in wooded districts and
there removal is effected by simple methods without
medical assistance. I'sually I heir presence is not fol-
lowed by any untoward results.
Many authors report psoriasis-like eruptions and
phlegmonous inflammation following tick bites. Yet
a lick may hang on for days without being per-
ceived and experiments to inoculate germs through
ink bites have thus far proved negative. Whenever
the tick is forcibly removed and the rostrum left
imbedded in the flesh of the host the wound is painful
i much more serious. A drop of turpentine.
benzine, petroleum, or even oil or melted butter,
placed on the head of the tick, will usually cause it to
loosen its hold and drop from the skin. Sometimes
ticks penterate beneath the skin of the host. Several
oases are on record in which living ticks have been
found in cysts or tumors on the human skin. These
reach the size of a nut but are easily removed.
Texas fever in cattle is transmitted by ticks and
dipping is practised extensively to relieve these hosts
of the infecting agents.
Nine genera are recognized; of these only Ixodes,
I), rmacentor, and Amblyomma are of especial signifi-
cance here.
Ixodes. — Anal grooves surrounding the anus in
front. Xo eyes; without festoons. Spiracles round
278. — Ixodes hexagonus, male, in Ventral Aspect. X13.
(After Neumann.)
or oval. Sexual dimorphism pronounced. Ventral
surface of male covered by non-salient plates. Type
species:
/.codes n'n7!t/.s(L)( The Cast or BeanTick) =/. reduvius
of many writers. Male brown, oval, larger posteriorly,
2.5 mm. long by 1.5 mm. broad. Female 4 mm. long
and :> mm. broad, or when gorged 10 to 11 mm. long by
ti to 7 mm. broad, ashen gray tending to brown or
yellow.
This species is abundant in Europe and occurs
throughout the United States from Pennsylvania,
Kansas, and California to Florida and Texas. It occurs
apparently by preference on sheep and cattle, though
frequent on the horse, rabbit, many wild mammals,
and less often on birds and reptiles. It is the chief
carrier of redwater in cattle (bovine piroplasmosis)
with which its connection has been conclusively
demonstrated by experimentation. Cases of septi-
cemia in man are recorded by European writers as the
apparent result of the bite of this species, but ex-
perimental work has thus far failed to confirm this
view.
Ixodes hexagonus Leach( The European Dog Tick)
(Fig. 278). The breadth of the median plate and the
shorter rostrum distinguish this from the preceding
pecies. It is very widely distributed in Europe and
Fig. '279. — Stigmal Plate of Male Dermacentor anderBoni. Notice
the relatively large aperture and chamber and the prominent
dorsolateral prolongation which forms a right angle at the caudal
margin; the goblets are numerous (157) and evenly distributed,
but areabsenl from the margin; the middle layer is visible. Greatly
enlarged. (After ritiles.)
has been reported from a wide range of hosts. It
occurs in the territory east of the Rocky Mountains
in North America. Canine piroplasmosis is trans-
mitted by this species. Blanchard cites cases in which
it has penetrated below the skin of man.
Boophilus annulatus (Say), the Texas fever cattle
Fig. 280. — Stigmal Plate of Female Dermacentor andersoni.
Notice the acute angle formed by the dorsolateral prolongation;
the anterior margin of the prolongation is broader than the caudal
margin; 120 goblets are present. Greatly enlarged. (After
Stiles.)
tick, exceeds in economic importance all other
species as the form by which Texas fever in cattle is
transmitted. The organisms of this disease {Piro-
plasma bovis) are transmitted through the eggs from
one generation of ticks to the second or even the third,
which can accordingly produce the disease in non-
Vol. I.— 33
513
Arachnlda
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
immune animals. The larvae occur only very rarely
on man. Even in Texas where the species is very
abundant, accurate observers have found it on the
human skin only half a dozen times in ten years.
Apparently it does not transmit any germs to man
here. In Africa, however, "tick-bite fever" with a
fairly definite train of symptoms may follow the bite
of a variety of this species.
Fig. 2S1. — Dermacentor andersoni, young female. Dorsal View.
(After Stiles.)
Dermacentor. — Anal grooves surrounding the anus
behind; rostrum short. Ornate with eyes and fes-
toons. Basis capituli rectangular dorsally.
Stiles has demonstrated that the stigmal plates
(Figs 279 and 280, form a ready and accurate
method for the distinction of the numerous species.
This genus includes the species responsible for the
transmission of Rocky Mountain spotted fever, and
Fig. 282.
Dermaeentoi andersoni, male from Montana.
View. (After Stiles.)
al~o several others commonly found on man in
various sections of the country. The most impor-
tant species uiniiiestionably is:
Dermacentor andersoni Stiles (The Rocky Mountain
Spotted Fever Tick) = D. venustus Banks; D.
occidentalis < >f writers on Rocky Mountain Spotted
I ' er. Gray to red, brown, or even nearly black.
Stigmal plate large; its dorso-lateral prolongation
distinct. Goblets in plate very numerous and
crowded. Male 4 by 2.5 mm; female may attain 16 by
9.5 by 6 mm. when replete (Figs. 2S1 to 284). Hosts:
man, cattle, horse, dog, rabbit, gopher. Habitat:
Montana, and parts of Washington, Oregon, Idaho,
Nevada, Wyoming, Utah, and Colorado. It is the
common tick of the Bitter Root Valley. It occurs
Fig. 283.-
-Dermacentor andersoni, young female.
(After Stiles.)
Ventral View
at elevations of from 500 to 9,000 feet but reaches
its maximum at an elevation of 3,000 to 5,000 feet
where it is often found in large numbers.
The view that Rocky Mountain spotted fever is
conveyed by the wood tick of that region was ad-
vanced in 1902 by Wilson and Chowning. By
a series of careful and convincing experiments ex-
tending from 1906 to 1909, the late Dr H. T. Ricketts
Fig. 2S4. — Dermacentor andersoni. male from Montana.
View. (After Stiles.)
Ventral
demonstrated that the disease was transmitted chiefly
if not exclusively by Dermacentor andersoni. This
tick is especially abundant in localities having much
fallen timber and underbrush. The immature
stages feed upon small mammals, such as gopher,
chipmunk and ground squirrel, but the adults attack
only the larger domestic animals. Ricketts demon-
514
REFERENCE HANDBOOK OK Till', MEDICAL SCIENCES
\ I.M lllllil I
strated that guinea-pigs are susceptible to t he dis-
ease; that larval or nymphal ticks contract the dis-
ease by biting an infected animal and can transmit
it in tin' following stage (nymph or adult); that
adult ticks having acquired the disease can transmit
it through tl gg to the succeeding generation; and,
finally, that infected ticks occur in nature. It has
been further shown that the actual distribution of
the tick is much broader than the limits within
which the disease occurs. This is an evident ele-
ment of danger and indicates for the disease a
much greater possible range than at present occupied.
I here is some reason to believe that the malady is
ading.
This tick hibernates through the winter and on
emerging seeks a host. During the period from about
March 15 to July 1.5, the parasites attack man and
transmit the genus of the disease. The eggs laid by
the earliest mature females may develop to adults
by September, but ordinarily this generation does
not progress so far and hibernates during the second
winter, thus repeating the history of the previous
general ion. The large majority of these ticks re-
quire two years to finish out the life cycle completely
and siime take even three years.
At present the virulent form of the disease with a
death rate of about seventy per cent, is confined to
the Bitter Hoot Valley. Measures have been formu-
lated for the restriction of this form of the disease to
that territory and the ultimate eradication of this
tick which though only one of several that carry the
disease, is the only one of the group that attacks
man.
The plan for the eradication of the disease, sug-
gested originally by Ricketts, is based upon the
Flo. 285. — Dermacentor variabilis, Dorsal view of male. X10
(After Osborn.)
practical restriction of the adult ticks to the larger
domesticated animals. It is favored by the limited
population and the isolation of the region. It
Consists in dipping all live stock, or in' hand treat-
ment of such as cannot be dipped. The plan de-
mands at least three years for its execution. Even
if more expensive and not as successful as pro-
phesied, the benefit resulting would be very great.
The microorganism which produces the disease
and is transmitted by the tick has not been positively
determined. Ricketts isolated a bacillus that may
be specific, but the question is still sub judice.
D. andersoni is easily confused with D. venustus
of Texas under which name it has generally been
included, and with I), occidentahs of California,
another species which occupies an immediately
adjacent range. Stiles (Public Health Repts., July
.;, L908) states tin- differences which are adequate for
the separation of the three species. Fortunately it
appears that neither of these closely related species
and contiguous species' can transmit the Rocky
Mountain spotted fever.
The Pacific Coast Tick, Dermacentor occidentalis
Marx, is limited in distribution to western Oregon,
California, and probably .Mexico, where it is the most
common tick. Abundant on live stock, it occurs
often on man. especially during the rainy season when
it is most numerous and the source of great annoyance.
It is often confused with the previous species but,
readily distinguishable by numerous red points
among the white markings.
The American dog tick, Dermacentor variabilis Say
(Fig. 285), is the most* common species east of the
Mississippi River; its range extends from Labrador to
Florida. It displays a strong tendncy to attach
tself in the ears of the host. No evil consequences
are known to follow its attack on man.
Amblyomma and Hyalomma are readily separable
from other ticks by their long palps. The latter,
found in Africa, is the agent in transmitting various
piroplasmas in domestic animals, including the camel
and dromedary. The former includes two important
American forms and may be distinguished by the
absence of anal plates in the male. Each of these
species are frequent on man. The long beak enables
it to maintain a firm hold. The severe results follow-
ing its attachment to man in some cases appear to be
due to the introduction of bacteria. In Africa it gives
rise to a definite train of symptoms and the condition
is designated "tick-bite fever." The disease affects
new comers and old residents appear to have acquired
immunity.
Amblyomma americanum Koch (The Lone Star
Tick) = Ixodes unipunctata Packard. Male: body
brownish red, oval, much elon-
gated posteriorly, 3 mm. long,
2.5 mm. broad. Female (young) :
colored like the male with a white
spot on the back of the living
animal. Length 4.5 mm., breadth
3 mm., increasing in gravid fe-
males to 8 by 12 mm. (Fig. 286).
This characteristic American
species occurs from Labrador to
Florida and Texas and is known
from South America as well. It
is common on cattle in the south-
ern part of the United States, and
is reported from other domesticated as well as wild
species. Packard reports a case in which a specimen
had penetrated into the arm of a young girl, forming
there a tumor. It is said to be very annoying to man
in the warmer portions of the country, and a corre-
spondent in Texas writes that he removed several
females from his own children in one evening.
Amblyomma maculatum Koch, the Gulf Coast tick,
occurs along the Gulf Coast, especially in Louisiana
and Texas. It extends far south into South America.
In size and general appearance it resembles the pre-
vious species but lacks the bright metallic star on the
shield of the female Lone Star tick. It is more in-
clined to attack man than any other North American
species, except the Rocky Mountain spotted fever
tick. Henry B. Wabd.
Principal Articles Used.
Braun: Die thierischen Parasiten des Menschen; vierte Aufl..
Wiirzburg, 1895.
Canestrini und Kramer: Demodicidie und Sarcoptida 1 . Das
Tierreich; 7. Lief., Berlin, 1899.
515
Fig. 286.— Ambly
omnia americanum
Koch, Adult female.
(Original.)
Arachnida
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Darling and Clark: Linguatula serrata (larva) in a Native Cen-
tral American. Arch. Int. Med., 9; 401-5, 1912.
Hessler: An Extreme Case of Parasitism. Indiana Academy of
Science, 1893; also Amer. Naturalist, vol. xxvii., pp. 346-52, 1893.
Megnin: Les parasites et les maladies parasitaires, Paris, 1880.
Neumann: Parasites and Parasitic Diseases of Domesticated
Animals. Translated by Flemming, London, 1892. Revision de
la famille des Ixodides. Mem. Soc. Zool. France, vol. ix., pp. 1-44;
X., pp. 324-420; xii., pp. 107-294, 1S96-99.
Nuttall: Insects, Arachnids, and Myriapods as Carriers of Dis-
ease. Johns Hopkins Hospital Reports, vol. viii., pp. 1-154, with
3 plates, 1899.
Nuttall, Warburton, Cooper, and Robinson: Ticks, A Mono-
graph of the Ixodoidas. 3 pts. Cambridge, 190S-1911.
Osborn: Insects Affecting Domestic Animals. United States
Dept. Agr., Div. Entom., Bull. 5, N.S., 1S96.
Railliet: Traite de Zool. Med. et Agric, 2me ed., Paris, 1893-95.
Ricketts: Investigation of the Cause and Means of Prevention
of Rocky Mountain Spotted Fever. Also other important papers
by same Author Reprinted in Contrib. to Med. Sci., Univ. Chicago
Pre-., 1906-08: reprinted 1911.
Riley: Poisonous Insects. First edition Reference Handb. of
the Med. Soc, Nov York, 18S7.
Salmon and Stiles: Cattle Ticks of the United States. Ann.
Rept. Bur. An. Ind, 17: 3S0-492, 1910.
Sambon; Porocephaliasis in Man. Jour. Trop. Med., 13: 17-23,
212-216,258-267,1910. .
Shipley: Revision of the Linguatulidse. Arch. Parasitol. vol.
i., pp. 52-80, 1898.
Stiles: Stigmal Plates in Dermacentor. Bull. Hygienic Lab.,
No. 62, 1910~ Also smaller papers by the same and other authors.
Araliaceae.— (The Ivy Family.) A family of some
forty genera and about 400 species, widely distrib-
uted through temperate and tropical regions of both
the old and the new worlds. Its plants are highly
ornamental, some, like the ivy, being extensively
cultivated for this purpose. Medicinally, it is of
note as yielding the famous ginseng. Its constitu-
ents are simply aromatic and without special prop-
erties. The spikenard, and several other species of
Aralia, were formerly very extensively used, and are
still used to a considerable extent, for these prop-
erties. Some of them contain amaroids in connec-
tion with their resins and volatile oils.
H. H. Rusby.
Araneida. — Araneida, Aranem. The order of the
class Arachnida, which includes the true spiders,
of which the tarantula is an example. Respiration
is by means of tracheal tubes and "lung-hooks";
the abdomen is provided with spinning glands.
See Arachnida. A. S. P.
Aranzio, or Arantius.— Born in Bologna, Italy, in
or about 1530, Aranzio acquired in time the reputation
of being one of the most skilful anatomists of tin'
sixteenth century. He received his medical educa-
tion in part from his uncle, Bartolomeo Maggi, a
celebrated surgeon of Bologna (and later physician
of Pope Julius III), and in part from the illustrious
Vesalius, professor of anatomy in the University of
Padua. The degree of Doctor of Medicine was given
to him by the University of Bologna, and very soon
afterward he was called by the same institution to
occupy the chair of medicine, surgery, and anatomy.
For a period of thirty-three years— that is, up to the
time of his death in 15X9— he faithfully performed
the duties of this position. Credit is due him for a
large number of anatomical discoveries. His most
important publications are: " De humano fcetu
opusculum.'' Rome, 1504; " Observationes anato-
mical" (with the treatise on tumors). Venice,
1595; "In Hippocratis librum de vulneribus capitis
conimentarius." Lyons, 1579. A. H.B:
Arbor Vita;. — See Thuya.
Arbuthnot, John. — Born in Scotland, near Mont-
rose; date of birth not known. He took the degree
of doctor of medicine at the University of Aberdeen.
He began his professional career in London, and his
practice grew rapidly. His reputation, however,
was based rather on his literary labors than on what
he accomplished in the domain of medicine. He
became in turn physician extraordinary to Prince
George of Denmark and one of the regular medical
advisers of Queen Anne. In 1710 he formed a close
friendship with the most eminent literary men of that
epoch, such men as Pope, Swift, and Gay. He died
in London in 1734 or 1735. He published three
essays on medical topics, viz., one on the regularity
of the births of both sexes; another in 1731 on the
nature and choice of aliments; and a third in 1733 on
the effects of air in the human body. A. H. B.
Arcachon, France, (latitude 44° 7'), is situated
thirty-five miles southwest of Bordeaux, in the midst
of a thick forest of pine trees, where once was only a
lowlying sandy desert waste. Some sixty or more
years ago this waste of barren sand dunes was planted
with pine trees, which thrive in sandy soil, by the
French government, for the purpose of fixing the
sand, which, by the action of the wind and waves,
was constantly encroaching upon the country of the
interior. There are nine thousand acres of these
pine trees, and, owing to the noiseless sandy roads and
the silent trees, there is a peculiar and, to some per-
sons, a depressing stillness.
Arcachon is about nine miles from the actual coast,
at the south of a large landlocked bay or basin, con-
nected by a narrow channel with the sea. A part of
the town is directly on this bay, the Ville d'Ete\ and a
part on the surrounding sand hills in the midst of the
pines, the Ville d' Hiver, which is the winter resort for
invalids.
The features of the climate are those of a marine
one, characterized by a very considerable amount of
moisture, equability, and a rather mild temperature.
In addition, there is the influence, whatever benefit
it may be, of the pine forests, the air of which is said
to be remarkably rich in ozone, and "perceptibly
impregnated with the balsamic odor of turpentine."
The winter climate, according to Yeo, is mild and
sedative, yet not relaxing. "The calmness of the
atmosphere, the silence of the forest, a certain isola-
tion of the habitations, and resinous emanations from
the fir trees, constitute a combination of sedative con-
ditions of which not one is superfluous," says Black.
("Southwest France," Black.)
Such are, doubtless, most excellent sedative condi-
tions, but it would generally require a very sedate
person to endure with equanimity such monotony, of
which invalids too often complain, says the same
author.
Lalesque ("Cure Marine de la Phthisie Pulmo-
naire," Paris, 1897) gives the monthly mean temper-
ature for the three seasons of winter, spring, and
autumn, as follows, the observations extending over
a period of nine months (the figures denote degn es
Fahrenheit).
December 44 72 March 52.00 September ... fi!' 94
January 43.37 April 58.09 October...
February 45.77 May 63.83
November . . . 51 75
From which we find the mean winter temperature is
44.62° F.; that of spring, 57.64° F.; and of autumn,
60.4° F. The daily and monthly variations are said
by the same authority to be small. The average
annual humidity is seventy-seven per cent, according
to Lalesque and eighty-five per cent, according to
Weber.
516
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Arco
The average number of clays of rain for the six
years from 1887 to L892 is as follows:
ISS7
L8S8.
117 [889
IliS IS'.IO.
I7S
151
189] MO
1892 liu
making an average of 152.6 days for the entire period.
November and December arc the rainy monthsof
tin' year. The rains are most severe during the night
or in the morning, and least so toward the middle of
the day.
Arcachon is both a summer and winter resort; the
portion of the town lying directly on the shore or the
suit water lake, or basin, being the resort for summer,
which is much frequented for sea-bathing, which is
excellent, and for boating, yachting, and fishing. The
Boulevard do la Plage runs the entire length of the
town, along the sea, and on it arc situated many of
the hotels, which are good. There are clubs, a
casino, English or English-speaking physicians, and
an English church — "all the appliances of advanced
ci\ ilizal ion."
The winter resort, known as the "Ville d'Hiver,"
is hack from the summer resort portion and separated
from it by a high sand dime, between the two por-
tions of the town is a large public garden. There are
numerous picturesque villas hidden in the pines,
hotels and boarding houses.
The walks and drives in the forest offer but little
variety of scenery, and one is advised to take a pocket
compass in order to preserve his direction.
Such a combination of pure sea air and pine forests
i< applicable to various maladies, such as irritative
bronchial or laryngeal catarrh, glandular and bone
tuberculosis in children, and, according to Yeo
("Health Resorts and Their Uses, J. Burney Yeo,"
M. D.), " cases of dyspepsia complicated with hysteria,
hypochondriasis, and nervous irritability." Pulmon-
ary tuberculosis, however, is the disease to which the
climate of Arcachon has been applied more than to any
other and the place has a local reputation for the
treatment of this disease.
Dr. Lalesque, who has written a book upon marine
climates in general and that of Arcachon in particular
(Cure Marine de la Phthisie Pulmonaire, Paris, 1S97),
as applied to the treatment of tuberculosis, speaks
with Gallic enthusiasm of the favorable influence of
such a climate upon this disease; and in ISA cases, of
which 79 were in the first stage, 45 in the second, and
60 in the third, he obtained 34 per cent, of cures and
50 per cent, improved of the first stage cases; 20 per
cent, and 53 per cent, respectively in the second
stage; and 6.6 per cent, and 35 per cent, in the third
stage. In the whole 1S4 cases he obtained 21.7 per
cent, of cures and 46 per cent, improved. He
applies very rigorously the "cure d'air et de repos,"
although his patients are not under sanatorium
control, and he thinks the "cure marine" as illus-
trated by Arcachon, gives results comparing favorably
wilh those obtained in the mountain resorts.
Undoubtedly, constant exposure in pure air is the
principal climatic factor in the treatment of pulmon-
ary tuberculosis, wdiatever the climate and whatever
the resort, other things being favorable. "I can cure
tuberculosis in any climate," once remarked the
distinguished Dettweiler to the writer. Nevertheless,
the high altitudes and resorts with a dryer climate
have given appreciably better results, as shown by
statistics. We are, however, more and more realizing
that climate is only one factor in the treatment of
tuberculosis, and others are quite if not more im-
portant. It is only in the skilful combination of all
by the expert that the best results are obtained.
Edward O. Otis.
Arco. — This village occupies in Austrian estimation
the position which is held in Italy by San Rerao, and
in France by Mentone. li is situated in the extreme
southern portion of the Austrian Tyro), OH the line of
the railway between Botzen and Verona, three miles
distant from the beautiful Lake (larda. It lies in a
valley enclosed, on all ides bul the south, by lofty
mountains rising from four to seven thousand feet.
The northern opening is protected by a ma of rock
370 feel high. The elevation of the village is slight,
viz., from 250 to 500 feel above sea level. It is aid
to be almost windless; but little rain falls and snow
IS seldom seen. Its climate during the winter, which
i i the time of residence for invalids, is mild and equa-
ble, as following chart indicates:
Observations of Temperature at Arco, Winter, 1875-1876
(From Bulenburg's " Real Bncyclopadie.")
i Fahrenheit Sen!- I
Month.
Monthly
mean
( )(■(<. 1 hT. , .
Noveml ier
1 >ecember.
January . .
February.
March ....
April
59 5°
41 s°
43 ii'
45 3°
50.4°
59.0°
Mean
ma dmum
(at noon i.
Mean
minimum
(at noon).
71 ,9°
60 6
53. 6°
61.7°
64 I
60.2°
7.", 2°
!
42 8°
3g
41.0°
44.6°
50.0°
The relative humidity is about 72 per cent.
Dr. Weber (Ziemssen's "Handbuch del allg.
Therapie," Bd. ii., S. 173) gives the following facts
concerning the climate of the Italian lake region, and
includes Arco in his list of places properly belonging
within this climatic district. The relative humidity
of such points he states as being between 72 and 78
per cent, during the autumn and winter months, and
somewhat less than 70 per cent, in the spring season.
The average number of rainy days is from 36 to 40
during the autumn, from 34 to 36 during the spring,
and from 15 to 20 during the winter. Snow falls, as
a rule, in this region, on not more than 6 or 8 da\ s of
the year, and seldom lies for several days together
upon the ground. Among the local winds which pre-
vail about, all great lakes, those blowing from the north
and from the northeast, are of most frequent occur-
rence in this region. Fogs are rare; there are few days
during which an invalid must keep within doors from
sunrise to sunset; and there is less dust than is found
along the Italian Riviera. The mildness of the
climate is shown by the fact that the orange ripens in
the open air, and the olive tree, the fig, and the
pomegranate also flourish.
The invalid's day is nine hours long in October,
seven in November, six in December, five in January,
six in February, eight in March, and the whole time
between sunrise and sunset in April. The season ex-
tends from September 1 to April 1. The class of
diseases for which Arco is suited as a residence are
affections of the chest and throat, anemia, want of
appetite, nervousness, chronic catarrh of the stomach,
intermittent fever, rheumatism, gout, and the scro-
fulous affections of children. There are provisions
for the various forms of hydropathic treatment, and
an Oertel Terrain-Cur.
The drinking-water is of good quality, and the
accommodations are said to be comfortable and easily
obtained. There are many attractive walks and
pleasant excursions in the neighborhood.
Weber classes Arco as among the lowest Alpine
climates and says its winter climate is "sufficiently
mild for persons with stationary phthisis, or con-
517
Arco
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
valescents from the same disease, and also for those
whose object is only to find change and a sunny
climate."
All eases of pulmonary disease suitable for the
medium and higher altitudes would of course be
suitable for this climate, which offers favorable con-
ditions for the open-air treatment; and, after all, this
is the principal factor in any climatic treatment of
pulmonary tuberculosis.
For the above account of Arco the writer is in-
debted to Dr. Huntington Richards' report in a pre-
vious issue of the Handbook, and to Roe's "Health
Resorts and the Bitter Waters of Hungary."
Edward U. Otis.
Arctic Springs. — Trempeleau County, Wisconsin.
Post-office, Galesville. Hotels in Galesville.
These springs are situated near the village of
Galesville, at the terminus of a branch of the Chicago
and Northwestern Railroad. The springs are at the
head of a small lake called "Marinuka," while the
village is at the foot, about a mile away. During
the summer a small steamer carrying fifty passengers
plies between the two points. The location is 750 feet
above the sea level. The country surrounding the
springs is broken by ranges of elevations called
"bluffs," between which are beautiful and productive
valleys from one to three miles wide. The main val-
leys are intersected by smaller depressions at inter-
vals of about a mile. All of these valleys contain
clear trout streams coursing down their centers.
This peculiar conformation gives the country an aspect
of picturesque beauty not soon forgotten when once
seen. The springs flow from beneath a precipitous
bluff out of the rocks, filling a pipe six inches in
diameter. The water as it flows has a temperature
of 4N° F.
The water is a mild alkaline-calcic, with light
chalybeate properties. It is useful in acid dyspepsia,
chronic constipation, renal congestion, the early
stages of Bright 's disease, and in general debility.
Galesville is a thrifty village of about 1,000 inhab-
itants, and numbers among its attractions telegraph
and telephone facilities, electric lights, water-works,
a fine water-power, etc. Emma E. Walker.
Arcus Senilis. — Gerontoxon (from Greek, rtpcov,
old man, and zi£ov, bow, arch); Macula arcuata or
macula cornea; Marasmus senilis cornea;; Annulus
senilis; German, Greisenbogen; French, Arc senile.
Arcus senilis occupies the peripheral portion of the
cornea as a light gray arc. The opacity, smooth on
the surface, is more pronpunced toward the limbus,
bring sharply defined from it by a narrow, trans-
parent strip, while the concavity of the arc emerges
gradually into the transparent cornea. The opaque
arc always appears first above, and gradually ad-
vances downward. It always remains broadest above
and is at the same time more opaque in this part.
Finally, the two arcs unite at the outer and inner side
of the cornea to form a closed ring.
The opacity is at first of a light gray color, appear-
ing like a silver band. At a later period, the opacity
a nines a denser and more creamy tint, increasing at
the same time in depth and width. Arcus senilis, as
the name indicates, is an affection of advancing years,
and rarely occurs under fifty years of age except in
those infrequent cases in which it seems to occur as an
inherited characteristic. Thus, for example, I know
of a family in which three male members have all
bad the completed arc as early as at the age of thirty-
five, and in none of them is there any apparent
cachexia.
I he condil ion is usually bilateral, although one eye
alone may be affected. It occurs more frequently
and at an earlier date in men than in women. In
warm climates it is developed earlier than in cold
latitudes, and it is frequently seen in negroes on the
north coast of Africa.
A condition resembling very much arcus senilis is
found in the young, but is not to be confounded with
it. It has been called by Wilde nreus juvenilis, and
may be distinguished from the former by the presence
of a diaphanous ring between the margin of the
eornea and the opacity.
Arcus senilis never interferes with vision, although
it may extend somewhat into the corneal substance.
Occasionally a genuine example of this affection
appears to have been noted in children (Hansell).
A rare change occurring in the arcus senilis consists
in its becoming steadily wider while the cornea in the
area of the arcus becomes thin, so that a gutter-
shaped depression is formed here, which, yielding to
the intraocular pressure becomes ectatic.
Pathology. — Arcus senilis is due to an infiltration
of a finely granular hyaline substance. It is com-
monly stated, even in the more recent text-books,
that it is due to a fatty degeneration or infiltration of
the cornea; but this has been shown by Fuchs not to
be the case, for he says it- is a typical example of
physiological, non-inflammatory opacity. He found
that the infiltrated material never has any relation
to the cells of the corneal tissue, but lies free upon the
surface of the connective-tissue fibers. Neither ether
nor chloroform has any effect upon it; consequently it
cannot be of a fatty character. Fuchs considered it
to be a hyaline degeneration of certain fibers. In
Fuchs' latest edition (English translation published
in 1911), he accepts Takayasa's view, and figures his
section of the cornea. Takayasa found very minute
drops of fat in the lamella? of the cornea even as far
back as Descemet's membrane.
This deposition of hyaline masses is also associated
with deposits of minute particles of lime on the more
superficial layers of the cornea, close to the limbus,
and the cause is assumed to be a senile atrophy of the
limbus, with involution of a portion of the vascular
loops contained therein. Gruber attributes the
appearance of these changes in this particular portion
of the cornea to the peculiarities of the circulation in
the cornea; the peripheral zone being nourished
mainly by transudation of nutritive materials from
the circumcorneal plexus. At the same time the
changes in question are favored by the fact that,
with advancing age, the circulation grows less
active and consequently the nutrition progresses
more feebly.
Arcus senilis would, therefore, appear to be a
phenomenon that occurs in perfectly healthy people,
is due to the decrease of nutrition incident to advanc-
ing years, and has no relation to fatty degeneration
of the heart, as was formerly supposed.
There are no symptoms. The slight disfigurement
and the apprehension of future trouble which many,
not knowing its character, anticipate, constitute the
only sources of annoyance. So far as the patient's
fears are concerned, these may easily be allayed; for
the condition never interferes with vision. Incisions
through the arcus senilis, as in the extraction of
cataract, heal as well as those made through the clear
parts of the cornea. William Oliver Moore.
Area Embryonalis. — The embryonal area, also
called germinal disk and embryonic shield, is that part
of the blastoderm of meroblastic eggs which gives rise
to the body of the embryo, as distinguished from the
extraembryonic part, from which the yolk-sac,
amnion, and chorion take their origin.
In the vertebrate series there are two types of
embryonal area; the selachian type, found in the
selachian and teleost fishes; and the reptilian type,
characteristic of reptiles, birds, and mammals
518
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Ari'.i Embryonalla
( Amnio ta). In this article attention will be confined
to the latter typo.
In an early stage of the amniote egg the embryonal
area (Fig. 289) may be distinguished as a circular or
oval area covering the animal pule of the egg, and
isting of two membranes. The outer membrane
is the ectoderm and may be several cells thick; the
inner membrane is the endoderm and is usually, for
the must pari, a single layer of cells.
Fig. 287. — Area Embryonalis of a Chick Incubated Fifteen Hours,
View by Transmitted Light. X 14. ao, area opaca; ap, area
pellucida; c, anterior crescent; in, mesoderm; p, priniitive streak.
(From Duval.)
In the bird 's egg, the embryonal area forms the
roof of a shallow cavity excavated in the yolk and
filled with fluid. This cavity is known as the sub-
mittal cavity (Fig. 28S). As a result of the seg-
mentation of the ovum, the yolk forming the walls
of the subgerminal cavity is provided with nuclei,
which also extend some distance along the peripheral
Cortion of the floor. The nuclei are not separated
v cell walls. The syncytium thus formed is called
the periblast. (Lillie 190S, p. 4S.)
If at an early stage a blastoderm be removed from
a hen's egg and examined by transmitted light
287), it will be seen that the central part is much
more transparent than the peripheral zone. The
central part is known as the area pellucida, the
flattened cells containing little or ao yolk; in the
opaque area the endoderma] cells are larger, deeper,
often columnar, and filled with yolk granules. The
endoderm of the area opaca and the marginal peri-
bla i together constitute the germ wall. (Lillie, 1908,
1). 51.)
In the area opaca three zones may be distinguished
Fig. 289. — Diagrammatic Reconstruction of a Pigeon's Blasto-
derm, Thirty-eight Hours after Fertilization. E, endoderm of area
pellucida; PA, outer boundary of ana pellucida; SO, subgerminal
cavity; 0, region of overgrowth; Y, inner germ-wall; Z, zone of
junction; R, mass of cells. X22. (After Patterson.)
(Fig. 289); (1) the inner germ wall, a ring of thickened
endoderm continuous with the endoderm of the area
pellucida; (2) the zone of junction, where the endo-
derm merges with the periblast, or rather where the
periblast nuclei become surrounded by cell walls and
give rise to new cells of the blastoderm; and (3) the
margin of overgrowth, where the edge of the blasto-
derm, chiefly ectodermal, is continually extending
over the surface of the yolk in advance of the expan-
sion of the germ-wall.
Fig. 288. — I. A Median Longitudinal Section of a Blastoderm of a Pigeon Taken Thirty-eight Hours after Fertilization, or Three
Hours before Laying. X 57. II. Enlarged anterior portion of the subgerminal cavity of the section represented in I. X 1.34.
III. Enlarged posterior portion of I. X 134. .4, Anterior end; P, posterior end; AC, subgerminal cavity; D, mass of cells at R
in Fig. 2S9; E, endoderm; EC, ectoderm; GW, germ wall; L, anterior limit of endoderm; M , yolk masses in subgerminal cavity;
0, zone of overgrowth. (From Patterson.)
peripheral part as the area opaca. Examined in situ,
the ana pellucida will be found to cover the greater
part of the subgerminal cavity, while the area dpaca
covers only the edges of the cavity and extends out
over the yolk in contact with the marginal periblast.
The difference in transparency of the two areas is due
to the differences in their endodennal cells. In the
pellucid area the endoderm is composed of thin,
The first indication of the axis of the future embryo
is the appearance of a linear opacity in the area
pellucida extending from a little behind the center
toward the posterior margin (Figs. 287 and 293). This
is the primitive streak. Soon a depression appears
along its median line, the primitive groove, bounded
on the side by two slight elevations, the primitive
folds. Examinations of sections through the priuii-
519
Area Embryonalis
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
tive streak i Fig. 290 and 292) show that it is produced
by proliferation of the ectoderm, which eventually
comes into contact with the endoderm and appears
to fuse with it. Behind the posterior termination of
the primitive groove the primitive streak spreads out
gw
en
\
ec
gw
1
Fig. 290. — A, Transverse Section Through the Posterior Part
of the Blastoderm of a Chick Incubated About Ten Hours, X21.
ii. Median portion of the same, X65. ec, ectoderm; en, endoderm;
gw, germ- wall; m, mesoderm; o, zone of overgrowth; ;>, primitive
groove; s, subgerminal cavity; y, yolk. (After Duval.)
forming the primitive plate. In front of the opposite
end of the groove is the anterior termination of the
primitive streak in an ectodermal thickening known
as the primitive knob, Hensen's knob, or the proto-
chordal wedge of Hubrecht (190\S).
-I"
Fig 291 — Embryonal Area of a Dog's Blastocyst Thirteen to
Fifteen Days after Coitus, Showing Primitive streak and Primitive
Knob, a and 6, planes of sections in Fig. 292. X 100. (After
Bonnet.)
From the sides and posterior end of the primitive
ik the cells migrate or grow out laterally and
posteriorly between the two primary germ-layers.
The middle layer thus formed is the mesoderm. The
lateral portions of the mesoderm are known as the
mesodermal wings, and the posterior parts, with
which they are continuous, is the ventral mesoderm
of Hubrecht.
Soon after the establishment of the primitive streak
a new axial structure appears extending forward from
the primitive knob. This is the head process, or
forward extension of the protochordal wedge of
Hubrecht. In a surface view of a hen's blastoderm
■MKS
§» — en
■
fc 1 i •
Fig. 292. — Sections of the Embryonal Area of a Dog shown in
Fig. 291, planes a and b. Upper section through the primitive
knob, lower section through the primitive streak, tc, ectoderm;
en, endoderm; p, piimitive pit; ps, primitive streak. X 180.
(After Bonnet.)
it looks very much like the primitive streak, but in
sections it is seen to be separate from the overlying
ectoderm and to be continuous with that layer only
at the primitive knob, from which it appears to be an
outgrowth. Below, it comes into contact with the
endoderm and fust's firmly with that part of the endo-
derm lving in the median line that Hubrecht calls the
protochordal plate. The axial cells of the proto-
■
j J
■
Mtiii.. . . .
Fig. 293. — Area Embryonalis of a Chick Incubai
Hours. X 13. c, anterior crescent; ch, notochord;
plate; p, primitive streak. (From Duval.)
d Nineteen
, medullary
chordal wedge and the protochordal plate are destined
to become differentiated into the notochord, the first
rudiment of the skeleton of the embryo.
In the primitive knob a depression appears, the
primitive pit (Fig. 292). This goes no further in the
chick, but in some other birds and in the reptiles it
penetrates the blastoderm, so that there is an opening
from the subgerminal cavity to the exterior, called
520
REFERENCE IIAX11ROOK or T1IK MKDICAL SCIENCES
Area Embryonalis
,1, nteric canal. In mammals the pit extends
M ., lender, horizontal canal into the head proce
where at first it ends blindly, and is culled the noto-
chordal canal. The cells in the roof of the canal are
ined to take part in the development of the noto-
n
Fio. 294. — Area Embryonalis of a Chick Incubated Twenty
Hours. ■ 11. av, area va* ilosa; c, anterior crescent; cA, noto-
. , medullary fold; p, primitive streak. (From Duval.)
chord. The floor of the canal acquires one or more
irregular openings into the underlying yolk-cavity
and finally disappears, leaving only the part of the
canal that penetrates the knob; this part then becomes
the neurenteric canal.
"1
L . - -■ 1
Fig. 295 Area Embryonalis of a Chick Incubated Twenty-one
Hours. 11 a, head-fold; av, area vasculosa; c, anteri ir
ent; ch, notochord; ms, mesodermal somite; n, medullary fold;
p. primitive streak; st. sinus terminalis. (From Duval.)
The mesoderm continues to spread, not only pos-
teriorly and laterally, but also forward along the sides
of the head process, with which, in the chick and
many other forms, it appears to be continuous.
According to some authors all of the mesoderm is de-
rived from the primitive streak, while others believe
that the head process contributes its share to the
anterior portion of the mesodermal wings.
In the course of its growth the mesoderm extends
across the area pellucida and in ade i he inner zone of
the area opaca i Fig. 294). In this portion of the area
Fie,. 296.— Embryonal Area from a Dog's Blastocyst Seventeen
I laj 9 and Seven and ( (ne-half Hours After the Last Coitus, Show-
ing Primitive Streak, Primitive Knob, and Medullary Groove.
X 18. (After Bonnet i
opaca, which thus becomes three-layered, the first
blood-vessels arise, and, fusing, give rise to a capillary
net-work, which grows across the area pellucida and
enters the embryo. The part of the blastoderm that
contains this net-work of blood-vessels is known as
the area vasadosa. The first rudiments of the blood
vascular system consist of small thin walled vesicles
containing" clumps of cells that soon become colored
red with hemoglobin. These groups of cells with
their envelopes are called blood islands. They lie
between the endoderm and the mesoderm, and, after
lirsl appearing at the posterior edge oi the mesoderm,
spread rapidly round its sides. Because of their
equal proximity to two germ-layers, their origin is
still a disputed question. The best view, however,
appears to regard them with Hubrecht as mesodermal
structures of endodermal origin. The rudimentary
blood-vessels and blood were regarded by His as
constituting a separate tissue, or embryological unit,
to which he gave the name, angioblast. The origin
ami fate of this layer is discussed more full}' elsewhere
(see article Blood-vascular System, Origin of).
Finally the area embryonalis is completed by the
appearance of the medullar}! jdale. the first rudiment
of the nervous system. This is differentiated out of
the ectoderm in front of the primitive knob along the
median line and for some distance on each side of it.
It may also extend backward along the sides of the
anterior part of the primitive streak. In time of
appearance it is nearly synchronous with the head
process. (Fig 295.)
In the chick the medullary plate is a flat layer of
521
Area Embryonalis
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
ectoderm, several cells thick. This merges without
any sharp line of demarcation into the surrounding
ectoderm. In mammals the plate appears almost
from the first as a shallow groove, the medullary
amniotic ectoderm and that of the embryonal area.
The endoderm is a minute vesicle of flattened epithe-
lium enclosing the so-called yolk-cavity. The area
embryonalis is represented by the adjoining portions
of the ectoderm and endoderm with a
very thin layer of rnesenchymatous tissue
between.
In Peter's ovum the ectoderm of the
area embryonalis is composed of high
cylindrical cells, and is thus differentiated
from the thin amniotic ectoderm. Be-
tween the ectoderm and the endoderm
there is a layer of mesoderm, which is
separated from the ectoderm by a mem-
brana prima. This appears in sections as
a fine contour.
Herzog (1909) has described a human
blastocyst that he regards as of about the
same age as Peters's ovum, but the men-
strual history is unknown. The embry-
onal area is distinctly differentiated and
is 0.112 mm. in length. It is boat-
shaped, rounded anteriorly, and pointed
behind, and it is concave, the concavity
being toward the amniotic cavity, which
is circular in transverse sections. A
transverse section through the middle of
the embryonal area shows all three germ
layers with diagrammatic clearness, but
at the extreme anterior end the meso-
derm is wanting. The ectoderm of the
embryonal area is two or three cells
deep, and in the median sagittal plane
is an opening that is regarded as possi-
bly a neurenteric canal. Rudimentary
blood-vessels are observed near the junc-
Fig. 297.— Area Embryonalis of a Rabbit of Eleven Days, with the Ectoplacenta ture of yolk-sac and connective stalk.
Partly Torn Off. (After Van Beneden and Julin.) pr.a., Pro-amnion; a. a., area The allantois has made its appearance as
amniotica; a.v., area vasculosa; a.pl., ectoplacenta; v.t, sinus terminalis. a rather slender, somewhat curved canal
of endodermal cells extending into the
groove, and in the dog (Fig. 296) (Bonnet, 1901)
it is only one cell thick.
The appearance in the blastoderm in front of the
medullary plate of a crescentic groove, the head
fold, (Fig. 295), carries the embryo beyond the scope
of the present article.
In some animals, of which
the mouse is the type, the area
embryonalis is covered perma-
nently by a specialized part of
the trophoblast, known as the
ectoplacenta. In adaptation
to this condition, the embry-
onal ectoderm, instead of form-
ing a fiat surface, becomes the
lining epithelium of an elon-
gated sac (Fig. 298). This sac
is covered externally by the
embryonal endoderm, and is
surrounded by the cavity of
the yolk-sac. In the mouse,
therefore, the development of
the primitive streak and other
structures of the area embryo-
nalis, is modified by this ex-
traordinary condition, which
has been called inversion of
the germ-layers. (See Blasto-
derm.)
Descriptions have been pub-
lished of a number of human
blastocysts in stages showing
the area embryonalis. In the
youngest of all, the Teacher-Bryce ovum, this area
is not sharply marked off from surrounding struc-
tures. The embryonal ectoderm is a spherical vesicle
composed of cubical cells and enclosing the amniotic
()1) with an embryonal area 1.17
mm. long and 0.6 mm. wide. The primitive streak
(Fig' 302) is well developed, 0.5 mm. long. A
anterior end is the neurenteric canal and at its
Fit . 300. — Transverse Section of Spee's von Herff Ovum,
a. amnion; .'. Ferdinand Graf (1889). Beobachtungen an eincr mensch-
lichen Keimscheibe mit offenen Medullarrine und Canalis neuren-
tericus. Arch. Anat. u. Phys., 18S9. Anat. Abt., p. 159-172.
1906). Neue Beobachtungen iiber sehe fruhe
Entwickelungsstufen des menschlichen Eies. I. c, 1896, p. 1-30.
Areca. — Areca Nut; Betel Nut. The ripe seed of
Areca Catechu L. (Fam. Palmos). The areca palm is
a fine large tree, with smooth, graceful stem and a
handsome crown of long pinnate leaves. The flowers
are monoecious; the fruit is egg-shaped, with a fibrous
mesocarp and a hard stone consisting of the seed
and adhering eridocarp. This tree is a native of
India, the Sunda Islands, and probably of other
neighboring parts. It is cultivated there and else-
where in the tropics for the sake of its seeds, which
have been an article of Asiatic commerce for centu-
ries. There is still an enormous consumption of
them in China and India, chiefly as a masticatory;
for this purpose they are boiled, or used when fresh
and soft. They are often chewed with the leaves
of the betel pepper and lime. Their introduction into
European medicine is rather recent.
Areca nuts of our market consist of the kernel of
the seed only, the testa being removed with the peri-
carp. They are about two centimeters in diameter,
and about as long as broad. Their shape is between
spherical and conical, with a very blunt rounded
point, and a broad, flat, or sometimes depressed base.
The surface is of a cinnamon brown or grayish color,
and covered with a network of vein-like lines, which
radiate irregularly and spirally from the base toward
the apex. The albumin is very hard and bone-like,
and upon being sawed through presents a marbled
surface like that of the nutmeg, caused in the same
way, that is, by the infolding of the brown surface
layer of the seed (endosperm), which takes place under
the reticulated lines above described. The general
color of the section is whitish, the lines are brown.
The important constituent of areca is its alkaloid,
arecoline, which is oily, volatile, miscible with water
or alcohol, strongly alkaline, very poisonous, and
yields crystalline salts. Its other three alkaloids,
arecaine, arecaidine, and guvacine, are not poisonous,
and apparently not active. Areca also contains
fourteen per cent, of fixed oil, much tannin, and some
resin. Although the teniacidal properties of areca
reside in the arecoline, which is given to horses for
this purpose in doses of 0.03 to 0.06 gram (gr. ss. to
i.), this dose acting also as a cathartic, it is too poi-
sonous for use in human practice. A solution of
one-per-cent. strength is instilled into the human eye
as a niyni ic.
Powdered areca is frequently given as a teniacide,
in doses of ~>ij. to iij. (8.0 to 12.0). It also acts as an
astringent, so thai the usual accompaniment of a
cathartic must be resorted to.
H. II. RXFSBT.
Aretaeus. — It is uncertain at exactly what period of
time Aretaeus flourished, but the consensus of opinion
favors the belief that he lived from the middle of the
first century of our era to about the year 138. It is
also not known surely in what part of the ancient
world he practised his art, although it is generally
believed that the scene of his labors was located in
Italy (but not in Rome). His birthplace was in
Cappadocia, in Asia Minor. Notwithstanding the
fact that all the historical documents relating to
Aretreus have long since perished, we still possess
to-day, in almost their entire completeness, the
monuments of his remarkable genius. His great
treatise on the causes, symptoms, and treatment of
acute and chronic diseases, published in Latin in
Venice in 1552, is a model of carefulness and accuracy
in the descriptions of disease which it contains and in
the correctness of the diagnoses made. The methods
of treatment advocated by Aretauis would be pro-
nounced to-day unnecessarily energetic. A. H. B.
Argas. — A genus of ticks which contains species
which sometimes attack man, though they are
usually found on birds. A. americanus, or A. persieus,
is a pest in some parts of this country; this species is
said to be able to live four years without food. See
Arachnida. A. S. P.
Argasinae. — A subfamily of the ticks, Ixodidce,
which have the rostrum below the anterior margin
of the body. These arachnids are parasitic on warm-
blooded vertebrates, particularly birds. Argas is a
genus sometimes found on man. See Arachnida.
A. S. P.
Argemone. — Mexican Poppy. Of these plants the
most important thing that can be said is that they are
eminently worthy of careful investigation. They
were formerly regarded as constituting but a single
species, but are now known to represent several.
Of these, it is not certainly known which supplied the
material upon which previous studies were based,
so that we are able to speak only of the group in gen-
eral. They are very widely distributed through the
tropical and warm parts of America, as well as widely
introduced into Africa and tropical Asia. The plants
are of striking appearance, two or three feet high,
with large, broad, glaucous, prickly-toothed leaves,
large poppy-like white or yellow flowers and prickly
capsules. On being wounded, they exude a thick
yellow juice. They grow in great abundance in
waste places and over dry sterile soil. They have
been used medicinally in the form of an extract of
the whole plant, of the expressed juice, of the si
and of the oil expressed from the seeds. The juice
has been ignorantly used in venereal diseases, and in-
stilled into the eye for conjunctivitis. This juice
contains in very small amount an alkaloid which has
been claimed to be morphine. The fixed oil of the
seeds, yielded to the extent of about thirty-six per
cent., has received the most attention. It has been
clearly shown to be mildly cathartic, without bad
effect, in doses of four to five grams, and to form a
tasteless and not unpleasant substitute for castor
oil. Taken in larger doses it and the seeds are cinet-
ico-cathartic, with the symptoms of local irritation.
H. H. Rusby.
Argentum. — Silver, a metal of lustrous white color.
It is one of the elements, symbol Ag, atomic weight
107.88. Metallic silver is used in medicine only in the
shape of fine wireasasuture material, and occasionally
in the form of a thin leaf in surgical dressings.
General Medicinal Properties of Compoum>s
of Silver. — In medicinal dosage the most important
effect that follows persistent internal medication
with silver is the tendency to a bluish-black discolor-
524
REFERENCE HANDBOOK OK THE MEDICAL SOIEM CS
ArRrnium
alion of ( lie skin and mucous membranes. (See Argy-
ria ) This staining shows first cm the mucous mem-
hrancs, so tliat liy inspection of the inner surfaces of
I he lips anil of the fanees, during a course of medical ion
by silver, and by stoppage of the medicine upon the first
beginning of a bluish discoloration of those parts, no
serious risk of staining of the skin need he incurred.
As a rule, efficient dosage with silver can be maintained
for from one to three months before coloration begins.
In overdosage silver is a constitutional poison, im-
pairing nutrition generally, and deranging the nervous
System particularly. Therapeutically, impregnation
of the system with silver tends to oppose feebly the
onward march of certain diseases of the nervous
tern, such as epilepsy and tabes dorsalis. Bui
in the more intractable of these diseases, such a>
i abes, t he influence is so slight as to be of no value — if,
indeed, it exists at all — and in epilepsy other remedies
are far more potent. The use of silver for con-
stitutional effect is, therefore, in modern practice
quite abandoned.
Locally, the effects of silver compounds differ with
the individual preparations according to their solu-
bility, and will be described in connection with the
several compounds themselves.
The Compounds of Silver Used in Medicine. —
These comprise the oxide and nitrate. The cyanide is
also official in the United States Pharmacopoeia, but
for pharmaceutical purpose only.
Argenti Oxidum. — Silver oxide, Ag,0, is a heavy,
dark brownish-black powder, odorless, but of a
metallic taste. It is liable to undergo reduction upon
exposure to light. It is very slightly soluble in water
and is insoluble in alcohol. It should be kept in
dark amber-colored bottles, protected from the
light. This oxide readily yields its oxygen in pres-
ence of oxidizable matter, and hence should not be
triturated with any such material. It dissolves in
water of ammonia. From its comparative insolu-
bility this compound has little local effect, but when
swallowed, probably through chemical conversion, it.
is capable of absorption, and exerts the constitutional
effects of silver such as they are. In such operation
the oxide is thought to be less prone to discolor the
skin than the nitrate, but it is certainly not wholly
innocent of this tendency. Upon the stomach and
bowels silver oxide has quite a marked potency to allay
irritability, tending to quell vomiting, even in such
complaints as ulcer and cancer of the stomach, and to
control diarrhea when arising as a reflex of nervous
irritation. The principal employment of the medicine
is iu such disorders of the digestive apparatus. The
average dose is about gr. j. (0.06), best given in
powder or capsule. The pill form is bad, because
of the deoxidation of the compound by the organic
matter of the excipient, which reaction may even
be attended by explosion. Gum arabic is recom-
mended as the least objectionable excipient.
Argenti Nitras. — Silver nitrate, AgN0 3 . This title
in the U. S. P. signifies the salt in crystals. These
crystals are smafl, transparent rhombs, originally
colorless, but gradually becoming grayish-black on
exposure to light and air. They are odorless, but
have a strong metallic taste. They dissolve freely in
water, in twenty-four parts of cold alcohol, and in
five parts of boiling alcohol. When heated to about
200° C (392° F.), the crystals fuse to a faintly yellow
liquid, which, on cooling, congeals to a purely white,
crystalline mass. Silver nitrate should be kept in dark
amber-colored vials protected from the light. These
crystals constitute the purest form of the nitrate, and
are used for internal administration or for the making
of solutions.
_ Argenti Nitras Fusus. — Moulded silver nitrate, fused
nitrate of silver. Lunar caustic. The crystals are
melted by heat, and the fused sa.t poured into moulds
where it sets on cooling. But inasmuch as the pure
nitrate is, when fused, inconveniently brittle, the
Pharmacopoeia provides for a trifling admixture of
silver chloride, which is a tough compound. To
this end about four per cent, of hydrochloric acid is
added to the melted crystals, whereby a small portion
of the nitrate is converted into chloride. Reaction
ha\ ing ceased, the mixed mass is ready for moulding.
Lunar caustic is cast in narrow cylindrical sticks
which are hard, brittle, and, when freshly made, white
i u color. As commonly found, however, I hey are gray,
or even blackish, through chemical reaction with mat-
ters present in the atmosphere. Fused nitrate of silver
should be used only for its legitimate purpose, that of
external application. The sticks should be kept,
protected from the light.
Argt nli \ itras Mitigatus. — .Mitigated silver nitrate.
Silver nitrate and potassium nitrate, the latter in
double the quantity of the former, are melted to-
gether by heat and the fused mass moulded into sticks
like those I'f the simple moulded silver nitrate. The
sticks of the mitigated nitrate resemble those of the
pure nitrate except that they are granular rather than
fibrous in texture. They should be kept protected
from the light. The sticks dissolve freely in water and
possess the same properties as the undiluted lunar
caustic, only in milder degree. They are used only
for local application.
Silver nitrate differs from the oxide in the essential
particular of free solubility, on which property depend
the most valuable medicinal virtues of the salt. The
most important reactions of the nitrate are that its
solutions are precipitated by soluble chlorides to
form the very insoluble salt, silver chloride. This
reaction is one of the most delicate in chemistry, and
since traces of chlorides are present in almost all
natural waters, the use of distilled water is necessary
for solutions of siver nitrate, if a clear, bright solution
be desired. Silver nitrate also reacts on organic
matter generally, suffering decomposition, and form-
ing with the organic substance compounds insoluble
and acquiring a rusty brownish-black color under
the action of light. Hence sticks of lunar caustic
grow gray and black on the surface by keeping, by
reaction with the organic dust of the atmosphere, and
solutions of silver nitrate deposit a fine black sedi-
ment and stain textile fabrics and skin. The stain on
the skin, if recent, can be removed fairly well by
rubbing with a moistened lump of potassium cyanide,
and washing — always remembering the very irritant
and poisonous character of such cyanide. But if the
stain be old, and fixed by exposure to sunlight, the
cyanide fails, and the following means may be re-
sorted to: Moisten the stains, drop on them a little
tincture of iodine, and then wash in a 6 per cent,
solution of sodium hyposulphite. Or, very efficient,
mix in a saucer a few bits of iodine with a little water
of ammonia; rub the stains quickly with the resulting
preparation, and immediately wash both skin and
saucer wdiile they are still wet. This latter precau-
tion is necessary, since the compound of iodine and
nitrogen spontaneously explodes upon slight agitation
when dry. Other reactions of silver nitrate are its
precipitation by sulphuric, phosphoric, hydrochloric,
and tartaric acids and their salts; by the alkalies
and their carbonates, lime water, and the vegetable
astringents, and arsenical and albuminous solutions.
Silver nitrate is an irritant astringent, with also the
peculiar specific effects of silver compounds already
detailed, viz., the allaying of gastric irritability, and
the induction of certain constitutional control over
nervous disease. The local effects are the more
important and are as follows: The salt readily com-
bines with albumin to make an insoluble compound,
the albuminate of silver; hence, when in strong solu-
tion or in solid stick, its application to the surface of a
mucous membrane or of granulation tissue produces a
white streak of cauterization, which, by the insolu-
bility of the compound formed, limits the action of
525
Argentum
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
the caustic to the production of such shallow slough.
Concentrated applications to the skin speedily blacken
the epidermis, and, more slowly, raise a blister. In
solutions less than ten per cent, in strength the salt
is hardly caustic, but acts only as an irritant astrin-
gent. When swallowed, quite small doses act locally
like the oxide, while large dosesproduce irritant poison-
ing. Therapeutically, local applications of silver ni-
trate judiciously made have a marked tendency to
promote absorption in such tissues as are capable of
undergoing this process; to induce healing; to limit
and abate the catarrhal process; to destroy skin para-
sites, though not very searchingly; and to neutralize
the virulence of specifically noxious pus.
The medicinal uses of silver nitrate are such as may
be deduced from the foregoing. Internally the medi-
cine may be given, for constitutional or local effect, in
doses of about gr. £ (0.01) in pill or solution. In
neither way of giving does the salt probably reach
the stomach as nitrate; for, if in solution, a medicinal
dose must almost certainly be decomposed in the
swallowing, and, if in pill, be acted on similarly by
the necessary organic matter of the excipient. To
obviate this effect as far as possible in the case of
pills, it is advised that bread-crumb be particularly
avoided as an excipient, beeause of its containing a
soluble chloride (common salt) as well as organic
matter, and that some vegetable extract, or a dry
powder made sticky by a minimum of gum, be selected.
In any case the crystallized silver salt should alone
be prescribed. Externally, silver nitrate may be
used as a caustic, but only where a superficial
effect is wanted, as for the destruction of the lining
membrane of a cyst. The fused stick is in such cases
used, its moistened surface being swept over the sur-
face to be destroyed. More common is the applica-
tion to promote absorption, as in case of exuberant
granulation tissue or trachoma bodies; to determine
healing, as in unhealthy ulcers; or to shorten and
abate the course of a catarrh. For such purposes
various strengths of the nitrate are used, from appli-
cation of the pure or mitigated sticks of lunar caustic
to that of solutions of not more than the one-fifth of
one per cent, strength. To determine absorption the
stronger applications are necessary, to control catarrhs
the weaker, but in all cases care should be taken not
to overdo the matter, and, by too strong or too fre-
quent application actually to interfere through excess
of irritation with healing or with resolution. In the
case of catarrhs, moreover, the remedy should not be
used at all until the second stage of the process is
reached, as betokened by the establishment of the
catarrhal secretion and abatement of the initial pain
or sensitiveness. Then, too, the strength of the
application should be adjusted to the different degrees
of sensibility of the different mucous membranes;
for while the comparatively insensitive membranes,
such as those of the fauces or vagina, may take a five-
per-cent. solution, or even stronger, hardly more than
the one-tenth of this strength can be applied without
undue irritation to the nasal passages or to the male
urethra. ^Tien a very brief action is wanted, the
application of silver may be followed immediately by
one of a solution of common salt, which salt immedi-
ately precipitates all excess of nitrate as the insoluble
and therefore inert compound silver chloride.
Argenti cyanidum, silver cyanide, AgCN, is an
insoluble white powder not used in medicine, and
official only for the making by the pharmacist of
diluted hydrocyanic acid.
Besides the foregoing, a number of unofficial
preparations of silver deserve brief notice.
Argyrol. — Silver vitelline. A salt solution of
vitelline, a derived protein obtained from gliadin, is
precipitated by silver oxide. Such precipitate —
silver vitelline — properly dried, appears as a dark-
brown powder. The substance contains from twenty
to twenty-five per cent, of silver, and is remarkable
for being extremely soluble in water, while at the
same time it does not precipitate albumin or
sodium chloride, and is wholly unirritating. Its
solution also penetrates albuminoid tissues very
readily and thoroughly. Silver vitelline thus pos-
sesses all the desiderata for an ideal silver preparation,
and has been used with great success as a local appli-
cation in inflammations of the mucous membrane of
the eye, ear, nose, vagina, urethra, and bladder.
It is employed in aqueous solution ranging in strength
from one-tenth of one per cent, to twenty-five per
cent, and upward, according to the character and
sensitiveness of the part. Even a ten per cent,
solution applied as an injection in acute gonorrhea
produced no irritation (Christian).
Collargol. — Colloidal silver. This is a bluish-green
substance obtained by precipitating with silver nitrate
a mixed solution of ferrous sulphate and sodium
citrate. Collargol contains about eighty-five per
cent, of silver, dissolves in twenty-five parts of water
forming a dark reddish-brown solution, and is easily
decomposed. Its aqueous solution, on standing,
deposits a small sediment of insoluble silver.
Collargol introduced into the general circulation is
said to exercise curative power over the conditions of
general septic infection, whether by action on the
microorganisms themselves or on their toxins is not
clear. At the same time the remedy is non-poison-
ous and, being rapidly eliminated after absorption,
does not produce argyria. The only untoward effect
observed has been a slight chill and rise of tempera-
ture, but even this is not seen if (using by intraven-
ous injection) care is taken that the solution be free
from sediment.
Collargol may be administered by inunction or by
intravenous injection. For the latter method a
carefully prepared, freshly made solution in distilled
water is to be used, of a strength of one-half to one
per cent. If a sediment forms, the supernatant
liquor must be decanted. Of such a solution from
half a fluidram to five fluidrams may be injected
directly into some superficial vein once or twice daily,
or every two or three days. The more common
method of administration, however, is by inunction.
For this purpose a fifteen per cent, ointment is used,
of which the quantity of from thirty to forty-five
grains is rubbed thoroughly into the skin of the inner
side of the arms or thighs, or of the back, from one
to three times daily. Collargol ointment decom-
poses readily and should not be exposed to the air.
An ointment should not be used that shows white
crystals on the surface, or that fails to color the skin
black on inunction. An ointment, "Unguentum
Crede" contains fifteen per cent, of collargol in a mix-
ture of lard, wax, and benzoic ether.
Urol. — Silver citrate, Ag,C H 5 O 7 . This compound
is a fine dry powder without taste or smell, very
slightly soluble in water. Its solution is immediately
decomposed by organic matter. Like silver vitelline,
it is non-irritant and penetrating, and has been pro-
posed as a surgical disinfectant and for injection in
gonorrhea and cystitis. The strength of solution
ranges from 1 to 4,000 to 1 to 10,000.
Actol. — Silver lactate. AgC 3 H 5 3 . This compound
is a white powder, without taste or smell, and soluble
in from fifteen to twenty parts of water. It is
a powerful germicide, and penetrates tissues, although
decomposed by contact with the same. It is used as a
surgical antiseptic, and strong, even saturated solu-
tions may be applied to infected parts. Ordinary
strengths are from 1 to 100, to 1 to 2,000 parts
of water.
Argentamin. — This name is given to a solution of
silver nitrate (10 parts) in a ten-per-ccnt. aqueous
solution Of the organic base ethylendiamine. It
is a clear fluid, strongly alkaline, and is devised to
give a non-poisonous and unirritating antiseptic so-
lution which shall not precipitate albumin. It is
.v_v,
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Areyrla
used in the anterior urethra in 0.25 to 1 per cent,
solution; in the posterior urethra in from i to 4 per
solution; and in the eye in ."> per cent, solution.
Argonin. —Casein silver. This name is given to a
body obtained by precipitating with alcohol a mixed
tion of silver nitrate and a sodium compound of
casein. Argonin is a white powder, neutral in reac-
tion; insoluble in cold water, hut readily soluble in
u or albuminous water. Solutions must be kept
away from exposure to light. It has been used in
g >rrhea in solutions of from 1 to 7 parts in 1,000
Of water.
Protargol. — This name is given to a silver albumose
containing eight per cent, of silver. It is a yellow
der, freely soluble in water; unaffected by heat.
albumin, or sodium chloride in weak solution, and
wholly unirritating. It may be used with great
freedom as a local application, being employed in
.solutions varying in strength from 0.25 to lit per cent.
AVbargin. -Gelatosilver. A compound of silver
nitrate with gelatose, containing about fourteen
per cent, of silver. It is used as a substitute for
silver nitrate.
—Colloidal silver oxide. L'sed as a
substitute for the ordinary compounds of silver in
treatment of inflamed mucous membranes, and as an
intestinal antiseptic; in diseases of the eye and of
genitourinary tract, it is used in 5 to 25 per cent.
colloidal suspension; on other mucous membranes in
10 to 50 per cent, colloidal suspension.
Hcgoimn, contains about seven per cent, of organ-
ically combined silver and is used as a substitute
for silver nitrate.
Ichthargan. — Argenti ichthyol sulphonas, silver ich-
ilate, said to contain thirty per cent, of metallic
silver, and fifteen per cent, of sulphur in organic
combination. It is chiefly used in gonorrhea in 0.04-
tii 0.2 per cent, solution; in posterior urethritis in
3 percent, solution; and in trachoma in 0.5 to 3 per
cent, solution.
tfovargan. — Argenti proteinas, silver proteinate,
contains ten per cent, of silver. It is said to be use-
ful in gonorrhea, especially in the first stage.
R. J. E. Scott.
Argyria. — This is a term (also argyrism, argyrosis,
argyriasis) applied to the discoloration of the skin and
certain other tissues of the body resulting from the
long-continued medicinal use of soluble silver salts,
and caused by the deposit in the affected tissues of
metallic silver, or some of its lower compounds, in a
state of minute subdivision. The same condition may
be produced by the absorption of soluble silver com-
pounds from mucous membranes or wound-surfaces.
or from the entrance of silver-dust through the skin
or respiratory tract.
Clinically the condition is characterized by a slaty
or grayish-brown, or in the most severe cases, by a
bluish-gray discoloration of the skin (Moor's skin),
conjunctiva?, and visible mucous membranes. When
caused by the internal administration of silver the
first signs of the pigmentation appear in the form of a
blue or violet line on the gums, resembling the lead
line but usually more violet in color. The internal
organs, with the exception of the central nervous
sy.-tem, suffer a similar pigmentation. The discolor-
ation of the skin appears to vary in different regions,
being less intense where the horny layer is thick, as
in the palms of the hands and soles of the feet; and of
greater intensity where the horny layer is thin. The
pigmentation first appears in those portions of the skin
exposed to light. The hair and nails are not affected,
but the bed of the latter is usually deeply pigmented.
Scars formed before or during the period when the
silver was taken are pigmented, but those formed
after the cessation of its use remain white. The
apparent intensity of the pigmentation also varies
with the tempera t ur.' ,.i the surface of the body, being
mosl marked in the cold, and greatly decreased when
the skin is warm and flushed,
The pigmentation increases as long as the internal
use. of the silver salt is kepi up and for some time
after its use is stopped. Its degree and extent are
in direct proportion to the amount used and the
period of time through which it- administration is
extended. It is essentially a chronic process. The
n coloration never disappears, and il is doubtful if the
silver deposit is ever removed from the body, though
it has been claimed in a number of instances that
after the lapse of years a decrease of the color has
taken place. (See author'-, case mentioned below.)
The condition has been known since the alchemistic
period when the internal use of silver salts was very
popular, and descriptions which undoubtedly refer to
argyria exist in the literature of that time. The first
i e mentioned in medical literature is the one ob-
served by Schwediauer and reported by Fourcroy in
1791. In the early part of the nineteenth century
numerous cases were described, and the number of
these increased greatly about the middle of the cen-
tury when the use of silver nitrate in epilepsy and
tabe- reached it- greatest popularity. At that ti
a generation of individuals affected with argyria may
be said to have arisen, and frequent examples of the
condition came to the postmortem tables of the
great European hospitals. That generation has
now practically disappeared, and cases of general
argyria resulting from long-continued use of silver
salts have been of very rare occurrence in the last gen-
eral ion. In recent years there has been apparently an
increase of cases of argyria as the result of the careless
use of the newer silver preparations, particularly in
geni to-urinary, ophthalmic, and otolaryngological
practice. The present cases of argyria are for the
greater part localized discolorations resulting from
local medicinal applications of silver nitrate, or
from absorption through the skin or respiratory
tract of silver dust, as in the case of workmen who
file, grind, or polish the metal. Three forms of argyria
may be distinguished clinically: argyria universalis,
argyria localis circa mscripta, argyria local is dissi m inala.
Argyria Universalis. — The condition of universal
pigmentation of the skin and mucous membranes is
usually caused by the long-continued internal use of
silver nitrate but may be due to long-continued
occupational contact with silver, or to prolonged
local use. The discoloration develops independently
of any preexisting condition of the skin or body
tissues, and its intensity is in proportion to the amount
of silver absorbed and the period of time covered by
its administration. As a rule the pigmentation ap-
pears several months after the use of the silver is be-
gun, and develops slowdy. As the discoloration is
usually not observed until it has reached a certain
degree of intensity, it is impossible to speak with
certainty of the exact course of the pigment deposit.
It has been claimed that a blue or violet line on the
gums is the earliest symptom, but this does not oc-
cur in all cases. When the argyria is the result of the
internal use of silver the blue line on the gums is
almost always present and is an important diagnostic
sign. As it usually appears before the pigmentation
of the skin has developed it should be regarded as an
indication for stopping the use of silver. The degree
and extent of the pigmentation of the skin vary in
different cases: the face, thorax, and abdomen may
show it earliest and to the greatest degree while the
extremities may remain unaffected. The pigmenta-
tion of the skin appears in patches, first over areas
exposed to the light; the patches become con-
fluent until ultimately the entire surface may be-
come pigmented. The discoloration usually increases
for some time after the use of the silver has been
discontinued owing to the presence of unreduced
silver still in the body. The mucous membranes
527
Areyrla
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
may show no discoloration in intense argyria of the
skiii; while on the other hand a marked degree of
pigmentation may exist in the internal organs without
any great change in the skin. A metallic odor of the
breath accompanied by a stomatitis with or without
salivation has been described, but the occurrence of
these symptoms is very rare or doubtful. There are
no symptoms coincident with or following the con-
dition that can be said to be the direct result of the
deposit of the pigment.
The total amount of silver nitrate which must be
taken in order to produce a well-marked case of
argyria varies greatly, the lowest limit being placed at
live to thirty grams. The administration of the metal
must be extended through a considerable period of
time. Large doses given within short periods pro-
duce symptoms of poisoning without the deposit of
pigment, while minute doses administered for many
months or years produce the most intense discolora-
tion. Slight degrees of argyria have been produced by
the administration of two grams only (thirty grains).
Lionville reported a case in which the total amount of
silver nitrate used was only seven grams, but there
resulted an intense argyria of the internal organs, the
skin over the abdomen alone being slightly discolored.
The same writer also claimed to have seen in another
case the appearance of the blue line on the gums after
the use of thirty pills each containing 0.01 gram of
silver nitrate. The skin in this case was not affected.
It is, of course, evident that it is the amount of
silver absorbed and not the amount taken into the
body that influences the degree and extent of
pigmentation. With the minute doses of silver nitrate
now given and the relatively short periods of
administration there is but little danger of the
production of argyria; but if the salt is given for
any considerable period, the possibility of its
occurrence must always be borne in mind and the
patient duly informed.
A general argyria may also be produced by the
local absorption of silver nitrate, as in the long-con-
tinued use of applications of the salt in affections of
the throat, eye, and urethra. It may also be caused
by the long-continued use of hair-dyes containing
silver preparations. Lavage of the stomach and
large intestine with dilute solutions, when continued
for long periods of time, may also lead to general
pigmentation. These cases are very rare. Neu-
mann observed a case in which after twelve lavages
of the stomach with a solution of 1.45 gram of silver
nitrate to ninety of water, an intense argyria of the
skin of the face, head, neck, thorax, and back
was produced. The skin of the extremities was
but slightly discolored, and the mucous mem-
branes remained normal. In a case observed by
the writer the daily irrigation of the colon with
a one-per-cent. solution of silver nitrate led in
eighteen months to a very marked grayish-brown
discoloration of the entire skin, which was most in-
tense over the face and extremities. The patient
was a lad of fourteen years, suffering from a chronic
ulcerative colitis following measles. At the beginning
of the treatment there was present a severe grade of
anemia with very marked pallor of the skin, the con-
dition having persisted for about two years. There
were also very severe nutritional disturbances witli
stunting of growth and delayed puberty. After six
months he had so improved that he was allowed to go
home. At this time no discoloration of the skin was
noticeable. The treatment was continued during
his stay at home, and when he returned three months
later the pigmentation of the skin was the first thing
noted, although neither the patient nor his friends had
observed it. The visible mucous membranes, especi-
iilly those of the anus and rectum, were also discolored,
but no line could be seen upon the gums. The treat-
ment was continued for about nine months longer.
During this time the discoloration of the skin increased.
He was then discharged as cured. Six years after, he
had become very stout, having matured rapidly.
The pigmentation while still present had so decreased
in intensity that the patient declared that it
had entirely disappeared. It is probable that the
total amount of silver in his body had not decreased,
but that the increase of tissues made it less prominent.
Continual exposure to atmosphere laden with silver
dust, as in the case of silver grinders and polishers, may
lead to a general argyria through absorption from the
lungs (see below).
There are no other pathological changes associated
with general argyria that can in any way be said to be
secondary to it. Edema of the skin and degenera-
tive changes in the kidneys have been thought to be
caused by the deposit of the pigment, but there is no
definite evidence to this effect. Chronic interstitial
changes in the kidneys, liver, and lungs, associated
with arteriosclerosis are believed by some writers to
be due to the deposit of silver in these tissues; but
the etiological relationship of the silver deposit to
those changes has not been definitely shown. Large
or frequently repeated doses of silver nitrate may
lead to a severe gastritis or even to ulceration of the
stomach. Death may result from very large amounts,
as in a case reported by Scattergood of a child whose
death was caused by the accidential swallowing of a
portion of a stick of the nitrate which had been used
for painting the throat.
Argyria Localis Circumscripta, — The local absorp-
tion of silver may result from the continued use of
nitrate of silver applications in solution or in the solid
stick to mucous membranes or to a wound surface.
The single application of the salt leads usually to a
precipitate, which is cast off with the superficial
slough; but after repeated applications the salt pene-
trates more deeply into the subepithelial tissues, where
it is chemically changed and precipitated in the form of
minute black granules, which, according to their
number, lead to a greater or less pigmentation. The
discoloration is confined to the seat of application and
is as permanent as that of general argyria. Such
local pigmentations may occur in the conjunctiva",
urethra, throat, gums, tongue, etc. In very rare
cases the local condition has been followed by general
arg3 r ria. This is most likely to occur in the treat-
ment of chronic affections of the mouth and throat,
where some of the silver application may be swallowed
and absorbed through the stomach.
Argyria Localis Disseminata. — In workmen who are
engaged in cutting or polishing silver there may
appear in the exposed portions of the body, must
frequently in the hands and arms, grayish or bluish
spots. These may also appear in the face. The
spots are pale in the beginning, but gradually increase
in intensity and remain unchanged throughout the
life of the individual. The pigmentation develops
from small particles of silver which either penetrate
or are rubbed into the skin. The condition is said
to be not so frequent in silver polishers as in workmen
who cut or grind the metal. Long-continued expo-
sure to an atmosphere laden with silver dust may
lead to absorption of the metal through the respira-
tory tract and to a general argyria. Such an occur-
rence can be explained only by the assumption that
the silver particles taken up by the lung are dissolved,
and passing into the general circulation are precipi-
tated in other parts of the body in the shape of tine
black granules. As a support to this view is the
fact that silver cannulas, when kept in tracheotomy
wounds for long periods of time, show signs of gradual
dissolution. Silver wire or plates remaining in the
tissues for a long period of time may become disin-
tegrated and the local lymph nodes show a heavy
deposit of black granules. In the case of a mattress
of silver wire retained for twenty years at the site of
a hernial operation the writer has seen extensive
argyrosis of the regional lymph nodes, the deposit of
528
REFERENCE BAND-BOOK OF THE MEDICAL SCIENCES
Argyria
the pigment following the endothelium of the lymph-
sinuses.
Microscopical Appearances.— In general argyria the
pigment appears microscopically as very fine blacl
granules which are deposited in the connective-tissue
stroma near the walls of the capillaries; and maj 1"
id in the ill 'i'n lis, mucosa of the mouth, larym
tine, kidney, intima of the larger vessels, adven-
,; the mailer ones, mucous glands, peritoneum,
icles, bone marrow, liver, spleen, lymph glands,
, horoid plexus. The epithelial structures, brain,
•Is, muscle fibers, cartilage, bone, hair,
nails are not affected. In early stages the leuco-
are said I" contain silver-granules, being the
i : lis to 'how them.
In the .-~ k i ! i the deposit of the pigment is most
marked in the stroma of the papillse just beneath the
.■ind around the glands. Toward the subcutane
tissues the pigmentation decreases in intensity.
In the intestine the basement membrane of the
mucosa, the connective tissue of tl"' muco a a
submucosa, together with the Iymphadenoid struc-
how the pigmentation in the greatest degree.
In the kidneys the deposit is greater in the glomeruli,
especially about the afferent vessels, and occurs to a
much less degree in the intertubular connective
■sss.^f^^*'
Fh:. 304. — Silver Deposits in the Tunicie Propria? and in the
Connective Tissue of the Renal Papillie, in a Case of General
Argyriasis. X230. (Aschoff.)
tissue. In the liver the pigment is found in the con-
nective tissue about the blood-vessels and bile ducts
and in the intima of the larger branches of the hepatic
veins. Of the other organs, the mesenteric glands, the
spleen, choroid plexus, and the testicles show the
greatest intensity of pigmentation.
The microscopical sections of the spots found in the
skin of silver workers present a somewhat different
appearance from that of general argyria. The
process is analogous to that of tattooing: the small
particles of silver which have been rubbed into the
skin become surrounded by a connective-tissue cap-
As a rule the silver granules are larger than
those found in general argyria. In recent cases
silver particles may be found in the epithelium, but
the epidermis is never involved in argyria due to the
internal use of silver. In the neighborhood of the
larger particles smaller granules are found scattered
throughout the connective tissue, and the elastic
tissue of the papilla? and corium is colored brown or
black by a very fine precipitate of silver granules
similar to that found in general argyria. As in the
latter condition, these granules are most abundant
just underneath the rete. Fig. 273 shows a section
taken from such a silver spot. The elastic tissue
network of the papillse and corium i ontains through-
out a fine precipitate of silver granules, while coa
granules are seen at the periphery of the papillse and
t;ii tered through the coi ium.
With the exception of the connective <
found in silver spots the pre i nci ol thepigmenl gi
ules dors not seem to lead to any ei lat patho-
logical change. 1 1 has been claimed i hal inter
nephritis has followed the deposit of the pigment in
the kidney-, but it is much more probable that the
two processes were coincident, or wholly unrelated.
The problems of thepathogi irgyria remain
he present day unsettled. Animal experiments
have aided but little in the solution of the que tion,
as the artificial argyria produced in animals differs
very greatly in its localization and intensitj from the
argyria of the human body. Cone, ruing the patho-
genesis of the latter various views are held. The
olilest of ll i the one introduced by Kramer and
supported by Frommann, which holds that the silver
nil rate taken into the body is changed by the stomach
and intestinal juices into a soluble silver albuminate,
which is absorbed from the intestines into the circula-
tion and is ultimately passed with the lymph through
the walls of the blood-vessels into the tissues, where
it is precipitated in the form of fine granules.
Opposed to this view is the theory supported by
Virchow and Riemer that the silver nitrate is reduced
in the intestinal tract and taken up from the latter
place in the shape of line granules, partly through the
lymph and partly through the blood, into the general
circulation, where by metastasis these are deposited
in various parts of the body. Jacobi showed that the
reduced particles of silver cannot penetrate the epi-
thelium of the intestine, and further proved experi-
mentally that the greater part of the silver nitrate
taken into the body is not reduced in the intestine,
but is changed to silver chloride and albuminate, and
absorbed as such, the reduction taking place in the
tissues. Loew held that the reduction of the silver
held in solution in the circulating blood is the result,
of the action of living cell-protoplasm, most probably
that of the endothelium. On the other hand, Robert
holds that the reduction takes place only in certain
organs — the liver, kidneys, papillse of skin, and
intestinal wall — and that the reduced silver is carried
elsewhere by leucocytes, for the greater part to the
spleen, lymph glands, and bone marrow, where it is
ultimately deposited in the connective tissue.
Through "the agency of the wandering cells containing
silver granules a part of the silver may be removed
from the body. The reduction in the wall of the
intestine he holds to be clue to the absorption by the
intestinal wall of certain gases, hydrogen and hydro-
gen sulphide, which are formed in the intestinal tract
by the growth of anaerobic germs, the hydrogen
leading to a reduction of the silver, and the hydrogen
sulphide to the formation of a silver albuminate
sulphide. The reduction of the silver in the papillse
of the skin Robert holds to be due to or associated
with the process of cornification, which he regards as
a reduction process. He explains the fact that
argyria in human skin is of so much more constant
occurrence than in the skin of animals by the assump-
tion that the process of cornification takes place to a
much greater degree in human skin. This theory,
however, does not receive the support of the actual
facts.
In the light of our present knowledge the most
reasonable hypothesis is that the silver is absorbed
from the intestine into the general circulation in the
form of a soluble albuminate which is taken out of the
blood and reduced by the protoplasm of the endothe-
Vol. I.
34
529
Argyrla
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Hal or perithelial cells, and secreted by these cells into
the neighboring connective tissue, where it may
remain or be further transported by means of wander-
ing cells. The deposit of the silver in certain parts
of°the bodv cannot be explained by the theory of
simple metastasis, and as it has been established
beyond doubt that the endothelium in different parts
of the body has a selective action, it seems to the
writer that the best hypothesis for the explanation of
the pathogenesis of argyria is the theory of endo-
thelial-cell activity. In surfaces exposed to light
reduction may take place as a result of photochemical
action, but in the internal organs it must be the
result of cell activity.
The chemical nature of the fine silver granules in
the tissues has not as yet been definitely determined.
According to Kobert, the pigment is a loosely held
organic compound of silver and presents the following
reactions: The granules are insoluble in acetic and
dilute mineral acids, fixed alkalies, and ammonia;
they lose their black color but do not vanish in strong
nitric acid and in moderately strong solutions of
potassium cyanide; the black color may be restored
by means of hydrogen sulphide. Substances which
decolorize the organic pigments have no effect upon
the silver granules. If a piece of tissue heavily
pigmented with silver is warmed with nitric acid until
it loses its color and the acid then filtered off, the
filtrate will contain no silver, the metal remaining in
the decolorized tissue. Other investigators hold that
the pigment is metallic silver or a low oxide (AgO, or
AgOJ.
The amount of silver deposited in the tissues is very
small compared to the amount taken into the body.
Experimental analyses of tissues showing a high
degree of argyria have yielded only minute quantities
of silver. Frommann obtained from 760 grams of
liver which had been preserved in alcohol only 0.009
gram of silver chloride, equalling 0.0068 gram of
metallic silver. Versmanns found the same amount
of metallic silver in 14.1 grams of dried liver, and in
8.6 grams of dried kidney 0.053 gram of the metal.
Symptoms. — Pigmentation is the essential symp-
tom. Gastric ulcer, chronic nephritis, neuritis,
headache, loss of memory and mental depression
have been associated with the condition. The
relation is not clear. In the case of mental depression
and melancholia the psychical effects of the disfigure-
ment may be responsible.
Diagnosis. — The discoloration of the skin may be
mistaken for cyanosis or for the pigmentation of
Addison's disease. The blue line on the gums may
be confused with the lead line. If the history is not
clear, small bits of the skin or gum should be excised
and tested. On treating with potassium cyanide or
concentrated nitric acid the pigment granules dis-
appear, but reappear upon the addition of ammonium
sulphide.
Treatment. — Since the silver pigment is deposited in
the connective tissue outside of the vessels, its com-
plete removal during the life of the affected individual
is very improbable. Through the agency of wander-
ing cells a very slow removal may take place, but it is
doubtful if in well-marked cases this leads to any
noticeable decrease in the degree of pigmentation.
Cases of recovery have been reported, but they are
doubtful. Rogers affirms that blistering will lighten
the color very much, and Eichmann claims to have
produced a cure by means of potash baths. Yandell
has reported two cases in which large doses of potas-
sium ioditle were given in connection with mercurial
vapor baths for several months in the treatment of
syphilis with complete cure of the existing argyria,
the pigmentation fading very gradually. In spite of
these reported cures the great majority of cases arc
unaffected by treatment, and the affected individual
canies his pigmentation to the end of his life. In
ca es similar to the one reported by the writer in
which the argyria is produced at an early period of
life before puberty, the later increase of tissues may
lead to an apparent decrease in the intensity of the
pigmentation. The prophylactic treatment consists
in the exercise of great care in the administration of
silver salts. Very small doses should be given, and
for a very short time. Prescriptions of silver com-
pounds should not be given to patients, and in all
cases warning should be given as to the danger
attending their use. De Schweinitz and others have
given warning concerning the prolonged use of
protargol. Aldred Scott Warthin.
References.
De Schweinitz : Trans. Am. Ophthal Soc, 1903.
Eichmann : Husemann's Toxicologie, p. 871.
Fourcroy: La medecine eclairee par des sciences physiques,
Paris, 1791.
Frommann: Virchow's Archiv., 1S59, xvii.
Jacobi: Arch. f. exper. Path., 1S7S, viii.
Kobert: Arch f. Derm. u. Syph., 1S73, xxv.
Kramer: Das Silber als Arzneimittel betrachtet, Halle, 1S45.
Liouville: Gaz. de med. de Paris, 186S.
Loew:Pfliiger's Archiv. f. d. ges. Physiol., 1S94, xxxiv.
Riemer: Arch. d. Heilkund., 1875, xvi.
Rogers: Cited in Wood's Therapeutics.
Scattergood: Brit Med. Jour., 1871.
Versmanns: Virchow's Archiv., 1S59, xvii.
Virchow: Cellularpathologie, 1S71, p. 250.
Yandell: Amer. Practitioner, 1872.
Aristol. — See Thymolis Iodidum.
Aristolochiaceae.— (The Serpentaria Family). A
small family of some five genera, widely distributed
over the warm parts of the earth. A species of Aristolo
chia produces one of the largest of known flowers,
some five feet in length. Many species have been
ignorantly reputed as antidotes to serpent poisons.
Medicinally, the family, rich in volatile oils and resin,
is well represented by Virginia, Texas, and Canada
snake roots. Many species are used in native practice
as vulneraries. H. H. Rusby.
Arizona. — This ancient land and new State, situated
on the Mexican border in the extreme Southwest
corner of the U. S., offers to the archeologist, the
geologist, and the climatologist a field of study if
surpassing interest. Here prehistoric races once
developed a civilization of no mean order, as evidenced
by the traces of great public works still remaining.
Here later came the Indian races, the ancestors of
those still found here, in various degrees of civiliza-
tion, to the number of 24,000 or more. Then came
the intrepid and restless Spanish explorer and
conqueror, accompanied by the Jesuit or Franciscan,
exhibiting a self-denial and heroism only equalled by
his brother in the Canadian wilderness, and devoting
his energies to the bringing under Christian denomina-
tion the native whom the Spanish warrior had
subdued to Spanish rule.
Later, the Presidios, established by the Spaniards,
lose their hold, and the Friars are expelled. Indian
wars arise, and the American comes. The Mexican
War follows, and Arizona becomes American territory.
After a stormy period of Indian and border warfare,
with all the excesses incident to the occupation of
new territory by a motley crowd of adventurers, the
territory becomes more peaceful and grows in popula-
tion and prosperity until at last, with a population of
204,354 (1910), it arrives, in 1912, to the dignity of
statehood.
Arizona, with the adjoining New Mexico, have been
aptly called the Egypt and Arabia of America, for
both in archeological interest and climatic character-
istics, the resemblance is close. Especially is south-
ern Arizona comparable with upper Egypt in the
lowness of its humidity, the clearness of its atmos-
phere, and the absence of vegetation. In general,
530
REFERENCE HANDBOOK OF TIIK MKDIC'AI, SCIKXCKS
Arizona
the climate of Arizona is a warm and very dry one.
\, ., certain season of the year (between Ma\ anil
October), the heat is extreme; and ai another season
(April i" June), there is no rain. The thermometei
. high as 130 F. and as low as —8 ' I''.
1 1 !,. rainfall varies from two to two and one-half
Inches at various points in the lower Gulf valley and
on the western borders, to twenty-five to thirty
inches on the plateau and in the mountains. Tins
scanty rainfall i~ distributed from July to April, with
marked increase from July to September, and a
lesser increase in December. In the holiest portions
ne t ru e desert on the Mexican border, the daily
maximum temperature is about 1 10° F., but owing to
the rapid radiation, the temperature frequently falls
,i 50° at night. We may have ice at high levels
ight and at midday the thermometer may reg-
ister over 100° F. Such great diurnal variations of
ure are characteristic of desert climates,
and we have the same phenomenon in Egypt. These
[en changes are not without risk, and one must
ireful as to underclothing. It is safe to wear
nels the year around.
fhe sunshine is abundant. The proportion of
perfectly clear days in the year varies at different
points, from one-half to two-thirds, and of the rest
more than one-half are without brilliant sunshine
part of the day.
In so large an area as is embraced in Arizona, with
its varied topography, there is, of course, a wide
variety of local climate, which is but the modification
the general climatic characteristics, mentioned
:ihi ive, by the latitude and local conditions of altitude,
moist ure, soil, etc. There are three distinct topograph-
ical regions into which Arizona divides itself, and within
lin limits these regions have their own peculiar
climatic characteristics. We have, first, in the
: portion of the State, the great Colorado
Plateau, 4.5,000 square miles in area, covering more
than half the State, with an average elevation of
5,000 feet; second, a broad zone of mountain ranges
running in a southeasterly direction; and, third, a
on of desert plains embracing about one-third of
the territory, lying in the southwest quarter, and of
an elevation below 3,000 feet.
The first, or plateau region, the high altitude re-
gion of Arizona, large areas of which being from 6,000
i" s,(i00 feet in elevation, consists of a broken, rough,
rocky region, with hills and isolated barren mountains
studding the great elevated plain, and with few
rivers running in narrow canons. On account of the
mountain systems near which it lies, this division is
one in which the rainfall is heaviest, being from ten
to twenty inches. The climate is agreeable and
temperate, the mean annual temperature being 45°
to "ill F., quite like that of many of the northern
States, but without their extremes. The summer
temperature is moderate. At Flagstaff, the "Sky-
light City," in the central portion of the State,
with an elevation of about 7,000 feet, and which
may be included in this region, the mean tem-
perature for the hottest months does not ex-
ceed 6S°. For the three summer months of 1901
(Weather Bureau Observations), the mean tem-
perature was 64.6°. The highest temperature
recorded was 92° and the lowest 30°. There were
twenty-seven clear, thirty-three partly cloudy and
thirty-two cloudy days during the period. The
total rainfall was 4.56 inches and the number of
rainy days was twenty-eight. For the same year
1901), for the three winter months, December,
January and February, the mean temperature was
31.6° F. The highest 65° and the lowest -4°. The
total rainfall for the year, at Flagstaff, in an average
of fifteen years, was 16.97 inches.
The mountain region has a width of from seventy
to one hundred and fifty miles and consists of
short parallel ranges of mountains, averaging from
7. IIIM) to 9, OIK) feet, with some higher peaks. The
climatic characteristics of this region are similar to
those of the plateau region men! toned abo\ e, and Pre-
scott (5,320 feet), some eighty miles south of I lag-
staff, may betaken as an illustration. For the three
summer months of l'.MII the mean temperature was
70.5°; the bighe I L02° and the lowe i 33 '. There
were IS clear, 36 partly cloudy and s cloudy days;
and the number of rainy days was 21, the total
rainfall being 5.29 inches. For the three winter
months, December, January and February, the mean
temperature was 39.1° F.; the, highest 70' and lie-
lowest 1° F. The total rainfall for the year was 12 97
inches. Oracle in the southeastern portion of the
State, about forty miles northeast of Tucson, with
an elevation of 4,500 feet, may bo included in this
mountain belt, and is known a< a health resort of im-
portance, situated in a beautiful country, free from
dust, and where good accommodations can he obtained.
()n account of its elevation, the climate is not what
the latitude would indicate. For the three winter
months, December, January, and February, the aver-
age temperature is 45.8° F., and for the three sum-
mer months, June, July, and August, 78.8° F. For the
year 1901, there wen' 269 clear, fifty-eight partly
cloudy, and thirty-eight cloudy days. The mean tem-
perature for the year was 62.7° F.; the highest was
101° and the lowest 19. It is cooler and more bracing
than Tucson.
The third topographical division is the region of
the plain, a desert occupying about one-third of the
southwest quarter of the State, below the level of
3,000 feet. On this low plain the rainfall is only
from two to six inches during the year, and, including
the desert on the California side of the Colorado
River, the records approximate the absolute minimum
of rainfall of the world. In the lower valley of the
Gila River, the highest temperature of the year is
near 130°, and the mean for the hottest month, July,
is about 98°, while the mean for the year is from
68.9° to 74.4° F. The night temperature is also high.
From the dryness, there is a great amount of dust,
particularly in summer, but with the completion of
the great Roosevelt Dam seventy miles from Phoenix,
which is said to confine the largest artificial lake in
existence, a body of water one and one-half miles
wide and twenty-five miles long — Phoenix and an
area of thirty square miles about it will be transformed
into an oasis and the dust annoyance will disappear.
At the foot of the Gila Valley also the Reclamation
Service will conduct water under the Colorado to
irrigate large areas of the desert on the Arizona side.
It is mostly in this plain or desert region that the
winter health stations exist, affording an admirable
climate in winter, but too hot in summer. Phoenix
(1,108 feet), the capital of the State, population
11,134, is one of the best-known health stations in
this region, and its winter climate is favorable for
pulmonary tuberculosis, bronchitis, asthma, and
such conditions as require a warm, dry climate without
altitude. The annual average temperature at
Phoenix is 69°. The average January temperature
is 49°, and the average Jul}' temperature, 90°. The
relative humidity is about forty-five per cent. The
rainfall is seven inches, and for the winter 1.89 inches.
There is a very large amount of sunshine, the percent-
age of which is said to be greater at Phoenix than that
recorded at any other U. S. Weather Bureau office.
In the year 1900 there was said to be only five days
in which the sun did not shine. The mean daily
range of temperature is great, as in all warm desert
regions under cloudless skies. The mean daily
variability, however, that is, the difference in the
mean temperature from day to day, is small. There
is no fog, and the temperature rarely reaches the
freezing-point. What is called the "sensible tem-
perature (M. W. Harrington) is that which is
supposed to be the temperature felt at the surface
531
Arizona
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
of the skin, especially when the skin is exposed, is
considerably lower than that indicated by the
ordinary dry bulb thermometer, more nearly approxi-
mating to that of the wet bulb thermometer, for the
ible temperature depends upon evaporation, and
the greater the dryness of the air, the greater the
difference between the ordinary temperature and the
sensible temperature. Hence, in Phoenix the sensible
temperature ranges considerably lower — from 0° to
IS (Hinsdale) — and the heat, in consequence, is less
oppressh e. The writer recalls a June day in Phoenix
when the thermometer registered nearly if not quite
100°, but when protected from the sun the heat was
not oppressive. "It appears," says Mark W.
Harrington, the former Chief of the Weather Bureau,
"that in arid regions the reduction of temperature
caused by evaporation (that is, the sensible tempera-
ture) may make hot weather not onty endurable but
agreeable and refreshing." Phoenix has good
hotels and accommodations, reliable physicians, and
isfrequented by tuberculous patients. The consump-
tive, however, should not go to any health resort
without the advice of a competent physician, and on
arriving at the resort should at once place himself
under a physician's care.
Tucson (2,400 feet), population 13,193, is situated
about 110 miles southeast of Phoenix. Being higher,
the climate is more bracing and the air cooler than in
the latter city. The annual average temperature is
69° and the average winter temperature is 57° F.
The average relative humidity is forty-two per cent.
The rainfall is twelve inches for the year. The roads
are said to be good and the scenery attractive. The
accommodations are fairly good. "Cases of tubercu-
losis, neuralgia and rheumatism do remarkably well"
here. (Hinsdale, "Climatology and Health Re-
sorts.") Like Phoenix it is a winter resort.
Yuma (140 feet), population about 3,000, is in the
extreme southwestern corner of the State, at the
junction of the Gila and Colorado Rivers. It is but
a few miles from the Mexican border. The winter is
the season for invalids, the summer being extremely
hot. In the former season the climate is mild, dry,
warm, and pleasant, and the peculiarities of the desert
air are here best illustrated. The mean annual
temperature is 72°, that for January 53° and for
July 92°; almost exactly the same as the averages for
Cairo, Egypt, except that it is a little hotter in
summer. The mean monthly winter temperature is
56°. The average number of davs during the year
above 90° is 163; below 32°, 4; cloudy days, 21 (mean
for six years). (Solly.) In 1893, from April to
October, inclusive, out of 214 days, 162 days were
over 90°. The maximum temperature for the year
was 111°. The average annual relative humidity is
46 per cent, and average annual rainfall 2.9 inches.
Yuma is rightly famous for its sunshine and heat.
The accommodations are ordinary.
Castle Creek Hot Springs (2,300 feet), about fifty
miles northwest of Phoenix, are situated in the foot-
hills of the Bradshaw Mountains, in the midst of
beautiful and striking scenery. The Springs are
reached by a drive of four hours from Hot Springs
Junction, over an excellent road, affording extended
views of mountain and valley. The average max-
imum temperature for the months from November
to April, inclusive, for four years (1900 to 1904) was
72.16° F. and the average minimum for the same
period, 44.67° F. In these observations the maximum
temperature was taken in the shade during the day
and the minimum during the coldest part of the
night. For a period of three years the average
number of clear days for the same portion of the year,
November to April, was 160; of cloudy days, 15.6;
of rainy davs. ."..:;. Months are said to go by without
a cloudy day; and hardly a day passes throughout
(lie year without some sunshine. The hot water
l!o',\ from the crevices in the rocks at a temperature
of 115°. Bathing takes place in the open pools, and
may be enjoyed throughout the year. The character
of the waters is that of a mild mineral water, contain-
ing principally sulphate of sodium, chloride of
sodium, and bicarbonate of lime. They are of
benefit for rheumatism, anemia, and disturbances of
metabolism. The climate is favorable for asthma,
hay fever, chronic bronchitis with much secretion,
convalescence from acute diseases, and various
nervous disturbances. The accommodations are
excellent, there being a well-equipped hotel with all
modern conveniences, attached to which are a
physician and nurses.
Other localities in Arizona with a mild winter cli-
mate are Tombstone (2,300 feet) in the extreme
southeastern part of the state; Calabaras (about
4,000 feet); Nogales (4,000 feet); Huachuca (4,780
feet); Crittenden (4,100 feet). Comfortable accom-
modations, however, at these places are questionable.
There, are also various other hot and cold mineral
springs. One of them, Agua Caliente, 100 miles
east of Yuma, enjoys a local reputation for the cure
of rheumatism, chronic skin diseases, and neuralgia.
A sort of acclimatization has to take place when one
takes up his residence in Arizona, especially if in the
plain or desert region. The extreme dryness of t In-
air exercises a marked influence upon the various
secretions of the body. The skin becomes hard and
rough, as there is no sensible perspiration; the upper
respiratory tract becomes irritated, and we may
have chronic inflammation of these passages; the lipa
crack; cystitis is said to be not unusual (Hinsdale,
loc. cit.) and the kidneys and bladder become irritated
on account of the concentrated urine. Constipation
is common and obstinate. One is also apt to lose in
weight. On account of the heat, one is not inclined
to take much physical exercise, and the common form
of it — walking — is unpleasant and not without its
dangers from the alkali dust. It is also to be remem-
bered that in the plain country where most of the
health resorts are situated, there is no vegetation,
except where irrigation exists — it is but one great
treeless plain, wonderful in its clear skies and perpet-
ual sunshine, but desolate and dreary from its waste
of desert sands. Edward O. Otis.
von Arlt, Ferdinand. — Born on April IS, 1812, in
Obergraupen, near Teplitz, Bohemia. His father
was a village blacksmith of small means. He re-
ceived the degree of
Doctor of Medicine in
1839. His prepara-
tory training as an
ophthalmologist
carried on under the
guidance of Prof. J.
N. Fischer. From
October, 1S46, to
July, 1S49, he acted
as a temporary sub-
stitute for the regular
occupant of the Chair
of Ophthalmology;
from 1S49 to 1850 ae
served as full Pro-
fessor of this branch
of medical science in
the University of
Prague; and from the
latter dale until 1883J
when, according to
the laws of Austria, he was obliged to resign his chair,
he was full Professor of Ophthalmology in the Fni-
versity of Vienna. Although his official duties then
ceased, he continued to interest himself actively in
ophthalmology up to March 7, 18S7, the day on which
his death occurred from senile gangrene.
Fie,. 305. — Ferdinand Kitlrr von Arlt.
532
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Arm and Forearm
li is a fact, universally admitted, that Aril was one
of the most conspicuous representatives and promote]
of the science and art of ophthalmology in the nine-
teenth century. He ranks as a worthj a ociate of
such heroes in this special field as von Graefe and
I londers. of his published writings the following de-
serve to receive special ntion: "Pfiege der ^.ugen
lt n gesunden und kranken Zustande, nebst einem
lange ueber Augenglaeser, " Prag, 1846 (revised
ion in 1868); " Krankheiten des Auges," 3 vols.,
j, 1851, LS53,and 1856; " Operationslehre, " Leip-
lig, ls~l. In is.")."), In 1 became associated with
Donders in the work of editing the"Archiv fur Oph-
thalmologic, " founded by von Graefe. Pagel, from
whose " Biographisches Lexikon hervorragender
des neunzehnten Jahrhunderts" the present
sketch has been compiled, says thai " Arit was a man
ie intellectual powers, a. very close observer, and
an ardent lover of truth. He was a very skif ul opera-
a t nisi worthy diagnosticum, and an admirable
lecturer. It is an interesting fact that von Graefe's
decision to devote his professional life to ophthalmo-
logical work was largely due to the influence exerted
by Arlt." A. H. B.
Arm and Forearm. — THE ARM. — The arm (or upper
beginsat the lower anterior margin of the axilla,
tin' lower border of the pectoralis major muscle,
ami ends al the elbow-joint, where the joint capsule
joins the humerus before and behind.
The skin of the arm is similar in structure to that
of other uncovered skin surfaces of the body, is thin,
especially at the front and sides, loosely attached to
lying structures, and is free from large hairs.
Cephali
head I
Radial n
it ifun- 1
A irj
Ti iceps, ex- 1 -
tn aal head
/ Biceps, short
1 head.
Mnsculo-cut. n.
j Median neri e
jv^l— Brachial artery
tlii — Basilic vein.
Int. cut nerve.
Ulnar nei \ e,
Inf. profunda a
f Triceps, in-
1 ternal head
Triceps, long
head.
1 .106. — Transverse Section of Arm just below Insertion of
Deltoid I rom Joessel: "Lehrbuch der topographisch-chirur-
.i Anatomie," Bonn, 18S4.J
The superficial fascial layer contains fat tissue that
rounds out the contour in the well-nourished, and
especially in the female and female art figure.
The brachial fascia (deep fascia) is derived from the
deep fascia of the pectoralis major in front, and from
the insertions of the ten's major and latissimus and
their sheaths behind; from a prolongation of the
deltoid fascia on the outer side, and, through the
axillary fascia, from the deep fascia of the serralus
magnus, upon the inner side of the arm. Coming
together from these origins these fasciae join to form
a thin but firm sheath from shoulder to elbow. Aris-
ing from the external condylar ridge of the humerus
and passing outward to meet this sheath is the ex-
ternal intermuscular septum, which extends from the
condyle to the deltoid tubercle. Arising from the
internal condyle and the internal condylar ridge, and
■nding from the coracobrachial insertion to the
v is the internal intermuscular septum. Just
above the elbow this may be clearly felt as a whip-
like firm cord. These two septa divide the arm
into two regions, the front and the back.
The front compartment of the arm contains bicep
and brachialis; the coracobrachialis being added at.
an upper third arm section, and the brachioradiali ,
and io a certain extent al o the extensor carpi radi-
al is long us, a I a. lower third arm ection.
The back compartment contains triceps andanconeu .
These compartments contain also their respective
blood and nerve supplies. The mu culo piral (radial)
nerve passes backward, downward, ami outward, with
its accompanying superior profunda (deep brachial)
artery, through the intet eptal pace between the
interna] and external heads of the triceps, from a
point high up in the back compartment. In its
course it supplies various blanches to the triceps
muscle; and, through its posterior interosseous divi-
sion, the anconeus. The musculocutaneous nerve
pa es forward, downward, and outward from the
brachial plexus in the axilla, through tin' coracobra-
chialis and between the biceps ami brachialis above
in the front i partment, supplying the e three
muscles; (he brachial artery supplying this compart-
ment throughout. Still lower down in the arm,
above t he elbow, we ha \ e pi act ica 1 1 y in the external
intermuscular septum the musculospiral nerve and
the superior profunda artery, and within the enfolding
of the internal inter muscular septum, the ulnar nerve
and the inferior profunda artery.
The conformation of the front of the arm is due to
the form of the biceps, which rounds well forward.
\i i he slight, groove at the inner and outer base ,,(
the biceps are placed respectively the basilic and ceph-
alic veins, which extend from their ana tomo i ,
at the elbow upward along the borders of the biceps
to join their outlet, the axillary veins, at the inner
and outer sides of the arm and shoulder.
In association with the skin we find, forming the cu-
taneous supply of the outer arm, from the shoulder
to the wrist: circumflex, upper external cutaneous
branch of the musculospiral, lower external cutane-
ous branch of the musculospiral, and cutaneous
branches of the musculocutaneous. In the skin and
superficial fascia of the inner arm and forearm is the
cutaneous supply of the inner arm and forearm:
intercostohumeral, internal cutaneous branches of the
musculospiral, lesser internal cutaneous (Wrisberg's),
and internal cutaneous.
A few small lymphatic nodes upon the inner side of
the arm, just above the elbow, may be found in the
superficial fascia near the course of the basilic vein.
I I e nodes, enlarged, are pathognomonic of syphilis.
The lowest point of the insertion of the deltoid
marks the middle of the humerus, the middle of the
musculospiral groove behind, the lower border of the
coracobrachialis insertion, and the upper limits of the
brachialis.
The Front of the Arm. — Just within the anterior
fascial compartment is the biceps, which lies upon the
brachialis, while the latter, in turn, lies upon the
anterior surface of the humerus. Along the inner
border of these two muscles is the brachial artery.
The artery winds about the humerus from the mid-
axillary space, high up in the arm, to the internal
septum in the mid-arm, to the anterior part of the
brachium at the elbow. The terminal branches of
the brachial plexus also conform to this route through
the arm.
The biceps arises from the scapula by two heads:
the long head above the glenoid fossa of the scapula,
the short head, in common with the coracobrachialis,
from the tip of the coracoid process, from these
two tendinous origins, these heads swell into long
muscular bellies that converge and lie side by side
in the upper third, and unite at the lower third of the
arm. Toward the bend of the elbow the muscle
libers converge upon a centrally placed short, stout
tendon, which is inserted upon the posterior facet of
the tuberosity of the radius, a bursa, not connecting
533
Arm and Forearm
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
with the joint, occupying the anterior facet over
which the tendon plays when the forearm is flexed.
As rarely happens a rupture of the long head of the
biceps causes an egg-like swelling of the muscle
just above the elbow; while the still more uncommon
rupture of the tendon of insertion causes a large
muscle swelling above near the insertion of the
deltoid. Pus in the shoulder-joint often burrows out
following the long tendon of the biceps to appear at
the anterior of the arm just below the insertion of the
pectoralis major tendon. Itis the tendon of insertion
of this muscle that becomes so "lame" through pro-
longed cranking of gasoline engines and motor cars;
and it is the muscle proper that so often tires in pro-
longed paddling. In pitchers the muscle-bundle
tire of this muscle especially allows the spontaneous
fracture of the humerus.
The fascial sheath of the arm anteriorly, after
becoming distributed to bony parts of the elbow and
condylar ridges, receives in front of the elbow a strong,
flattened band of fibers from the biceps tendon, the
semilunar or bicipital fascia,
which is continuous with the
deep fascia above and is lost
over the pronator teres below
in the ulnar fascia. This
fascia bridges over the
brachial artery and separates
it from the median basilic
vein.
The brachialis arises from
the whole lower half of the
inner and outer surfaces of
the humerus, from the front
of the internal intermuscular
septum, and from a part of
the external intermuscular
septum above a point where
the musculospiral nerve
pierces it. Its origin em-
braces the insertion of the
deltoid. The muscular fibers
converge broadly into a short,
thick, tendinous insertion
upon the coronoid process.
This muscle is overlaid by the biceps, but projects be-
yond it inward and outward. It is overlapped on the
inner side by the brachial artery, by the median nerve,
and by the pronator teres; also, deeply, by the anterior
branch of the anastomotica magna and the anterior
ulnar recurrent artery. Upon its outer side it [s
overlapped by the radial recurrent artery, by the
radial nerve, and by the brachioradialis and extenso-
carpi radialis longus; also deepl)', by the musculo-
spiral nerve ami by the terminal branch of the su-
perior profunda artery.
The coracobrachialis is an elongated muscle arising
in common with the short head of the biceps from the
tip of the coracoid process. It is inserted on the
inner border of the shaft of the humerus at about its
middle. It lies, in its lower part, along the inner
border of the biceps, the two muscles lying to the
outer side of the brachial artery.
The brachial artery is the direct continuation of the
axillary at the level of the lower border of the teres
major. Therefore the lower half of the third por-
tion of the axillary artery lies uncovered by muscle
in the upper ami. The brachial extends a short
distance below the elbow where it ends in its two ter-
minal branches — the radial and ulnar arteries — on o
Opposite sides of the radius near the junction of its head
and neck. The course of the artery is sinuous; it lies at
first internal to the humerus, slightly overlapped
by the coracobrachialis above, then in front of the
bone, slightly overlapped by the biceps; and, at the
bend Of the elbow lies midway between the condyles.
Compression of the artery at any point in the arm
should be outward toward the bone above, outward
and backward at its lower third, directly backward
below. Throughout its course the artery occupies a
position near the surface and can be felt pulsating.
Not pulsating, it may be found upon a line drawn
from the inner border of the coracobrachialis above
to mid-elbow just internal to the biceps tendon. It
lies at first upon the long head of the triceps, but is
separated from the muscle by the musculospiral
nerve and superior profunda artery, and is overlapped
by the biceps. Next, it rests upon the inner head
of the triceps, at the middle third of the arm, ami is
overlapped by the insertion of the coracobrachialis.
At its lowerthird, just before bifurcation, it lies
upon the brachialis. It lies
beneath the skin and fascia
and is partially bridged over
by the coraco-brachialis and
biceps upon" its outer side.
At the bend of the elbow
it is overlapped again by
the strong bicipital fascia,
is crossed by the median
basilic vein, and dips deep
into the triangular (anti-
cubital) space between the
brachioradialis and the pro-
nator teres. The sheath of
the artery is closely incor-
V
porated with the
deep fascia of the
biceps, so that in
ligation of the
artery it moves in
its position accord-
ing as tension is
put upon the
muscle.
The median
nerve follows
closely the artery
and its sheath,
lying first to its
outer side, then in
front of it, and
finally toward the
elbow at its inner
side. The ulnar and the internal cutaneous nerves lie
to the inner side of and behind the artery till about
the middle of the arm, when the ulnar diverge- to pass
well backward, to reach the internal intermuscular
septum above the internal condylar ridge, where it
enters the posterior compartment of the arm. The
internal cutaneous pierces the brachial fascia ami pa
forward just below the middle of the arm, and it lies
between the brachial artery, to the outer side, and
the basilic vein upon the inner, to be wholly super-
ficial at the elbow. The musculospiral nerve lies for
a very short distance behind the brachial artery upon
the long head of the triceps before it is joined by the
superior profunda branch and gains the musculo-
spiral groove.
Fig. 307. — The Inner Ann. Muscles
contracted. (After Gerrish.)
534
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Arm and Forearm
The artery gives off the superior profunda, the
inferior profunda, tlio anastomotica magna, t lu-
QUtrient, the muscular, and the terminals — the
radial and ulnar arteries.
Tlit' superior prufu mln arlrri/ which lies first to the
inner, then to the posterior side of the brachial, rises
usually just below the teres major, perforates the
septum, and then penetrates to the musculospiral
>ove, in which it rims for a certain distance. It
gives off above, an ascending branch that supplies
ad£SL
Fig. 308. — Course and Branches of the Brachial Artery.
(Heitzmann.)
the triceps and forms an important anastomosis with
the posterior circumflex. The cutaneous branches
follow the nerve and supply the skin over the outer
arm. The articular branch is given off behind the
external intermuscular septum and runs downward
in the substance of the triceps, anastomosing with
the interosseous recurrent below, and, across the
joint behind, immediately above the olecranon fossa,
by an arch with the anastomotica magna. The
terminal branch perforates the septum to become
anterior at the elbow, and it, anastomoses with the
radial recurrent. It often gives off a nutrient artery
or arteries to the upper end of the humerus, and it
gives muscular branches to the triceps.
The inferior profunda usually rises from the inner
side of the brachial about opposite the lower part of
the coracobrachial!- in 11 lion. It passes with the
ulnar nerve through the internal intermuscular
septum to the back of the condyle, and there, under
cover of the tendinous aponeurosis of the lle\ or carpi
ulnaris, it anastomoses with the- posterior ulnar
recurrent- and ana tomotica magna. It supplies Ihe
humerus, triceps, and elbow-joint, and it frequently
gives Off a branch, that passes to the In ml of the joint
and anastomoses with the anterior ulnar recurrent.
The anastomotica magna usually rises from the
inner side of the brachial, a short distance above the
bend of the elbow, runs downward and inward across
the brachialis, and divides into an anterior and a
posterior branch. The anterior branch anastomoses
in front of the internal condyle, beneath the pronator
teres, with the anterior ulnar recurrent. From this
branch a branch often passes behind the condyle to an-
astomose with the posterior ulnar recurrent and the in-
ferior profunda. The posterior branch perforates the
internal sept uui, passes to the posterior surface of the
internal condylar ridge, pierces the triceps, and there
anastomoses with the articular branch of the superior
profunda and with the interosseous recurrent.
The nutrient artery is given off variably from the
brachial or one of its branches and passes through the
nutrient foramen, downward toward the elbow.
After entering the shaft of the bone, a branch passes
upward toward the head and neck.
The muscular branches, from five to eight in number,
are variably given off, from the outer side of the
artery, to the coracobrachialis, the biceps, and the
brachialis muscles, usually at the points where the
nerves enter these muscles.
The musculocutaneous nerve, arising from the outer
cord of the brachial plexus, soon perforates the
coracobrachialis, and, still inclining outward, reaches
the bend of the elbow and there piercing the fascia
becomes superficial just at the outer border of the
biceps tendon.
The Back of the Arm. — The triceps occupies the
whole of the posterior compartment of the arm and is
made up of three heads of origin. The long head
rises by a flattened tendon from the upper part of the
axillary border of the scapula and its adjacent lower
glenoid rim. This tendon, with its muscle bundles,
together with the outer (upper) humeral head, forms
most of the superficial part of the muscle.
The inner head, rising below the musculospiral
groove, is more deeply placed. The muscle bundles
from these three heads converge below into a short
common tendon which is inserted into the posterior
part of the top of the olecranon process. A bursa
underlies the tendon over the rest of the top of the
process. The long head is joined upon its inner side
by a slip of aponeurotic fascia derived from the lower
border of the tendon of the latissimus. The outer,
or upper, head occupies all the posterior and external
surfaces of the humerus from the teres minor insertion
to the groove. It also has fibers which are attached
to the external intermuscular septum and the ap-
oneurotic sheath bordering the groove. The groove
is free. The inner, or lower, head rises from the
posterior surface of the humerus below the groove and
receives a narrow-pointed slip from high up near the
insertion of the teres major, upon the inner side of the
groove. It rises also from the whole length of the
internal intermuscular septum and from a small
part of the external intermuscular septum. The
fibers of origin of the long and outer heads join and
form a broad, flat tendon of insertion. Some of
the fibers of this tendon are given off especially over
the outer part of the elbow-joint, and ultimately
they expand so as to form a strong fascia that covers
535
Arm and Forearm
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
the forearm. The short fibers of the inner head are
in great pan inserted upon the deep surface of this
tendon. A few fibers, however, are inserted directly
upon the olecranon or into the posterior ligament of
the elbow. The musculospiral nerve and the superior
profunda artery supply muscular branches to each
of the three heads. _ _
The musculospiral nerve is the continuation ot the
posterior cord of the brachial plexus after there have
been given off, in the axilla, the circumflex and the
subscapulars. After passing for a short distance
behind the lower part of the axillary artery and the
upper part of the brachial artery, it dips backward,
downward, and outward, from the position where it
lies upon the lower part of the triceps, and then,
alter being joined by the superior profunda artery,
it enters the musculospiral groove. Not infrequently
in fractures of the humerus at this point the nerve is
pinched or stretched over a fragment or caught in
repair callus with resulting "wrist drop." It turns
round behind the shaft of the humerus and appears
at the outer side of the arm, where, at about four
inches above the elbow-joint, it pierces the external
intermuscular septum and lies in the front compart-
ment of the arm, deep between the brachialis on the
inside and the brachioradialis and the extensor carpi
radialis longus upon the outside. In front _ of the
external condyle of the humerus it divides into its
terminal branches, the radial and the posterior inter-
osseous. It gives off three cutaneous branches, and
supplies muscular branches in the arm to the three
heads of the triceps, the anconeus, the brachialis
(in part) the brachioradialis, and the extensor carpi
radialis longus. The last three muscles are supplied
by branches given off in the front compartment.
The internal cutaneous branch usually rises in the
axilla in company with the branch which goes to
the long head of the triceps, and then passes back of
the arm. It supplies a middle dorsal strip of in-
tegument nearly as far down as to the elbow. The
eT external cutaneous branch pierces the deep
fascia in the line of the external intermuscular sep-
tum at the upper third of the arm, accompanies the
cephalic vein in the lower half of the arm, and sup-
plies a -trip of skin, from exit to elbow, on the antero-
extemal surface of the arm. The lower extern,,)
cutaneous branch, which is much larger pierces the
ia somewhat lower down, and supplies the skin
of the middle of the back of the forearm as far down
as to the wrist. In its course it passes between the
internal cutaneous nerve upon the inside and the
musculospiral upon the outside.
The lesser internal cutaneous nerve ( Wnsberg s)
rises from the inner cord of the brachial plexus,
passes as far down, in the front compartment, a to
the inner side of the axillary vein, which latter sepa-
rates it from the ulnar nerve, at the middle ot the arm.
At the elbow it turns backward to supply the skin
over the olecranon. .
The internal cutaneous nerve rises from the inner
cord of the brachial plexus, and passes down the arm
to the inner side of the brachial artery. With the
basilic vein it perforates the deep fascia and supplies
the skin of the upper and inner arm. Above the
elbow the terminal branches, anterior and posterior,
diverge slightly at the anterointernal side ot the arm,
to pass the elbow, where they supply the skin of the
inner forearm, anteriorly and posteriorly, as far down
as the wrist.
\ terminal branch of the musculocutaneous nerve
p a , over the elbow and lies below in front of the
radial artery. It supplies the outer side of the fore-
arm, front and back.
Should the shaft of the humerus need to be cut
,| (l ,i upon for wiring fracture, caries and the like,
with least injury of the soft parts it may be done:
(1) at its »/)/'"' third, anteriorly, at the anterior bor-
der of the deltoid muscle just external to the bicipital
groove, thereby avoiding the sheath of the biceps
and severing "only the small anterior circumflex
artery; (2) at its upper third, posteriorly, at the
posterior border of the deltoid muscle, care being
had in avoiding the circumflex vessels and nerve
exposed above and the musculospiral nerve below;
(3) at its lower third, posteriorly, by an incision
posterior to the external intermuscular septum from
the external condyle extended upward.
THE FOREARM. — The forearm is that portion of
the pectoral girdle or upper extremity lying between
the elbow and the wrist joint. Its various structures
are most intimately associated with the functions of
the hand. Its bony framework comprises two bones,
the radius and the ulna. The ulna is directly con-
tinuous with the humerus, the radius with the hand
and its functions and movements.
The skin of the forearm is soft and is usually well
supplied with hairs, especially along the postero-
external surface. Along the anterior surface the
hairs are fewer and finer. The skin is freely movable
throughout the forearm upon the deep fascial sheath.
The bursa over the olecranon gives it free mobility at
that point. Lying within the layers of the super-
ficial fascia are the superficial veins and the cutane-
ous nerves.
The superficial veins rise in two plexuses: the
large plexus of the dorsum of the hand which is derived
from the digital veins, and the smaller plexus of the
front of the wrist, from the palm and thumb. These
veins are larger than those of the deep set, have fewer
valves and return most of the blood. At points of
communication between these sets of veins, valves
are regularly found.
The vein's arising from these two plexuses are
irregular in their distribution and are seldom sym-
metrical upon the two sides in the same body. Foi
convenience four principal vein trunks are distin-
guished upon the outer, anterior, and inner surfaces
of the forearm: the radial, the median, the anterior,
and the posterior ulnar veins respectively. The
median vein as it reaches a point opposite the inser-
tion of the biceps receives a communication from the
deep set which perforates the deep fascia. This
trunk is short and is known as the profunda. The
median at once divides into branches that diverge
in V-form, the median cephalic to the outer side and
the median basilic to the inner side of the biceps.
The n,,, Han cephalic ascends to a point a little above
the elbow, is joined by the radial vein, and this
trunk, called the cephalic, lies in the furrow to the
outer side of the biceps in the arm. The median
cephalic vein overlies the cutaneous branches o : the
musculocutaneous nerve as they pass the elbow.
The median basilic vein passes upward and inward
and is usuallv joined at a point about in front of the
internal condyle by both the vlnar veins. 1M
trunk so formed is called the basilic and lies to W
inner side of the biceps in the arm. The median
basilic is usuallv larger and shorter than the median
cephalic; the basilic is usuallv a considerably larger
trunk than the cephalic. The median basilic veil)
overlies from without inward the bicipital fascial
aponeurosis, the brachial artery, a part of the an-
terior division and the whole of the posterior division
of the terminals of the internal cutaneous nerve.
Superficial Nerves.— The cutaneous nerves arc
the musculocutaneous, with a few fibers from Uic
musculospiral near the elbow, for supplying the outer
side of the forearm, front and back; the internal
cut aneous, for supplying the inner side of the forearm
front and back. Lying between the two on the hack
of the forearm is the distribution of the lower (larger)
cutaneous branch of the musculospiral. All these
nerves pass the elbow. Behind, over a small area,
limited to the olecranon, is the nerve of \\ risberg.
536
KKFKIMAi !•: HANDBOOK o|' THE MEDICAL SCIENCES
Arm ami Forearm
Piercing the fascia at the Id wit third of the forearm,
the following nerves become superficial or cutaneous:
(he palmar branches of the ulnar, median, and radial
nerves on the front, and the dorsal branch of the
ulnar nerve and the radial nerve mi the back.
The brachial (deep)
at the elbow is j^_
firmly fixed to the bony
p ro m i n e 11 ees , a ml is
■ihened ill fniiil by
the bicipital fascia. This
slip is given nil' from the
on of insert ion of the
biceps, which bridges o\ er
the brachial artery, and is
over the pronator
and its sheath at the
inner side of I he forearm.
fascia! libers are al '•
Often received from the
hi of the triceps.
her iii the upper
third of the forearm this
deep fascia forms a strong
enveloping sheath. Near
the elbow at the internal
le it serves in part as
the origin of several mus-
hich spring from the
condyle. Lower down in
the forearm septa are
given oil' from its deep
surface to dip down be-
tween the various muscle
bellies. In the lower third
the fascia is continuous
with the various muscle
ns and at the wrist
forms the anterior and
posterior annular liga-
ments. It ends in the
fascia of the hand. It is
attached to the posterior
triangular area of the ole-
cranon and to the whole of
the posterior ridge of the
ulna, and is much thicker
behind. Between the su-
perficial and deep layers of
muscles, front and back, is
a thin membranous layer
of fascia. Below and be-
hind, the fascia is st rength-
ened by transverse fibers
to form the posterior an-
nular ligament of the wrist
which passes from the
anterior border of the
radius above the styloid
process backward and in-
ward, over the series of
ridges forming grooves for
tendons, over the ulna
serving as an orbicular
ligament, to attach itself
to the inner aspect of the
wrist, especially over the
pisiform and cuneiform bones.
Muscles. — The muscles of the forearm, for con-
venience, can be divided into groups: those of the
front, those of the back, and those of the outer side
of the forearm. Those of the front (anterior radio-
carpal) consist of a superficial set, five in number:
the pronator teres, flexor carpi radialis, flexor carpi
ulnaris, tlexor digitorum sublimis, and (flexor) pal-
niaris longus; and a deep set, three in number: flexor
digitorum profundus, flexor pollicis longus, and pro-
nator quadratus. The muscles of the outer ide
i radial), three in number, are: brnchioradialis,
extensor carpi radialis longus, and extensor carpi
radialis brevis. 'I'll., e ..I the bad (po terioi radio-
carpal) comprise a superficial set, four ill number:
extensor digitorum communis, extensor digiti
minimi, extensor carpi ulnaris, and anconeus; and a
deep set, five in number: supinator (brevis), extensor
ossis metacarpi pollicis, extensor pollicis longus,
extensor pollicis brevis, and extensor mdicis.
The five muscles of the superficial flexor group are
intimately associated at their origin from the internal
condyle. Arising from it is a tendon common to them
all, which gives libers to each and sends septa between
every two contiguous muscles. The muscles, from
without inward, are the following:
537
Arm and Forearm
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
The -pronator teres, the most external, crosses ob-
liquely the upper half of the forearm. It rises by two
heads: one, large and superficial, from the inner
condyle of the humerus by a tendon common to both
S
<
a
&
heads, and from the supracondylar ridge, fascia, and
intermuscular septa; the other, a thin and deep band,
coming from the inner side of the coronoid proci
and sunn joining the deep surface of the large head.
This slip separates the median nerve from the ulnar
artery, The muscle thus formed passes outward
anil ends in a Battened Irndon which turns over Hie
radius and is inserted into a rough impression on the
outer surface of the shaft of the radius about at its
middle. Near the insertion the muscle is crossed
by the radial artery and is covered by the brachio-
radialis.
The flexor carpi radialis
rises from the flexor tendon,
from fascia, intermuscular
septa, and adjacent muscles.
At about the middle of the
forearm its fleshy belly merges
into a long flattened tendon,
passes in a special compart-
ment of the anterior annular
ligament, grooves the trape-
zium, and inserts itself into
the base of the second and
frequently into the third
metacarpal bone.
The (flexor) palmaris longus
is a long slender muscle, the
smallest of the group. It
rises from the flexor tendon,
fascia, and septa, to form a
small round belly. It soon
ends in a long slender tendon
which inserts itself into the
lower border of the annular
ligament and the palmar
fascia. This muscle is very
variable and is often absent.
The flexor carpi ulnaris, the
innermost muscle of the
group, rises by two head-:
the one from the back part of
the flexor tendon, the other
from the inner side of the
olecranon and, by an aponeu-
rosis, from the upper two-
thirds of the posterior border
of the ulna. The two heads
bridge the space between the
internal condyle and the ole-
cranon and between and be-
neath them the ulnar nerve
is transmitted. The muscle
converges into a tendon
which is placed along its
front surface and inserts itself
into the pisiform bone.
The flexor digitorum sub-
limis (flexor perforatus) is a
broad flat muscle placed be-
hind the preceding. It rises
by a strong head from the
flexor tendon, from the in-
ternal lateral ligament of the
elbow-joint, from the inner
border of the coronoid proc-
ess, and from the overlying
muscles and septa; and by a
second head, a thin flat band,
from the anterior oblique line
of the radius and its anterior
border. It merges from a
broad muscle into four sepa-
rate tendons which first pass
through the middle compart-
ment of the anterior annular
ligament, then diverge, and
continue their course, each
one separately, in company with a corresponding ten-
don from the profundus (behind), to each of the lust
four fingers. At the wrist the tendons pass in pairs,
those for the third and fourth fingers being in front,
those for the second and fifth lying behind the first pair.
The tendons opposite the first phalanx divide, allow
the profundus tendon to pass between, then unite
behind to insert themselves into the second phalanx.
538
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Arm and Forearm
■
This group of muscles is supplied by the median
nerve, save the ulnar flexor which receives its supply
from the ulnar. . .
The '/' i p-si 'ii' 'I flexor group comprises the following
muscles: .
The /?' j''"' ilii/ii'intm profundus (flexor penetrans;,
•i large thick muscle, rises from the upper three-
fourths of
the front
and inner
side of the
ulna, from
the ulnar
half of the in-
-e U S
in b ra ne
and from the
urosis ol
the flexor
ulnaris.
It divides \
Bnallyinto four ten
for the inner
four fingers, but the
tendon for the index
becomes dis-
tinct in theforearm.
tsses behind the sublimis
at the wrist, behind the sub-
limit tendons in the palm, and
perforating the sublimis
inserts itself at the buses of the
phalanges of the inner four
fingers. The lumbricales take
origin from its tendons in the
palm.
The flexor pollicis longus, to
the outer side of the profundus,
rises from the front of the
radius between the oblique line
and the pronator quadratus,
the adjacent interosseous
membrane. From a fleshy
belly, a round tendon passes
under the annular ligament
thenar eminence to its
insertion at the base of the
id (last) phalanx of the
thumb. Occasionally a second
head rises from the coronoid
process or internal condyle in
common with the sublimis.
The pronator quadratus rises
from the pronator ridge and
from the front of the ulna at
its lower fourth, passes close
to the bones, and inserts itself
into the front of the lower end
of the radius.
This group of muscles is supplied by the anterior
interosseous branch of the median nerve; with the
exception that the ulnar nerve supplies the outer
half of the deep flexor, i.e. the ring and little
fingers.
The muscles of the outer (radial) extensor group are:
The brachioradialis (supinator longus) rises from
the upper two-thirds of the external supracondylar
ridge and from the front of the external intermuscular
septum. It forms a long slender muscle which, near
the middle of the forearm, merges into a flat tendon:
and this, in turn, inserts itself into the outer side of
the radius near the base of the styloid process.
The extensor carpi radialis longus rises just below the
preceding muscle from the ridge and septum, a few
fibers being derived from the common extensor ten-
don. From this origin a long tendon passes under the
posterior annular ligament in its second compartment
and passes to its insertion into the base of the second
Fig. 313. — Skiagraph
Showing Relations of Bony
Framework of the Shoul-
der, Arm. and Elbow to
the Soft Parts which Sur-
round Them. (After Ger-
rish.)
icarpal. In its course ii lie- upon the following
muscle.
The extensor carpi radialis brevis rises by the com-
mon extensor ten. Inn from the external condyle of
the humerus, from the intennu epta, and
from the external lateral ligament of the elbow. lis
tendon passes with the longus in the same compart-
ment at tin' wrist and is finally inserted into the i,
of the third metacarpal.
This muscle group is supplied by the mUSCulo-
spiral nerve, that to the short radial extensor being
through the posterior branch of the nerve.
The group from without inward,
contains the following muscles:
Tile by the c -
iiiiin extensor tendon, fascia, and septa. 1 rom a
fleshly belly four tendons are ultimately given off,
and these pass through the fourth compartment of
the posterior annular ligament on their way to the
hand. Here they diverge ami then pass on to the
points where they are inserted at the bases of the
id and the third phalanges of the inner four
fingers.
The. extensor digit! n lies a! the inner side of the
preceding muscle. It rises in the same manner as
does that muscle and passes through the fifth com-
partment at the wrist (between radius and ulna); its
points of insertion are the same a- those of the corre-
sponding tendon of the preceding muscle.
The extensor carpi ulnaris rises in the same manner
as the preceding, and also by an ulnar aponeurosis
common to it, the flexor carpi ulnaris, and the flexor
profundus. The tendon emerges near the wrist,
passes in the sixth compartment, and i inserted into
the base of the fifth metacarpal near its ulnar border.
The anconeus rises from the lower part of the back
of the external condyle and from the adjacent pos-
terior ligament of the elbow and is inserted into the
outer surface of the olecranon and the upper third of
the back of the ulna. This muscle is sometime-;
continuous with the triceps and is usually described
in connection with it, as a fourth head.
This group is supplied by the posterior interos-
seous branch of the musculospiral nerve.
The deep extensor group comprises the following:
The supinator (brevis) rises from the back of the
external condyle, the external lateral ligament, the
orbicular ligament of the radius, and the back part
of the bicipital hollow of the ulna, from which point
it extends a variable distance down the outer border
of the ulna. Over these fibers of origin is a strong
aponeurotic cover. The muscle passes out and down
over the back of the radius to insert itself into the
back of the neck of the radius and upon the outer
and front surfaces of this bone as far down as the
insertion of the pronator teres. The muscle is divided
into superficial and deep layers by the posterior
interosseous nerve as it passes to the back of the
forearm.
The extensor ossis metacarpi pollicis (abductor pol-
licis longus) rises from the outer part of the back
surface of the ulna at the junction of the upper and
middle thirds, from the corresponding portion of the
interosseous membrane, from a small part of the back
of the radius near its middle, and from intermuscular
septa. The muscle extends down and out, emerges
between the extensor digitorum communis and the
extensor carpi radialis brevis, and in company with
the extensor pollicis brevis it crosses the two radial
extensors. At about this point it merges into its
tendon, follows down the outer side of the base of
the radius, and enters the first compartment of the
posterior annular ligament. It is inserted into the
outer side of the base of the first metacarpal bone and
by its aponeurosis into neighboring structure-, nota-
bly the back of the trapezium, and also into the pal-
mar fascia, especially that part which covers the
thumb.
539
Arm and Forearm
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
The extensor pollicis brevis (extensor primi inter-
nodii pollicis) rises from the middle of the back of the
interosseous membrane just below the preceding,
from the back of the radius extending obliquely
outward and downward, and from the intermuscular
septa of this group of muscles. It extends obliquely
down and out and forms its tendon at the lower third
of the forearm. From this point it accompanies
the tendon of the preceding muscle, lying behind it,
to lie inserted into the base of the first phalanx of
the thumb.
The extensor pollicis longus (extensor secundi inter-
nodii pollicis) rises from the outer part of the back
of the ulna at its middle third, close to the outer
border, from the interosseous membrane, and from
the septum between it and the extensor indicis.
This muscle, somewhat stronger than the preceding,
passes down and out to merge into a tendon placed
along its back. The tendon becomes free just above
the posterior annular ligament, passes through its
third compartment, then over the radial extensors,
lies close to the inner side of the tendon of the pre-
ceding, and is inserted into the base of the second
phalanx of the thumb.
The extensor indicis rises from the back of the ulna
(from a [joint just below the preceding muscle to one
situated nearly at the lower end of the bone), from
the adjacent interosseous membrane, ami from the
septum between it and the preceding. It merges
into a tendon which is placed along its radial border.
This becomes free at the lower third of the forearm,
passes through the fourth compartment beneath the
tendons of the extensor digitorum communis, and
after it emerges from this it is inserted into the inner
border of the tendon of the common extensor of the
index finger at about the metacarpophalangeal joint.
This muscle group is also supplied by the posterior
interosseous branch of the musculospinal nerve.
Arteries. — The brachial artery ends just below the
bend of the elbow where it divides opposite the neck
of the radius into its two terminals, the radial and the
ulnar.
The radial artery, the smaller of the two, extends
downward, in direct continuation of the brachial
artery, along the outer side of the front of the forearm
to the lower end of the radius. Here it turns around
the outer side of the radius to the back of the wrist,
over the external lateral ligament, and under the
extensors of the thumb.
In the upper forearm it lies in the outermost inter-
muscular space between the brachioradialis and the
pronator teres, and is covered by fascia? and skin.
In the middle and lower thirds of the forearm it lies
along the inner border of the muscle and tendon of
the brachioradialis, which latter serves as a guide in
the operation for ligating this vessel. In this part
of the forearm it is covered only by fasciae and skin,
and by a few superficial veins and cutaneous branches
of the musculocutaneous nerve. The radial at the
wrist lies directly upon the bone, and forms the pulse.
The radial nerve approaches the artery above at an
acute angle; in the middle and lower thirds it lies
along its outer side. The venae comites accompany
the artery on either side.
The radial artery in the forearm, besides the irregu-
lar and numerous muscular branches, gives off the
radial recurrent, the anterior radiocarpal, and the
superficial volar.
The rail in} rerun-, ,.',. a branch of considerable size, is
usually given oil from the outer side of the radial
just below its origin from the brachial. It runs out-
ward between the brachioradialis and the supinator
(brevis), divides into several branches and anastomoses
with the interosseous recurrent and superior profunda,
and gives of! a branch to supply the elbow-joint.
The superficial volar and the anterior radiocarpal
are brain In i en oil' just above the wrist.
The ulnar artery, the larger of the terminals of the
brachial, from the inner side of the neck of the radius
l>a~It, vtuecuC
ffl
Tenia
fiLsjp. long. !'
M. ulnar im.
'It. dorsal
Fig. 314. — Course and Branches of the Arteries of the Forearm
(Heitzmann.)
In the upper half of its course the artery lies deeply
beneath the pronator teres and the superficial flexor-;
in the lower half of the forearm it is overlapped only
by the flexor carpi ulnaris muscle and tendon which
lie to its inner side and serve as a guide in operations
for ligating the vessels. Only in the last inch or so
is the artery superficial. As the artery lies beneath
the pronator teres it is crossed from within outward
by the median nerve, the deep head of the muscle
540
KKl'KliKNCK HANDBOOK OF THE MEDICAL SCIENCES
Ann and Forearm
usually separating the two. The ulnar nerve ap-
proaches the artery from behind the inner condyle at an
acute angle, being separated from it l>\ the flexor
ublimis, and in the lower two-thirds ii lies close to
th e i nner s ide of the artery. The latter is covered
by superficial ulnar veins, in addition to fasciae and
i is crossed by branches of the internal eu-
tane'o ' he arterj is ace panied by two
coniites.
The ulnar artery, besides m tous and irregular
muscular branches, gives off the anterior and
n current ulnar, the anterior and postei ior
llS| the anterior and posterior ulnar carpal,
i-illv the nutrient of the ulna.
The anterior recurrent ulnar, the smaller of the two
branches, runs up in front of the inner con-
dyle of the humerus, be-
en the pronator teres
and the brachialis, and
anasi omoses with the an-
terior branch of the an-
astomotica magna and a
branch of the infei ior pro-
funda.
The ' poxt< Hot r< current
ulnar, the larger, passes
inward bet ween I he flexor
sublimis and the flexor
profundus, then up and
back of the inner condj le
of the humerus, and t 3
to lie, with the ulnar nerve,
ctween the two heads of
he flexor carpi ulnaris.
t anastomoses with the
osterior branch of the
nastomotica magna,
ith the inferior profunda,
nd with the intern eous
recurrent to form the ole-
cranal rete.
The interossei rise
from the ulnar by a
common trunk
about half an inch
in length from the
outer and back part
of the ulnar just be-
fore the median
nerve crosses the
main vessel. This
trunk arises about
an inch below the
origin of the ulnar,
and proceeds back-
ward to the interos-
seous membrane,
where it divides into
its two terminals.
The anterior inter-
osseous, the smaller,
fellows the front of the membrane in company with
two veins and the deep branch of the median nerve
which lies to its outer side. It usually supplies
nutrient branches to both bones.
rhe posterior interosseous, the larger, passes back
a the interosseous membrane and the oblique
ligament above, descends between the superficial and
de ip muscles, and, crossing the extensors of the thumb
and index finger, anastomoses below the latter mus-
cle with the anterior interosseous.
These ulnar recurrent and interosseous branches
supply in main the muscles of the forearm, the large
of the radial and ulnar passing through to
supply the wrist and hand.
rhe anterior and posterior ulnar carpals are small
carpals which, in company with the anterior radial
carpal, anastomose and form the carpal arch.
Yir.. .'. . Eti gion of Wrist,
showing Arrangement of Tendons, Ar-
tery, Nerve, etc. The skin and fasciffl
been removed. (After M. H.
rdson.)
.\ii:\i in iks. rhe nerve trunks of the forearm
are the radial, posterior inteross - median, and
ulnar.
The musculi tior) distance abo> e the
elbow, lying upon the brachialis and covered by the
brachioradiali , divides into its terminals, 'lie |"
rior interosseous and the radial nerves.
Tin 1 >ack, out .
and down between the brachialis and i carpi
radialis longu . through the supinatoi o the
leep layer. if the forearm extensors. It approaches
the posterior intei i artery at an angle, and is in
relation with it as far as to a point bi i in of
t he e\iii, i ir pi illici li mgu where it approach and
is in relation with the posterior branch of the anti rioi
interosseous artery. Lower down, it pa es thro
the fourth compartment of the wrist, with the exten-
sores communis and indicis, to the back of the wrist
e ii be is ganglionic.
The radial nerve passes directly downward under
co er of the brachioradialis. At the middle third
Of the arm it lies along the outer side of the radial
artery, then winds around the outer side of the
radius under cover of the brachioradialis tendon,
and pierces the deep fascia iii the lower forearm,
breaking up into its terminal branches on the back
of t he w rist.
The' median nerve, from the bend of the elbow,
where it lies to the inner side of t he tendon of t he biceps,
the brachial, and the beginning of the ulnar artery,
passes down the center of the front of the forearm
beneath the condylar head of the pronator teres and
over the ulnar artery, being separated from the latter
by the deep head of the same muscle. Beyond this
point it passes beneath the radial head of the flexor
digitorum sublimis, and later still it lies deep beneath
the flexor sublimis and on the flexor profundus. At
the wrist the nerve becomes superficial and lies be-
tween the tendons of the flexor sublimis to the inner
side, and of the flexor carpi radialis on the outer side.
It passes superficially through the large flexor com-
partment of the anterior annular ligament and soon
divides into an inner and an outer terminal. Besides
muscular brain lies in the forearm, the median gives
off thi' anterior interosseous and small branches to
the elbow-joint.
The anterior interosseous nerve is given off from the
median opposite the insertion of the biceps, runs
down the front of the membrane in company with
the anterior interosseous artery, and supplies the med-
ullary arteries, the periosteum of the radius and ulna,
and the wrist-joint.
The xdnar nerve, from the angle between the ole-
cranon and the internal condyle, passes between the
inner and outer heads of the flexor carpi ulnaris to
the front of the forearm. It passes down upon the
flexor profundus under cover of the flexor carpi ulnaris
and overlapped by it upon the inner side. It passes
nearly to the wrist along the outer side of this muscle
and its tendon, when it becomes superficial and
enters the hand anteriorly to the annular ligament.
In the lower two-thirds of the forearm the ulnar
artery lies to its outer side, separating it from the
flexor sublimis. It also, besides giving off mus-
cular branches, supplies the elbow-joint.
The interosseous membrane bridges across between
the interosseous borders of the radius and ulna
from a point a little below the bicipital tubercle of the
radius to the wrist-joint. Its fibers pass mainly in
an oblique direction from the radius to the ulna.
The posterior interosseous vessels pass back over its
upper border and are in relation with its back surface
low down in the forearm. The anterior interosseous
vessels and nerve are in relation with the front sur-
face throughout. Except in supination of the fore-
arm and in full pronation this membrane is usually
tense. It serves also to carry strains from the radius
to the ulna and to bind the bones together.
oil
Arm and Forearm
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
The forearm is subcorneal, so that the lateral flap
operation is a necessity, since the skin cannot be
pushed far upward in the lower forearm. The skin
is also quite adherent to the underlying aponeurosis.
Roughly speaking, the intermuscular septa, the bones,
and the interosseous membrane form a front and a
back compartment. The ulna is subcutaneous from
olecranon to styloid process, so that any injury or
fracture is readily manifest. The radius lies deeply
lodged among the upper forearm muscles and it is
only occasionally that its head can be felt. In the
lower forearm the radius becomes gradually sub-
cutaneous and can be examined. The interosseous
membrane is tense in the semiprone position of the
foicarm, which indicates the best position, in fracture
of the radius or ulna, for splinting. Care should be
exercised not to permit the fractured ends of the
Fig. 316. — Dissection of the External Region of the Right Wrist
The radial artery is seen between the relaxed tendon of the flexor
carpi radialis below, and the braehioradialis on the outer (upper)
side. It then passes beneath the first two extensors of the thumb
and a small branch of the radial nerve, crosses the base of the
thumb obliquely, and disappears under the tendon of the extensor
pollicis longus. (After M. H. Richardson).
radius to rest upon the ulna, thereby causing injury
to interosseous vessels and nerves and favoring an
eventual ankylosis. Anteroposterior splints may
press too much upon radial and ulnar vessels and
nerves and injure them.
The muscles of the forearm in extremely muscular
subjects after too long and severe use may cause
pressure upon arteries and nerves, and resultant
pains and neuralgias. Muscular spasm may effect
the same results. Muscles become greatly hyper-
trophied under special exercises (as occurs, for ex-
ample, in the pronator teres muscle of the "tennis
arm"). A spasm of the same muscle may take
place, as in the "glass arm" of baseball pitchers.
Hypertrophy of both of the pronators, the result of
"feathering," may take place in the ease of oarsmen.
The inner edge of the braehioradialis is the guide to
the radial artery and nerve; the inner edge of the
pajmaris tendon is that for the median nerve; and the
outer border of the flexor carpi ulnaris indicates
where the ulnar artery and nerve are to be sought for.
Both arteries may be ligated at any point above the
annular ligament for severe hemorrhage of the palm.
Above the anterior annular ligament the two synovial
tendon sheaths of the flexor pollicis longus and thai
common to the sublimis and profundus extend for a
distance of an inch and a half, and often carry infec-
tion from the palm to the tendon spaces of the fore-
arm. In case of pus spreading deeply up the forearm
the median nerve should be used as a guide and
ion- made upon either side of it.
Through the posterior annular ligament extend
upward six such sheaths, all of which save the la i
extend well above the ligament. They are: one for
the two outer thumb extensors, one for the two
radiocarpal extensors, one for the long thumb ex-
ten, or, one for the common extensor, one for the
little finger extensor, and lastly one for the ulno-
carpal extensor,
suppurative.
Injuries of the
symptoms. (See
These sheaths are seldom
nerve trunks may cause varying
the Section on the Arm.) The
posterior interosseous nerve may be injured in resec-
tion of the head of the radius or in fracture of the
radial neck, and thus may cause paralysis of the
extensors. The posterior interosseous nerve may
suffer loss of function from fracture of the humerus
at some point near its middle. Pressure upon the me-
dian nerve in muscular spasm and in compression from
long and severe muscular exercise, may cause in-
creased cramps and pain or even a prolonged neu-
ralgia. The ulnar mrve may be injured in fracture
of the olecranon and may cause loss of sensation, or
numbness; or it may becaught in the callus of fracture,
either there or along the shaft of the ulna, and cause
pain; and, finally, the conditions may be such as to
necessitate excision of the nerve from the callus.
The numbness from a sudden blow upon the ulnar
nerve at the elbow — commonly spoken of as "striking
the funny bone"— is a familiar instance; and if
severe, this numbing and tingling may be persistent
and may be accompanied by loss of function of the
flexor muscles. In plumbism the ulnar nerve is
regularly involved, causing the "claw hand." The
ulnar and median nerves are both involved in alco-
holic neuritis. The radial nerve may be painful at its
points of distribution if the trunk is injured in Colles'
fracture. Neuromata along the nerve trunks, due
to injury, may demand excision.
Luzerne Coville.
Arm and Forearm, Diseases and Injuries of the. —
In considering the diseases and injuries of the arm ami
forearm, I shall take up the different affections of
the several structures under the following heads:
I. Affections of the Skin; II. Affections of the Fa.-cia;
III. Affections of the Bones, the Periosteum, and the
Joints; IV. Affections of the Muscles, Tendons, and
Tendon Sheaths; V. Affections of the Blood-vessels;
VI. Affections of the Lymphatic Vessels, Glands, and
Bursas; VII. Affections of the Nerves; VIII. Hyster-
ical Lesions; IX. Tumors.
It will be my purpose to discuss more fully .those
affections of these different structures which show
some peculiar manifestations when presenting them-
selves upon the upper extremities, and to deal with
them less in detail when exhibiting upon the arm
merely those features which are common to the same
affections elsewhere in the body. Particularly in the
case of diseases affecting the skin of the arm and fore-
arm, not all the dermatic affections which may be
found in this locality will be entitled to extensive con-
sideration, but such forms of skin trouble only as are
particularly prone to develop their lesions upon the
arms. Furthermore, it will suffice with regard to must
of these to call attention to the fact that certain
lesions may be expected on the arms and forearms,
and to describe their symptoms and appearance with
sufficient accuracy to allow of their diagnosis, while
more extended consideration of their pathology and
treatment is to be sought under other headings in this
work.
I. Affections of the Skin.
With regard to the diseases affecting the skin of the
arms, we have to content ourselves for the most part
with recording the observed fact of their appearance
in this locality, owing to our ignorance of the causes
that determine the outbreak of cutaneous lesions upon
this part of the body.
It is necessary to bear in mind that the general prin-
542
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Ann and Forearm, Diseases
and Injuries <»f *
dplea of dermatology are applicable here as in other
parts of the body, notably those which teach us thai
symmetrical lesions may generally bei ideredtobe
,li, r in internal causes, while for unsymmetrical lesions
there is a priori reason to think of local irritation as a
oause of the affection. Similar weight .should ln-
givcn in considering the relation of the cutaneous
lesion to the clothing of the part, inasmuch as certain
lesions are prone to appear on unprotected parts,
while others appear where the fricl ion of the clothing,
or vermin which the clothing may harbor, may give
i to local irritation. Other matters concerning the
of lesions of the skin on the arms, whieli may alTeet
the diagnosis, are the lines of cleavage of the skin, and
the presence of (lie lesions upon (he flexor or upon the
nsor surface of the affected limb, and finally the
in course of certain of the brachial nerves and
els. Nor should the general rule of der-
itological practice be forgotten which teaches us to
compare the integument of the arms witli that of the
of the body and so gain an accurate knowledge of
the anatomical distribution of the cutaneous lesions.
I In more recent nosological systems of dermatology
have sought in group the various lesions of the skin ac-
. irding to their pathological basis, and in the rapid
a which I purpose to make of such cutaneous
lions as have their common site upon the arms
and forearms, I shall consider the different lesions in
the general order of the classification of Jessner — to
wit, functional disorders, circulatory disorders, and
inflammations, superficial and deep-seated; finally,
I shall consider briefly traumatisms of the skin.
Functional Disorders of the Skin. — Of the first
class, that of functional disorders of the skin, such as
pruritus, hyperidrosis, seborrhea, it will suffice to say
that none of them have any predilection for the arms or
inns which would justify their consideration here,
if we except the entirely unimportant erythema
Bolare which is frequently seen on the arms of farmers,
bathers, and laborers who work in the open air with
i in sleeves rolled up.
Circulatory Disorders of the Skin. — Of the dis-
eases of the skin classified by Jessner as circulatory
disorders, the lesions of purpura and scurvy, while
undoubtedly they show themselves with comparative
frequency on the arms, yet it is rare that they should
show themselves there with any special preponderance
of distribution over other parts of the body. Peliosis
rheumatica, however, is a purpuric affection whose
predilection for the arms merits our attention in con-
sidering the cutaneous affections of these members.
In I'ELiosis rheumatica, also called purpura
rheumatica, a period of invasion precedes the erup-
tion for a variable length of time, and is shown by
general malaise, systemic disturbances and painful
swelling of the joints, especially of the knees, wrists,
and ankles. The temperature may be normal, but
more often it rises to 100° F. or more. In a few days
the eruption appears and the pain then subsides.
The lesions occupy practically the same regions as do
those of erythema multiforme (vide infra), namely,
the wrists, forearms, and lower legs, but sometimes
they are particularly located about and around the
inflamed joints. Some authorities indeed classify the
affection as a variety of erythema multiforme. The
lesions consist of bluish-red patches, and slightly
elevated, bright-red papules which quickly become
purplish; they may, however, be purpuric from the
first. Their color cannot be effaced by pressure.
After persisting for a few days, they pass through the
various gradations of color seen in a contusion and
disappear altogether. The disease may be limited to
outbreak, or the eruption may come out in several
crops and run a course of from four to six weeks, or
it may disappear altogether and ten days or more later
a relapse occur, and the joint and other symptoms
again become manifest. The recognition of hem-
orrhage into the skin is easy when it is borne in mind
that pressure does not cause the redness to fade. Such
lesions occupying the localities mentioned, ami a o
ciated with the systemic disturbance already de-
scribed, with the joint swellings, pains, etc., are
sufficient to constitute the diagnosis of peliosia
rheiimal ica.
Inflammatory Diseases of the Corium mid Sub-
cutis. of the inflammatory diseases of the skin,
we can at once dismiss the specific exant hemal oil :
fevers of childhood as having no special predilection
for the arms, and of i he di eases under the nosological
classification we are following, that known a lichi i
planus is the fii'st that arrests our attention. This
is a disease whose predilection for the arms as a site
for eruption is more marked than is the ease in that
just described. Indeed, if is often confined to the
flexor aspect of the forearm, though it manifests a
tendency in its course to spread over a greater part of
the lower arm and of the forearm; but ii never involves
the whole skin as do eczema, psoriasis, and lichen
ruber in certain cases. The following description of
the symptoms and course of t he disease is taken from
Gottheil: Lichen planus occurs most frequently as a
chronic ami localized malady, the more acute and
general form of the disease being rare. The site of
i he eruption is usually the flexor surface of the fore-
arms, especially around the wrists and on the backs
of the hands and the feet, but other regions are not
infrequent ly affected, and it occurs occasionally on the
palms, soles, and (he genitals. It is rare, however, on
the face and scalp. It is frequently symmetrical.
The lesions appear first as extremely minute papules
of a characteristic dusky red or purplish color, with
a waxy glance, and sharply differentiated from the
surrounding skin. Their sides are steep, and (heir
shape is distinctly angular. Their tops are Hat. and
marked with a central depression or capped with a
minute scale. On the palms and soles the individual
lesions may be hard to distinguish, the entire epi-
dermis of the affected region being elevated and
thickened, cracked in places and of a dusky hue and
covered with whitish scales. On the mucosae they
appear as whitish, flattened papules. They may be
scattered or irregularly grouped. As they gradually
enlarge to pea size, adjacent papules coalesce, and
thus extensive indurated and scaly areas are formed;
but the individual lesions do not increase beyond
their original size. After persisting for a long time,
months and years, they slowdy undergo absorption,
leaving atrophic, pigmented areas behind. No
vesicles or pustules are ever formed, nor are the nails
or the hair affected. The subjective symptoms are
confined to a moderate itching, and it is only in very
extensive forms that this becomes severe. The
patients are sometimes debilitated and run down by
excesses or overwork, but not infrequently they are
in excellent health. The malady occurs with about
equal frequency in both sexes. It is seen at all ages,
but is most frequent during middle life.
The diagnosis rests upon the peculiar shape, size,
grouping, and appearance of the papules as described
above. Papular eczema, especially when situated on
the forearm, may resemble lichen planus, but the
papules are rounded and frequently have a little
serum at their apices. They are intensely itchy,
round, run a rapid course, and leave no pigmentation
behind; and other eczematous changes, excoriation,
oozing, or crusting will probably be found somewhere
on the skin. In the papular syphiloderm the lesions
are round-topped and often arranged in crescentic or
circular form; they are generally distributed, and
more or less polymorphic; there is no itching, their
color is reddish. Other signs of syphilis are probably
present, and the disease responds to antiluetic treat-
ment. In lichen scrofulosum the round papules are
grouped upon the trunk and are accompanied by no
subjective symptoms whatsoever. Finally in psori-
asis the lesions are pink, covered with abundant,
543
Arm and Forearm, Diseases
and Injuries, of
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
heaped-up scales, and are situated solely on the
extensor surface.
The prognosis is favorable always. The disease is
chronic and obstinate, but it tends to recovery. It
may be added that the disease, though not common,
is K it excessively rare.
The grave progressive disease known as lichen
HUBEH may have some of its characteristic lesions
situated upon the arms, but its distribution is so
rarely limited to that locality that its discussion need
not detain us here. When present upon the arms
its tendency to follow and accentuate the folds and
lines of cleavage of the skin sometimes leads, in the
cubital folds, to the development of linear strings of
papules, constituting what is known as "lichen ruber
moniliformis."
Few of the forms of eczema confine themselves to
the arms, though small patches of scaly eczema are
not infrequently met on or near the wrists.
Eczema papulosum, however, is a form of eczema
both common and obstinate which has a predilection
for the limbs, both the arms and the legs, though it is
met with on the trunk as well. Host forms of
eczema are characterized by lesions with a more or less
fluid exudation which loosens the superficial portion
of the epidermis and spreads itself over the affected
surface. In some cases of eczema, however, the
tendency to exudation is lessened, and the probabil-
ities are that it is less fluid in character, and under
these circumstances does not gain the surface but
collects at points beneath the epidermis, raising little
solid projections which have received the name of
papules. These may be somewhat closely aggregated,
or there may be an appreciable distance between
them, and the surface will be dry unless the pruritus
leads to scratching and the edges of the papules are
torn; in that case a small quantity of lymph may
exude and dry into minute scales. In the course of
time, however, the papules themselves tend to subside,
and we have a surface somewhat glossy and scaly,
but not to the extent usually seen in other varieties
of eczema. This papular form of eczema has its seats
of election. It is perhaps never seen on the scalp and
some other parts, but it is quite common on the arms
and forearms, thighs, and legs, especially their flexor
aspects (Piffard).
Eczema fissum is still another variety of eczema in
which we have neither vesicles, pustules, nor papules,
nor the extensive exfoliation which characterizes the
exfoliative form of this disease. We may have a
more or less reddened surface, but instead of the
lesions already mentioned we find small cracks or
fissures extending through the stratum corneum and
sometimes through the stratum Malpighii as well. The
exudation in this fissured variety is slight, crusting is
slight, and after a time the skin returns to the normal
condition by a simple closing of the fissures and
disappearance of the congestion. These fissures are
perhaps more frequently met with behind the ears,
on the palms and soles, and at the various flexures
(Piffard).
Erythema multiforme is the next disease under
the head of cutaneous inflammations which claims
our attention, on account of its frequent appearance
on the forearms. Gottheil defines it as an acute
inflammatory disease, characterized by the appear-
ance of reddish papules, tubercles, vesicles, or blebs
of symmetrical distribution, and affecting by prefer-
ence the backs of the hands and the feet. Elliot
remarks that it is one of the most striking and con-
stant features of erythema multiforme that almost
invariably the lesions appear first on the backs of the
hands and extend to the forearms and then to the
lateral portion of (he neck ami face. Frequently
simultaneously, but more often later than on the hands,
the eruption is manifested on the dorsum of the feet
and on the anterior aspect of the legs. It is frequently
absent altogether from these regions, and besidesl
the eruption will present much variation in individua
cases. The eruption is always symmetrical, without,
however, presenting absolute symmetry. Often one
side of the body will be more severely affected than
the other. Its symptoms, course, and the differential
diagnosis are described by Gottheil as follows: After
a prodromal period marked by a moderate febrile
movement there appear on the backs of the hands and
feet, or on the palms and soles, and more rarely on
other parts of the body, a varying number of slightly
elevated, firm, reddish-violet papules fading on
pressure. This condition is known as erythema
papulatum. In a few days the papules grow into
tubercles perhaps one-third of an inch in size (ery-
t hema tuberculatum). The centers then begin to flat-
ten and fade out and assume a characteristic bluish-red
hue (erythema annulare). At the periphery where
the eruption is extending, the lesions preserve their
elevated form and reddish tint. Adjacent patches
may coalesce and form irregular figures, known as
erythema gyratum and erythema figuratum. More
rarely the appearance of blebs gives us the form
known as erythema bullosum. Herpes iris is the
designation given to a vesicular form of this erythema
in which new concentric rings of papulovesicles
appear in the depressed purplish center of an annular
erythema. These various forms, often looked upon
as distinct diseases, are in reality merely stages of the
same process with varying amounts of exudation.
A case may go through several of them and even show
them simultaneously, for multiformity is charac-
teristic of the disease; but usually one type only is
present, and the commonest by far is the papular
one. The malady occurs especially in the spring
and fall, and lasts for from four to six weeks. It
happens at any age, and issomewhat more frequent
in females than in males. The mucosa? are occasion-
ally affected. It is prone to relapse, and usually re-
aopears in its original type. It is occasionally com-
plicated with purpura, acute articular rheumatism,
and endocarditis.
Its typical course and location, the papules or
tubercles whose red color is removable on pressure,
and the absence of desquamation are sufficient to
characterize the disease. An eczema has exudations,
scales, and crusts, and itches intensely. Urticaria
has papules or pinkish, fugacious elevations, with
much itching and reflex irritability of the skin. A
papular syphiloderm is copper colored and not
removable by pressure; the palms and soles are usually
involved, and other syphilitic symptoms are generally
present. Prurigo has deep-seated, colorless pap!
begins in childhood, and itches intensely. Tri-
chophytosis corporis is scaly in the center, and the
parasite can usually be readily found.
While the arms are one of the rarer sites for the
vesicular eruption of herpes zoster, yet the fact
should be borne in mind that this disease occasionally
manifests itself in the course of the brachial nerves.
Its characteristic symptoms should make the diagno-
sis in most cases easy. Its symptomatology is this:
The eruption is almost regularly preceded by distinct
premonitory symptoms, consisting mainly in neuralgio
pains of variable degrees of severity over the area
about to be affected and lasting from a few hours to
several days, occasionally even for weeks. Some-
times they are missing entirely, particularly in young
children. The pain may be of a diffuse character, or,
again, confined to certain points which correspond
anatomically to the underlying nerves and their
ramifications. The cutaneous phenomena make
their appearance always in an acute manner. At
first there are redness and slight swelling over the
diseased area. This is soon followed by groups "f
small papular elevations, which in the course of a few
hours are transformed into vesicles from the size of a
511
REFERENCE IIAXDROOK OF THE MEDICAL SCIENCES
Arm and Forearm, Diseases
and Injuries v peripheral extension, become confluent
go as to form larger bulla-. They have generally little
dency to burst, and do so only accidentally.
Occasionally a larger surface may be uniformly stud-
.1 with these vesicles, but as a rule there are several
distinct and isolated groups of them, varying in size
from a dime to the palm of the hand, of irregular
tiape, and arranged more or less exactly in the form
i simigirdle when situated on the trunk. In other
regions the unilateral distribution of the eruption
ig the course of one or several cutaneous nerves
forms a striking feature. These groups Come Out
icessively, the one nearest the spinal column
Usually appearing first, but all the vesicles constituting
pat cli are formed and run their course contem-
poraneously. Their contents remain clear for three
or four days, then become gradually more turbid,
puriform, and by and by dry out, forming brownish
crusts which finally fall off and leave in their place
reddish or bluish discolorations. These persist for
.■■ time and gradually fade away. In some
instances, however, permanent marks may remain,
which, by their arrangement and distribution, are
quite characteristic of the preceding eruption. The
time consumed for the completion of the cycle in each
individual group is from eight to ten days, but through
the successive appearance of fresh crops of vesicles
n the older ones have almost reached the point of
involution, the whole process may last up to four or
even six weeks.
The subjective symptoms which accompany the
eruption are very variable. While in some cases the
preliminary neuralgia ceases with the advent of the
cutaneous manifestations, it is more often present
during the whole duration of the disease, and is
intensified by a burning and smarting sensation with
which every new crop of lesions is ushered in. Some
patients complain very little, others seem to suffer
very much, particularly from nightly exacerbations
which may disturb the sleep. Even after the com-
pletion of the eruptive stage there may remain for
some weeks, and occasionally for a long period, dis-
turbances in the sensory functions of the affected
area. Fever is frequently present with the zoster,
but is rarely of much consequence. A very remark-
able fact in regard to zoster is that it attacks a person
only once during a lifetime. Exceptions to this are
- few and far between that they do not materially
affect the generally accepted law.
The termination of the local manifestations does not
always indicate a complete restoration in the affected
territory- Not only may neuralgic pains persist for
some time and become the source of agonizing at-
tacks which deteriorate the patient's health, but in
ie cases there remain pruritus, hyperesthesia, or
complete anethesia and analgesia. Of particular
interest is the so-called " anesthesia dolorosa," which
occasionally follows a zoster. An explanation for
this peculiar phenomenon may be found in that the
pathological changes in the course of the nerve disturb
the transmission of sensation from the surface to the
center, whereby the anesthesia is produced, while the
use of the pain is located in the sensory root of the
spinal column.
U though zoster is generally attributed to disturb-
ances in the sensory nerves, the strange fact must be
recorded that often muscular atrophy and motor
paralysis are caused by it. Paralysis of the arm
muscles after zoster brachialis has been noted by
Schwimmer, Joffroy, Broadbent, and Gibney.
The characteristics of zoster are usually so marked
that little difficulty can exist in recognizing it. Its
unilateral distribution along the course of well-
inown cutaneous nerves, the successive appearance
Vol. I.— 35
of groups of vesicles, their cyclic course, and the con-
comitant neuralgia will easily establish the diagnosis.
From eczema it is readily differentiated by the larger
size of its vesicles and their tendency to pel i-t as
such, whereas in the former they burst very won and
give rise to characteristic oozing (Zei sler).
Psoriasis is a disease which on account, of its
customary distribution merits a description among
the cutaneous affections of the arm. The lesion of
psoriasis are characterized by the formation of a
thick imbricated covering of dry scales of a light
yellow, pearly white, or silvery color situated on a
reddish, slightly elevated, well-defined base. The
disease appears without premonitory symptoms, and
the first indication of its presence is the appearance of
small pin-head sized, rose-colored spots, w Inch in a
day or 1 wo become! covered with silvery scales, psoriasis
punctata. These spots increase at the periphery,
while the scales become piled up into thick crusts
which, from their resemblance to drops of mortar
spattered on the skin, constitute the form known as
psoriasis guttata. If the attack runs an acute course,
the patches rapidly increase in size, and in a week
may attain the dimensions of coins, psoriasis num-
mularis. Generally, however, the eruption is noted
for its chronicity, and months are required for this
development. The tendency of the psoriatic lesion
is to disappear of its own accord, although the time
occupied in this process may be months or years.
The activity of the scaly proliferation first begins to
subside in the middle of the patch, which finally goes
on to complete resolution, leaving a ring-shaped
margin standing out in bold relief — psoriasis annu-
laris. If the disease continues to extend, the rings
meet, giving figure-of-eight-shaped eruptions, and
as the healing proceeds, the point of contiguity
in turn disappears, leaving irregular or serpentine
lines — psoriasis gyrata.
The accumulation of scales, which is the most
distinct feature of psoriasis, varies in different cases
as well as on different parts of the body of the same
individual. On the scalp the scales are thick, and the
eruption tends to extend beyond the margin of the
hair. On the extensor surface of the limbs, also, the
scales become piled up on elevated bases to the
height of several lines. On the face and penis the
scales are less abundant. Although the scales are
adherent to each other and to the base underneath,
yet they may be detached by the finger nail, when,
if the disease is of recent origin, a pale reddish surface,
which readily bleeds and is but slightly raised above
the surrounding skin, will be seen. In cases of long
standing the base is of a dark or venous hue and
markedly thicker than the normal skin. The scales
thus removed are quickly renewed and in a few days
attain their former thickness. There is no discharge
or moisture connected with the eruption at any time,
and the sensation of itching may or may not be present.
Although all parts of the body may be involved, yet
there are regions of predilection which are generally
involved, especially at the onset of the disease. These
are the points of the elbows and the anterior aspect
of the legs just below the patella?. The scalp is also
a favorite position, and in typical cases the disease
is more marked on the extensor than on the soft, flexor
surfaces of the body. In all cases the eruption tends
to symmetrical distribution.
Although psoriasis is usually a well-defined disease
and easily recognized, yet it is subject to variations
and in atypical cases may baffle the skilled diagnosti-
cian. In appearance it varies from a simple furfura-
ceous desquamation which may be the result of fric-
tion, to a veritable inflammation as in scaly eczema.
Eczema squamosum, however, is less frequently
symmetrical, the flexor surfaces of the joints are
favorite positions, while the extensor surfaces of the
points of the elbows or knees are not affected as in
545
Arm and Forearm, Diseases
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psoriasis. In psoriasis the eruption is sharply de-
fined, and its margins frequently stand out like a bold
headland, while in eczema the patch is thickest at the
center and its margin merges gradually into the healthy
skin. A history of moisture will often enable one to
decide, for eczema at its outset is always moist,
while psoriasis is essentially a dry-eruption from the
beginning. In eczema the accumulation of scales is
less than in psoriasis, and they are of a bluish color
rather than white. The scales in eczema are more
easily detached, and the base when scraped be-
comes bathed with serous exudation and does not
bleed as in psoriasis. Eczema of the palms and soles
is more common than psoriasis in this position. It is
more fissured and may be the only part involved,
while psoriasis does not attack these parts alone.
The nails are affected in both diseases, but in eczema
they are usually all affected at once, while in psoriasis
one or more nails, but never all, are involved at the
same time. Lichen planus and lichen ruber may be
mistaken for psoriasis when the former are of long
duration. Lichen first appears in the form of small
pin-head to split-pea sized, flat-topped papules which
are distributed in clusters and extending at the peri-
phery run together, giving the eruption the appearance
of one continuous patch, not unlike psoriasis; lint
there is less scaling in lichen and the eruption extends
by the formation of characteristic islets which may be
seen on the outskirts of the original cluster. The
characteristic position of lichen is on the flexor
aspect of the wrist, a position seldom occupied in
psoriasis. Syphiloderma squamosum often resembles
psoriasis very closely, and next to eczema is most
liable to be mistaken for this disease. On account
of the close similarity, this form of syphilodcrm was
formerly called syphilitic psoriasis. But syphilis
attacks the mucous surfaces as well as the skin, and
is seldom present on the latter without appearing on
the former; while psoriasis never attacks the mucous
membranes. Syphilis but rarely occurs on the el-
bows and knees, but it is very commonly met with
on the palms of the hands and the soles of the
feet. One hand may be affected in psoriasis, while
both are usually involved in syphilis. The erup-
tion in syphilis is polymorphous, presenting from
time to time papules, pustules, and moist condy-
lomata which would at once enable one to distinguish
it from psoriasis. In late syphilis the destructive
nature of the disease will become apparent by scars
or fissures, while psoriasis leaves no mark behind.
The scales in syphilis are muddy gray, and the base
of the eruption is more infiltrated and of a darker
color; moreover, the history of the disease should
always be considered (Corlett).
Dehmatttis venenata is seen more frequently, per-
haps, on the wrists and forearms than on other parts of
the body, for the simple reason that these parts of
the body are those most frequently exposed to tin'
irritating influences which occasion the affection.
Surgeons and obstetricians are frequent sufferers from
a mild form of this difficulty, due to the application
to their hands of strong disinfecting solutions. In
this case, the prompt sequence of the symptoms,
namely burning, swelling of the skin, redness, and
occasionally the development of vesicles, upon the
application of the disinfectant render the diagnosis
easy and unmistakable. Workers in brass and
copper, those whose occupation brings them into
frequent contact with aniline dyes and other chem-
icals, and operatives engaged in handling gummy and
adhesive substances which have to be removed with
st long soaps or with special chemicals, present
similar lesions which are grouped by the dermatolo-
gists under this same head. In many cases the skin
of the hands will escape, while that of the wrists and
forearms is more susceptible to the causal irritant.
In all cases of dermatitis affecting exclusively or
preponderatingly the wrists and forearms, the
occupation of the patient and the opportunities for
special exposure to specific irritants should carefully
be considered in the diagnosis.
Deep-seated Inflammations of the Skin. — The in-
flammatory diseases we have so far reviewed are
classified in the nosological scheme of Jessner as
inflammations of the corium and subcutis. Of the
deep-seated inflammations which constitute the next
category, there is an affection classed by some as a
form of erythema multiforme, and by others as a
distinct disease, known as erythema nodosum which
while it does not often locate itself on the arms, might
yet prove puzzling to one unacquainted with its
course if met, as occasionally occurs, exclusively in
that locality. Its prodromal symptoms are practic-
ally identical with those preceding an attack of ery-
thema multiforme (q.v.), namely, fever, gastric dis-
turbances, and pains in the joints. It attacks like-
wise a similar class of patients, young people in a
condition of depressed vitality. Its lesions are an
exaggeration of those of erythema multiforme, but
its customary distribution is less frequently upon the
forearms. One of its alternate names, dermatitis
contusiformis, is descriptive of the appearance of its
lesions. The eruption appears in nodes of a con-
siderable elevation, rounded or oval in shape, varying
in size from that of a nut to that of an egg. They
are warm to the touch, surrounded by an edematous
area, painless, but tender to pressure. Their color
is at first a rosy red, changing to a darker and more
livid hue, and not removable by pressure. They
never coalesce nor suppurate. In the course of eight
or ten days they gradually disappear, going through
the color changes that are seen in blood extravasa-
tions and leaving a dark discoloration behind.
Three or four nodes only are usually present, and their
number rarely exceeds a dozen. Though the indi-
vidual lesions last only a few days, a succession of
fresh ones often prolongs the malady for two or three
weeks. Recurrences are rare.
Ordinary contusions may be mistaken for the nodes
of erythema nodosum, but they never have the
peculiar rosy color, are not usually multiple, are not
round, there are no general symptoms, and there is
the history of an injury. Syphilitic gummata may
resemble them closely, but the antecedent pains are
much severer. They are slower in their course, are
very rarely seen in the young, and are almost always
accompanied by other symptoms of lues, past or
present. The prognosis is generally good, though
complications may arise which may make the prog-
nosis more serious.
It may be stated as a general proposition that there
is but little tendency for the cutaneous lesions of
syphilis to localize themselves upon the arms and
forearms. Particularly is this true of the earlier
macular and papular eruptions, which have as a
pathological distinction the involvement of the
superficial anatomical elements of the skin and a
generalized distribution all over the body; in which
distribution, indeed, the arms are not exempt. An
occasional tendency toward characteristic localization
upon the arms is manifested in some of the later
syphilides, whose characteristics are an involvemi
of the deeper cutaneous structures and a less general
and less symmetrical distribution over the body.
Accordingly we see in some of the pustular syphilidea
a certain very limited tendency to a location of the
lesions on the arm, or what is more frequent, a tend-
ency to aggravation on the arms of a pustular erup-
tion elsewhere present in a milder degree. Thus an
acneiform or impetiginous syphilide upon the
and the trunk may be accompanied with an ecthy-
matous, exulcerated syphilide of the arms. It is
also to be regarded as somewhat characteristic of
syphilis that an acneiform eruption should make its
appearance upon the arms in portions so ill supplied
546
];i:ii:i;i.N('i: handbook of tih: mi.dk \i. si if.jtceS
Arm and Forearm,
and Injuries
Diseases
of
With BebaceOUS glands anil hair follicles as to be
ordinarily exempt from the manifestations of acne
vulgaris.
ill,, occasional development on an arm or forearm
of the later tubercular or gummatous syphilides can
hardly he regarded as more than an accident to which
any part of the skin of the body is liable in this protean
disease, and withal the arms and forearms seem
rather exempt than otherwise from any considerable
frequency of accidents of the kind.
Farcy. — There is one disease which presents, among
its other lesions a form of deep-seated inflammation
of the skin, whose pathological importance is very
t though the disease itself is not at all common.
namely, farcy, a name given to the lesions of (jlami. rs
when they affect portions of the body other than the
respiratory organs. The gravity of the disease, with
a mortality estimated at upwards of seventy-five
per cent., the comparative rarity of the affection,
making it unfamiliar to most practitioners, and its
tsional appearance on the arms as a result of
infection of the hands, are the reasons which lead
ine to include in this article a description which it is
will suffice to make possible its recognition.
The course of farcy or glanders includes a stage of
incubation, varying from two to fifteen days, a
premonitory stasre, consisting of ordinary pyrexia,
febrile excitement, etc., and including pain affecting
the muscles, simulating rheumatism, and sooner or
later a <;a>_'e of eruption, which develops the specific
characters of the disease. In acute cases the stage
of eruption appears almost at once, or soon after the
invasion, but in the more chronic cases there may be
an interval of weeks.
The most prominent of the local symptoms is the
glanders eruption, consisting of a crop of pustules,
remarkably hard, simulating those of small-pox, and
attacking the skin like an exanthem. Virchow
their development as follows: At first there
appear some red spots which are very small and
resemble flea-bites, these soon acquire a papular
elevation, subsequently rising above the level of the
ice like small shot, assuming a yellow color.
These shot-like nodules are either flat or round, and
they do not lie in a bladder-like elevation of the
epidermis, but in a kind of hole in the corium, as is
the latter had been punched out; they are not always
solitary, but are often disposed in groups. There if
• surrounding injection, and under the epidermis
there is found a puriform and yellow fluid, seemingly
homogeneous, which is formed chiefly from softening
of the nodule. These nodules attack in a similar
manner the mucous membrane of the nose, where
they are .-mall and linseed-shaped, and give rise to
the peculiar nasal discharge. Softening of these
tubercles next ensues, the skin gives way and ulcera-
tion follows, and thus are formed small holes filled
with debris, producing the pus of glanders and the
farcy abscesses.
These tubercles may r be developed in other situa-
tions, such as in the subcutaneous cellular tissue,
producing circumscribed, hard and painful boils, or
diffused swellings of great extent, which either
open spontaneously, or give rise to extensive sloughing
of the skin and deeper structures. In rarer instances
the tubercles subside and reappear in other parts, a
form of the disease which is termed "flying farcy."
npanying the eruption are found small, soft
tumors about the extremities, forming a kind of
pyemic abscesses, generally seated in the muscle-.
seldom attacking the glands, and, when subcutaneous,
remarkably defined, like an egg.
In acute farcy, which is generally induced by the
inoculation of a scratch or an abrasion, there is the
superaddition of inflamed absorbents and lymphatics,
and in these cases we have diffuse suppuration of the
limb and suppurating glands.
In chronic farcy the wound degenerates into a fotd
ulcer, and the inflammation and suppuration of the
lymphatics is slow and tedious. This form often
terminates in acute glanders.
Traumatic .1 of the Skin. — It should be
borne in mind that the forearms and bands are the
portion of the anatomy nio-t accessible to ;
neurotic patients who, for purposes of exciting
sympathy or from oilier morbid impulses, indie
their own person various lesions, rarely severe, yet
occasionally difficult of diagnosis. Such lesions are
ordinarily such as would result from the application
of irritant or vesicant drugs, or such lesions as would
result from prolonged mechanical irritation with
the finger tips, the nails, or some rough or sharp
instrument.
In considering the traumatic affections of the
cutaneous tissues of the arm and forearm, two forms
of injury present themselves as of special frequency
and importance, owing to the exposure of the upper
extremity to all manner of vicissitudes incident to
active life. These are extensive abrasions and
extensive burns. The treatment of burns and
abrasions of the upper extremity does not differ
essentially from the treatment of similar conditions
elsewhere, only on the forearm an extensive burn
may do more damage than elsewhere on account of
the subsequent contraction which may involve the
subcutaneous tissues and compromise more or less
seriously the independent action of the muscles which
move the hands and fingers. On this account skin
grafting according to the method of Thiersch is
indicated for a burn on the forearm many times when
a burn of like extent and equal depth, if situated else-
where on the body-, might be left to granulate with
impunity.
As stated above, it has been my aim in considering
the cutaneous diseases liable to affect the arm and fore-
arm, to present such a picture of the lesion as would
suffice for its identification. Further discussion of
the pathology, etiology, prognosis, and treatment of
the different diseases enumerated must be sought in
other parts of this work, or in treatises more espe-
cially concerning themselves with dermatology.
II. Affections of the Fascia.
The affections to which the fascia? and cellular
tissue of the arm and forearm are liable are of three
general types: erysipelatous, tuberculous, and syphil-
itic. To these we may add certain rare cases of con-
traction of the fascia antibrachialis, more or less
analogous to Dupuytren's contraction of the palmar
fascia, and of an equally uncertain pathology.
Streptococcic Invasion of the Fascia. — Erysipelas is
usually described as an affection of the integument,
and the process is undoubtedly frequently confined
to the skin, proceeding with its characteristic red
blush to extend in the direction of the lymphatic
current until the energy of the infecting streptococcic
colonies is exhausted, and the disease subsides after a
definite run of from six to fourteen days. This form
of simple cutaneous erysipelas occurs with greatest
frequency 7 upon the face, but may make its appearance
anywhere on the integument where streptococci may
find an entrance, through an abrasion, perhaps
extremely minute, or may have found lodgment in
the glands or follicles of the unbroken skin.
Identical with cutaneous erysipelas in etiology 7 , but
differentiated from it in course and sy T mptoms, is
streptococcic invasion of the fascial and connective-
tissue planes of the extremities and occasionally of the
head and trunk. On account of the difficulty of
access to the subcutaneous tissues through the un-
broken skin, the history of fascial and cellular ery-
sipelas will generally reveal a preexisting, probably
bad-behaving wound on the distal side of the focus of
the phlegmonous process. The liability of the fingers
547
Ann and Forearm, Diseases
and Injuries of
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
and hands to traumatisms small and great, and the
exposure of these parts to subsequent infection, ex-
plain the great frequency with which fascial phleg-
mons are met with on the arms and forearms, par-
ticularly of mechanics.
The "differentiation between the several types of
fascial infection is not in all cases easy from clinical
symptoms alone, but the behavior of typical cases is
sufficiently characteristic to permit a probable diagno-
sis, to which a bacteriological examination will in
most cases add confirmation. Although mixed infec-
tions doubtless often occur, other more strictly pyo-
genic, infections rarely confine themselves to definite
anatomical layers as do infections by streptococci. The
course of streptococcic invasion of the fascia and cellu-
lar tissue is accompanied by an amount of fever in
general commensurate with the extent to which the
lymphatic channels are opened up for the absorption
of the products of the germ life, rather than com-
mensurate with the mere extent of territory involved.
The temperature reaction in cases of infection of the
fascial and cellular tissue of the forearm is rarely
very great, it being rare to witness a temperature
higher than 102° to 102.5° F. when the trouble is con-
fined to the fascia and connective tissue of the arm.
In marked contrast to this is the course of the strep-
tococcic invasion of the pelvic tissues, where the
abundant lymph channels allow the absorption of
enormous quantities of toxins and even pus. A
similar difference is seen in erysipelatous infection of
the arm and forearm when along with the infection of
the fascia and cellular connective tissue there is like-
wise an invasion of the skin itself, phlegmonous
erysipelas, stricto sensu, where the general vascularity
of the tissue allows a much more active inflammatory
reaction to the microbial invasion. For this reason
the temperature is a much less fallacious guide to the
gravity of the condition in this than in many other
surgical diseases. The onset of the disorder is usually
marked with sensations of chilliness if not with posi-
tive rigors, and a general malaise, anorexia, and more
or less gastric disturbances are pretty constant ac-
companiments of at least the early course of any ex-
tensive affection of the kind. The amount of pain is
very variable, and is for the most part decidedly less
than one would expect to meet in a staphylococcic in-
vasion of equal extent. This difference is due largely
to the different anatomical tissues for which the two
kinds of germs seem to have an affinity. Staphylo-
cocci tend to form circumscribed colonies in the more
vascular structures, often beneath tough and resis-
tant connective-tissue planes, where the resultant pus
or exudation gives rise to great and painful pressure
upon the sensitive nerve fibers. Besides which it is
very probable that the toxins produced by the staphy-
lococci, particularly the staphylococcus aureus, are
themselves peculiarly irritating to sensitive nerve
tissue.
The streptococcus, on the other hand, has a pre-
dilection for the connective tissues and for the fascial
membranes themselves, invading by preference their
superficial surface; the resultant pus is not bound
down beneath the tough and resistant membranes,
and does not cause so much pain from pressure under
confinement, and it is perhaps probable that the
specific toxins of the streptococcus are somewhat less
highly irritating to the sensitive nerves. The hu-
man system, furthermore, seems to combat the
streptococcus by a more ready manufacture of an-
titoxin than it does in its efforts to overcome the
staphylococcus, and thus to establish a temporary
partial immunity to the attack of the streptococcus.
This will account for the tendency that is sometimes
manifested in streptococcic processes to linger on in a
mitigated yet protracted manner, continuing to
vegetate in the tissues in an obstinate yet less virulent
form than at the outset of the attack. Thisis partic-
ularly prone to be the case in cases of extensive in-
volvement of tissues of low vascularity. The vitality
of the germs permits their continuous growth in tissues
of feeble resisting-powers, while the system, through
the accumulated stores of antitoxin, can so far neutral-
ize the toxic products of the bacterial growth that
the materials absorbed do not poison the body, as is
shown by the diminished fever and the general sub-
sidence of general constitutional symptoms, in spite
of the lingering of the local process in the fascial
layers. Thus arises a prolonged, quasi-chronic
form of the trouble, which is particularly likely to
supervene when the fascial planes of the extremities
are invaded. The streptococcic invasion of the fascial
planes of the arm and forearm is generally first along
the deep fascia, with or without concomitant involve-
ment of the superficial fascia and the skin. Only
when the process has been for some time under way
do the muscular septa become involved, and then a
most formidable condition known as a deep dissecting
phlegmon results.
The systemic effects have already been mentioned
above. The local symptoms are characteristic in
typical cases, and allow a ready diagnosis. At a
point, it may be bordering on a wound, but more fre-
quently at a greater or less distance to the proximal
side of it, the skin will be seen to have a somewhat
livid hue, and will appear somewhat edematous; yet
there will be lacking the dense infiltration of all the
tissue layers which characterizes a general cellulitis
depending upon infection with the staphylococcus.
Then, too, the classical signs of inflammatory action
will be less marked, unless the skin and superficial
fascia are also involved — i.e. there will be, as coin-
pared with the staphylococcic infection, less redness,
less swelling, less heat, and less pain. The original
wound may or may not appear to be involved in the
infection, or if the wound is itself the seat of suppura-
tion, the channel of communication between the
original wound and the seat of the secondary suppura-
tive process may be difficult to trace.
The limit of the involved area is very indistinct, as,
owing to the want of vascularity of the affected
tissues, there is no marked inflammatory induration
acting as a wall of circumvallation about the focus
of infection. To the examining finger, the sensation
imparted on palpation is rather that of a layer of fluid
separating the tissues, than that of a localized abscess
with indurated borders and softening center.
When the skin and superficial fascia are also in-
volved, which is the exception rather than the rule,
the implication of these more vascular structures in
the morbid process will lend the appearance of a
more acutely inflammatory type to the disease. The
redness will be that of the angry blush of cutaneous
erysipelas. The inflammatory exudation into the
interstices of the skin will afford a more marked
swelling, and a brawny feel to the tissues on palpa-
tion. The epidermis may be lifted in more or less
extensive vesicles or blebs, whose original serous con-
tents may become sanguinolent, and the delimitation
of the focus of infection may be more distinct, the
deep fascia being rarely involved in these cases much
beyond the cutaneous blush.
The disease, if untreated or if refractory to treat-
ment, though it tends to recovery through exhaustion
of the virulence of the infecting germ, yet is likely to
be extremely destructive to the tissues which it at-
tacks; and if the accumulating pus is not freely evac-
uated, the process, although residing by preference
in the layers of connective tissue first attacked, yet
can easily transgress these limits and by the erosive
and solvent action of the pus, or by the progressive
outgrowth of the streptococci, involve contiguous
structures to an extent that may be dangerous to life
through secondary hemorrhage, due to erosion of an
artery, or from pyemia, due to septic thrombosis in
the veins followed by "yellow softening" of the clot
and embolism.
548
REFERENCE IIAXDROOK OF THE MEDICAL SCI] Ml S
Ann ami Forearm, Diseases
ami Injuries <>f
The prognosis, in the forms affecting the fascia
alone is good, if opportunity is given for a free hand
in the surgical treatment of the case, ami the patient
has a certain strength of constitution behind him.
In the form mine strictly known as phlegmonous
erysipelas -i.e. the form complicated by the involve-
ment of the skin and superficial fascia as well the
ignosis is grave if any considerable portion of the
limit is involved. In that form of the disease in which
the deeper eonneet ive-t issue planes are involved — i.e.
the intramuscular sepia and the perimysium — while
the prognosis as to life is fair, the prognosis as to
restoration of the limb, or even as to life without
ificing the limb, is uncertain.
The diagnosis of typical cases is not difficult, the
non-involvement of the adjoining structures being
more or less readily appreciable ami characteristic.
ipelatous infection of the fascia is to be differ-
iicd from the general inflammatory edema
ounding a focus of deep-seated suppuration, from
malignant edema, and from the tuberculous and
syphilitic forms of connective-tissue disease. The
ol differentiation from deep-seated and
destructive abscess of staphylococcic origin have been
ribed above. They are non-involvement of the
, or its involvement under a strictly erysipelatous
type of inflammation with the characteristic blush;
01 1 1 ci i ion of blebs and superficial infiltration and
thickening of the skin itself, quite different from the
brawniness accompanying the infiltration of the
ler la vers, which is characteristic of a deep
ess. Furthermore, there is wanting in this form
■ lamination the delimiting wall of inflammatory
exudate which marks ordinary abscess formation,
no distinct line of demarcation separates the
ted from the healthy tissue.
From malignant edema an erysipelatous infection
of the fascial planes is likewise to be differentiated by
the less malignant and acute character of the disease;
by the absence of the extreme fetor accompanying
lesion, and by its tendency to confine itself to
kind or to one layer of tissue. Malignant edema
is a rare disease in man, and, according to Park, is
ntially a specific form of gangrene. The infected
moreover, frequently contains gas.
From the tuberculous form of the disease, the
erysipelatous form is to be distinguished by- its rather
prompt following upon a wound on the distal side of
the phlegmon (two to twelve days'), by its rather
rapid rise to an acme (four to six days), by distinct
evidences of sepsis rather than cachexia, by the
character of the evacuated discharge (more distinctly
purulent and often containing more or less extensive
sloughs), and by the pain and heat, which are much
mure distinct than in the cold abscess.
From syphilis of the fascia, an erysipelatous process
can be distinguished by the absence of the gummatous
infiltration, by the fever and pain, by the sudden
onset often consecutive to a lesion on the distal side of
the phlegmon, and by the absence of other manifesta-
tions of syphilis. It must, however, be borne in
mind that a syphilitic subject may. quite as readily
as any other, become the subject likewise of a non-
syphilitic infection of the fascia.
The treatment of erysipelatous disease of the fascia
consists in giving the freest possible vent to the pus, in
vigorous local antisepsis, and in stimulating and
supporting the general system. Further means to
ider in combating this formidable malady are the
cautious use of either active hyperemia (induced by
the local hot-air bath) or passive hyperemia (induced
by a constricting bandage on the proximal side of the
lesion), the introduction into the circulation of certain
general antiseptics such as soluble silver or some
formaldehyde derivatives, the use of specific antitoxic
sera, and the use of specific, autogenous bacterial
vaccines.
As long as the disease is confined to the deep fascia,
we may expect by free incision and by the local
application of antiseptics to arresl the infectious
process. Incisions to this end should be made
subject to these rules: They should be parallel lo
the long axis of the limb; they should penetrate down
lo, but not beyond, the deep fascia; and they should
be numerous enough and long enough to give '
access to all demonstrably affected tissue. With
these rules in mind the surgeon -in mid and may Inci e
the tissues freely and extensively, and may do so
without great danger either of provoking extensive
hemorrhage or of exposing the patient to sloughing of
t he -kin, or to n lore extensive gangrene of the extrem-
ities, as the main blood-vessels run beneath the deep
fascia, and the cutaneous branches are fully as likely
to have been already obliterated by the -optic process
as they are to be divided by the knife. It is well to
avoid the large superficial venous trunks of the
forearm, and particular pains should be taken to
avoid the mediana profunda vein at the angle of
divergence of the median basilic and median cephalic
veins, as this is the main communicating branch
between the deep and superficial sets of blood-vessels,
and by extension along this vein a thrombus might
communicate the septic process to the deeper
tissues.
After free incisions have been made, there comes
up the question of whether or not it is best to use the
curette. This is generally to be answered pretty
decidedly in the negative. The introduction of the
curette, even of the rinsing curette, into the crevices
between the deep fascia and the skin, where the
infectious process is mainly located, can hardly serve
to dislodge septic material spread over a large area
to any such degree of thoroughness as will compensate
for the disadvantages attending the mechanical lifting
of one anatomical layer off the other, for by means of
this disturbance of the anatomical layers the infecting
germs are given more ready access to still uninvaded
regions. The case is quite different from that of a
circumscribed abscess, where over a region of com-
paratively small area necrotic tissue needs to be
removed to a considerable depth. In fascial ery-
sipelas a large area is affected to only a moderate
depth; and weighing the results of the unavoidable
trauma inflicted by the instrument, on the one hand,
with the proportionate gain in the removal of septic
material on the other hand, the balance will in most
cases be against the use of the curette in septic
fascial disease.
Less damage is likely to ensue from the careful use
of the probe in exploring the extent to which the puru-
lent process may have undermined the skin; in fact, a
careful exploration of this kind is indispensable to
guide the surgeon in making his incisions. It is
particularly necessary to make at least one incision at
the proximal border of the suppurating area, so as to
permit thorough flushing of the infected tract and to>
establish through-and-fhrough drainage, and the
upper limits of the suppuration can most conveniently
be determined by the use of the probe.
When once the limits of the disease have been
determined and the necessary incisions have been
made, a thorough flushing of the diseased area with
antiseptic solutions should follow. To this end con-
siderable hydrostatic pressure should be employed,
and every effort should be made to force the fluid
injected at one incision to escape at another. If this
does not readily follow on introducing the tip of the
irrigating-tube at one orifice, it is quite in order to>
make a passage for the fluid by subcutaneous dissec-
tion if necessary, either by dividing the obstructing
tissue bands with the knife, or by forcing the tip of the
glass irrigating-tube under the skin until the flow is
established from one incision to another. A solution
of mercuric chloride, 1 to 1,000, is frequently used for
this purpose, and should be passed through the
wounds in large quantities. Stronger solutions of this
549
Arm and Forearm, Diseases
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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
same salt may be used; but if they are, a second
flushing with plain water should follow on account of
the poisonous qualities of the salt.
Aside from its value as an antiseptic, certain
mechanical advantages attend the use of hydrogen
peroxide in septic infection of the fascial planes —
namely, the liberated gas lifts apart the layers of
tissue and opens up the diseased territory to the
further action of the antiseptic, yet lifts the superficial
layer very gently and evenly without carrying septic
material into uninvaded areas. Furthermore, the
development of the oxygen gas can be felt through
the integument, and the bubbling of the gas may be
sufficiently appreciable to the touch of the surgeon
to act as an indicator of the presence of suppurating
tracts, perhaps unsuspected from investigation with
the probe alone.
After free multiple incisions and thorough flushing,
seton drains should be inserted, passing subcutane-
ously from one incision to another; this is a far more
useful form of drainage than the mere packing of the
wound with gauze. In fact, distention of the pockets
is to be avoided on account of the undesirable tension
on the margins of the affected area where the process
is likely to extend. It is essential to the usefulness of
the seton that the incision through which it enters
and that through which it emerges should be suffi-
ciently ample so that the lips of the wound shall not
hug tightly the material of which the seton is composed,
otherwise the object both of the seton and of the in-
cision is nullified. The object of the seton is strictly
that of a wick, and this function is much better
fulfilled by a slender seton, easily movable to and fro
in its bed, than by a large mass of material which
chokes the orifices of entrance and of exit and dis-
tends the cavity which it meant to drain. The best
material for a seton is sterilized absorbent lamp-
wicking, or perhaps iodoform lamp-wicking. A
good substitute for this is a ribbon of plain or iodo-
form gauze, from one-half to one and a half inches
wide, folded once or twice on itself. Either the seton
should be threaded through the eye of a seton probe,
or through the eye of the probe should be threaded a
ligature of heavy silk and this loop be used as the
carrier for the bulkier seton.
After the incisions are made and the wound is
flushed out, and the setons are drawn through, the
question of dressings comes up.
Just here it is necessary to suggest caution in the in-
discriminate application of wet dressings. The ad-
vantages in the use of wet dressings lie in the greater
absorptive powers of the wet dressing by which the
discharges are more readily withdrawn from the
neighborhood of the wounds, and in the more efficient
action of the antiseptics with which the dressings
may be permeated.
The dangers from wet dressings, however, are also
twofold. First, they provoke a certain amount of
maceration of the skin, by which erysipelatous
dermatitis, an ever-threatening complication, is in-
vited. Secondly, the relaxation and softening of the
tissues, which is advantageous in relieving the stasis
in the capillaries where more vascular structures are
involved, may prove equally effective in furthering the
spread of the streptococci along the planes of soft and
comparatively non-vascular tissue which are involved
in fascial phlegmons, allowing the process to extend
in tracts which might otherwise be less vulnerable to
their attack.
In view of these two objections, I am convinced
that wet dressings must be used with considerable
caution in phlegmons whose principal seat is between
the deep fascia and the skin, to avoid encouraging the
extension rather than the arrest of the disease. The
more free and complete the drainage, however, the
less these objections hold, and where the incisions are
ample and numerous, the obvious advantages of the
wet dressings may more than counterbalance the
550
objections to them, to which attention has been
called by way of caution.
In any case the need of frequent renewal of the dress-
ings is imperative. When it is impossible, through
too great fatigue and pain to the patient, to redress
the wound sufficiently often to make headway against
the persistent suppuration, with the proviso that the
incisions shall be sufficient in number and in extent,
the constant drip or the constant bath may advan-
tageously be substituted for the wet dressing. Inas-
much, however, as the disease we are now considering
affects principally non- vascular tissues, the great bene-
fits which follow this form of treatment when another
class of tissues is involved, are not so conspicuous in
cases of purely fascial disease. In cases complicated
by cutaneous erysipelas, the constant bath, however,
will be found of great value.
At subsequent dressings, after abundant provision
has been made for the speedy discharge of pus, great
advantage will be found in saturating the wicks
which are drawn beneath the skin from incision to
incision with Peruvian balsam, ichthyol, or some
other tissue stimulant, and this use of stimulant
dressings within the wound cavities will be found use-
ful as long as these remain open.
In the later stages of the disease when the active
spread of the suppuration seems to have been arrested,
much may be done to hasten the obliteration of the
pockets beneath the skin and fascia by the skilful dis-
position of compresses so as to cause a mechanical
closure of the portions of undermined tissue which are
farthest removed from the track of the setons.
Similarly when, in the process of healing, the under-
mined tissues have become once more agglutinated,
with the exception of the tracks of the different setons,
each seton track should be mechanically cut in half
by the pressure of a compress, and be kept open only
in that part which is near the incision. For this
mechanical obliteration of parts of the undermined
territory, tolerably firm bandaging of the limb is
necessary.
The constitutional treatment of erysipelatous
disease of the fascia is simply that of the sepsis which
always accompanies it, and consists in pushing nutri-
tion, and stimulating the circulation, and maintaining
the activity of the emunctories.
We spoke above of the use of Bier's "hyperemia"
in the treatment of phlegmonous erysipelas of the arm.
The technique of "hyperemic treatment" must, how-
ever, be fully understood before it is safe to apply
this means to the treatment of the "type of difficulty
we are now considering. For those who are less
experienced in its application it is likely that "active
hyperemia," induced by the local hot-air bath would
present the safer proceeding. Those, on the other
hand, who have had a certain experience in the use of
the constricting bandage in the treatment of inflam-
matory troubles in the extremities may find at lea-t
two special advantages in this form of treatment;
first, the constricting bandage will act in a way anal-
ogous to its action in snake-bite, in that it will, for
a while withhold from the general circulation con-
siderable stores of virulent toxins, thus, for such time
as the bandage is in place, protecting the heart and
the nerve centers from their deleterious influence and,
it is claimed, modifying and mollifying these toxins
while locked up in the arm distal to the bandage so
that they are rendered less pernicious when allowed
to flow back into the general blood-mass, such periods
of mechanical protection of the heart and nerve cen-
ters being marked by a distinct remission in the fever;
econdly, in a process tending as distinctly as does
this to extensive sloughing and gangrene, the use of
"obstructive hyperemia" (Stauungshyperilmie) it is
claimed will decidedly promote the nutrition of the
threatened parts, enabling them to withstand a
decree of inflammation which, without this protective
means, might lead to extensive local necrosis. For
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Arm and Forearm, Diseases
and Injuries of
details of the technic demanded the article dealing
with the subject of hyperemic treatment in general
should be consulted.
Since the demonstration of the presence of formal-
dehyde or of its derivatives in most of the body
Quids after the administration by the mouth of
bexamethylentetramin, the use of this drug has been
suggested in the treatment of septic conditions such
as attend a phlegmonous erysipelas. French surgeons
lay considerable stress on the advantages of intro-
ducing by hypodermic; injection considerable quan-
tities of solutions, or suspensions of the colloid
metals, particularly colloid silver, into the circulation.
I he condition we are considering would seem an
appropriate one for this form of treatment.
Antistreptococcus serum has not given the constant
results which it was hoped that it would in combating
ptococcal diseases. This is probably due to the
immense variety in the attributes of the different
"strains" of streptococci derived from different
sources. If positive results are to be expected from
the use of a streptococcus antitoxin this, it appears,
must be a highly "polyvalent" antitoxin, derived
from as large a number of different virulent sources
as possible, in the hope that at least some of these
sources may have characteristics nearly parallel to
those of the particular "strain" of streptococcus
which we are combating. The uncertainty of such a
coincidence has caused the antitoxic sera to become
less depended on than streptococcus vaccines in
combating erysipelatous processes.
While for many bacterial diseases the use of
"stock vaccines" gives generally satisfactory results,
the very reasons which make for the unreliability of
antistreptococcus serum make it imperative that in
streptococcus processes an "autogenous vaccine"
should be used. In the intelligent use of autogenous
vaccinal injections we have a potent weapon in
combating phlegmonous erysipelas.
Tuberculosis of the Fascia. — Primary tubercu-
losis of the fascia is a somewhat rare disease, and is
prone to show itself, as do tuberculous joint lesions,
much more frequently on the lower extremities than
on the upper. Given, however, a tuberculous joint
lesion in the upper extremity, secondary involvement
of the fascia is probably as frequent at one seat as at
the other. Fascial tuberculosis differentiates itself
from fascial disease of other kinds by all the charac-
teristic signs of tuberculosis. The onset of primary
fascial tuberculosis is generally comparatively painless
in the absence of secondary infections, and it is
rarely possible to trace its direct connection with a
coexistent wound, for the reason that the development
of the tubercle germ is so slow that the wound of
ingress may long have healed and have been forgotten
before any tuberculous process manifests itself. On
the other hand, secondary involvement of the fascia,
where tuberculous joint trouble is present, is generally
of easy demonstration.
Though streptococcic infection of the fascia may
relapse into a chronic form, it does not begin insid-
iously as does a tuberculous process, and though
in the latter stages of a tuberculous fascial phlegmon
when secondary infection has occurred, so much of a
distinctly pyogenic type may have been stamped upon
the process as to render difficult a diagnosis from the
signs present, yet an accurate history of chronic,
almost latent disease, present for a considerable
number of days or weeks before the onset of acute
symptoms, is entirely inconsistent with what we
know of the behavior of the streptococci, and is
almost pathognomonic of tuberculous infection. In
the absence of an ingrafted secondary infection, the
febrile reaction to tuberculous disease of the fascia is
slight, and when the local process is not extensive the
general constitutional reaction may be almost nil.
The tendency to involve adjoining structures is not
marked, the skin proving resistant for a long period
to perioral inn ; on the other hand, the tendency to
metastatic involvement at a distance is one of the
most considerable perils attaching to the malady.
The slight tendency of primary fascial tuberculo is
to involve adjacent structures may be due to the slow
growth of the tubercle bacillus giving an opportunity
to the surrounding tissues to fortify themselves by a
defensive leucocytic infiltration against the advance
of the germ into more vascular, and consequently
more resisting, fields. In this comparative vulner-
ability of the fascia, and comparative invulnerability
of the surrounding tissues lie at once the safeguard
and the danger of this form of tuberculosis. So long
as skin, joints, and tendon sheaths are not involved,
the subjective symptoms and the impairment of
function are so inconsiderable that the process may
remain unrecognized, and radical measures for its
extirpation may be postponed until great destruction
of tissue has taken place beneath the integument, or
until with the final involvement of the skin in the
tuberculous process a mixed infection has become
imminent, or has actually taken place. On the other
hand, when attacked at an early stage the restriction
of the disease to one tissue favors greatly the chances
of its complete eradication by appropriate measures.
The disease at first is confined to the surface of the
fascia. There may be a small area affected, or it
may be quite extensive. There is a lay r er of tubercu-
lous granulation tissue which can be readily scraped
off, leaving the protecting wall of inflammatory
tissue which nature always throws round a tubercu-
lous abscess. With the occurrence of secondary
pyogenic infection, or with a primary seat in, or a
later involvement of, the deeper intermuscular septa,
the prognosis, which is otherwise pretty good, be-
comes very much more grave both as to restoration of
the function in the limb and as to life itself.
This knowledge of the prospect ahead at once
gives us the key to the proper treatment. The non-
vascular nature of the tissue involved in fascial tuber-
culosis diminishes very greatly the chances of a sponta-
neous subsidence of the disease through the process of
encapsulation and calcareous infiltration of the tuber-
cles. Mechanical ablation of the affected tissue is the
only hope of safety. Here, too, our knowledge of the
natural history of the infecting agent will influence the
technique of the operation. Whereas in cases of strep-
tococcic invasion of the fascia it was advised to keep
instruments out of the focus of infection, and to depend
upon copious flushing with antiseptics and linear in-
cisions with multiple drains, here the form of incision
should be so varied as to allow the raising of large
flaps whose under surface, as well as the beds upon
which they rest, should be thoroughly scraped with the
sharp spoon, or shorn with the edge of the knife, or
better clipped with scissors curved on the flat. Sinu-
ses involving the skin should receive still more radical
treatment; they should, if possible, be resected
through their whole extent.
It may be well to point out that V-shaped flaps
should be so cut as to have their apices away from
the trunk in order to secure their sufficient blood-
supply and to avoid sloughing.
When secondary infection has not taken place, or
does not seem to be virulent in character, drainage
should be dispensed with as far as possible, as it is
more than doubtful whether tubercle germs can be
discharged from the system by mechanical drainage.
If, on account of secondary pyogenic infection, it be
considered necessary to make use of gauze drains,
they should be few in number, should not be used to
stuff the cavities, and above all should be peremp-
torily withdrawn at the earliest possible moment.
The use of a moderately tight bandage by mechanic-
ally closing all "dead spaces" will in a large measure
obviate the necessity for the use of drains, whose
sole function it is to prevent the accumulation of
wound secretions, but whose unfortunate attribute
551
Arm and Forearm, Diseases
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it is, in many cases, by the irritation they cause as
foreign bodies, to excite secretion from the tissues with
which they lie in contact. A condition which would
seem to demand a longer continuance of the drain, in
reality indicates still more strongly a revision of the
operation; indeed, in all cases of the kind, it is well
for the surgeon to explain to the patient or to his
friends, before undertaking operative measures, the
possibility, or even probability, of further operation
being required, and to get consent to necessary revis-
ional operations at the beginning.
The free use of iodoform within the wound is
strongly to be recommended in tuberculous processes,
with proper caution to avoid its toxic effects. Pow-
dered iodoform should be rubbed into the curetted
surfaces with the fingers so as to distribute this pre-
eminent tuberculocide into the pockets and crevices of
the infected cavity. For situations where the turning
up of flaps is not possible, iodoform emulsion may be
injected with a syringe.
The studies of Beck, of Chicago, have demonstrated
the great usefulness of bismuth paste in many surgi-
cal tuberculous processes. This paste may be in-
jected in cases of fascial involvement by puncture of
the unbroken skin with a hollow needle. Where
operation has laid open the diseased foci, after the
thorough surgical treatment of the diseased area,
bismuth paste may be applied in a thick layer on the
under surface of the flaps, or it may be injected, after
the wound is stitched, by a needle introduced be-
tween the apposed lips of the wound in the interval
between two sutures, so as to interpose a thick layer
of the paste between the skin and the underlying
muscles.
As in other tuberculous processes, the use of
tuberculin should be considered, both in establishing
a diagnosis and as a means of treatment. It should
be used according to established principles.
Tuberculous processes affecting any of the structures
of the extremities are particularly favorably situated
for treatment by passive hyperemia. According to
the recommendation of Bier, a lightly constricting
bandage applied on the proximal side of the lesion, as
near the trunk as may be, for from one to two hours
daily has a favorable influence on most cases of local
tuberculosis of the extremities and does not interfere
with the use of other therapeutic means.
Syphilis of the Fascia. — Syphilitic involvement
of the fascia is almost always of one type — that of a
gummatous deposit. This type of syphilitic lesion is
one of the later manifestations of syphilis, and, except
in the precocious or malignant type of the disease, is
scarcely to be looked for until after the second year.
A painless, though possibly tender subcutaneous
tumor extending rather widely beneath the skin,
without the characteristics of malignancy on the one
hand, nor the encapsulation and lobulation of the
lipoma or soft fibroma on the other hand, nor yet the
fluidity of an advanced tuberculous or pyogenic pro-
cess, will suggest the diagnosis of fascial gumma.
When the gummy deposits have likewise invaded the
skin proper, and secondary infection with pus germs
has taken place, the differentiation between syphilis
and tuberculosis of the fascia may be somewhat am-
biguous. Incision into the mass will soon reveal
the characteristic appearance of the gumma if the
diagnosis be not already made. If still not made at
the time of the incision, the exceedingly intractable
character of the lesion under ordinary surgical treat-
ment will suggest the diagnosis, especially when
contrasted with its readiness to heal under antisep-
tic treatment when this is combined with the exhi-
bition of antisyphilitics.
It has been well said that the whole responsibility
of the surgeon is not discharged when a diagnosis of
syphilis has been made, and gumma of the antibra-
chial fascia is eminently a case in point. Although by
stimulating the activity of the lymphatics with po-
552
tassium iodide, even an extensive gummatous de-
posit may be eventually removed, yet the complete
and speedy restoration of the arm is much better
insured, especially when secondary pyogenic infection
is present, by free incision and vigorous clearing away
of the gumma with the rinsing curette, depending on
the constitutional treatment to complete the cure.
Contracture of the Antibrachial Fascia. — To the
diseases of the fascia which have thus far been described
must be added, for the sake of completeness, certain
rare cases of contracture of the antibrachial fascia in
which this membrane impedes the action of the mus-
cles governing the hand by rendering the member a- it
were "hidebound." Little or nothing is known of
the pathology of this rare condition, except that it is
sometimes seen as the sequel, either temporary or
permanent, of other forms of fascial disease. The
affection is sometimes seen, however, in a strictly
progressive form without traceable antecedent dis-
ease or injury.
Steaming and massage would suggest themselves
as the most promising means at hand for combating
the difficulty, and A. Richet has recorded one case
which yielded to potassium iodide, and was in con-
sequence deemed to be of syphilitic origin.
A certain number of cases, seemingly of this general
character, are reported to have beenfavorably affected
by the local injection of fibrolysin.
III. Affections of the Bones, the Periosteum,
and the Joints.
(o) The Boiies. — Of the bones of the arm and fore-
arm, the ulna or radius may be congenitally
absent; in which case the remaining bone undergoes
a compensatory hypertrophy, and this produce- a
lateral curvature of the wrist away from the enlarged
side.
The bones may atrophy as a senile change or from
disuse, especially in long-standing ankylosis, unre-
duced dislocation, or paralysis, or their develop-
ment may be arrested in the later stages of infantile
paralysis.
In achondroplasia the bones of the forearm often
appear much thickened and curved.
Rickets, as Park describes it, is a constitutional
dystrophy caused by improper deposition of calca-
reous material in the soft and somewhat perverted
fetal cartilages. Pathologically it is marked both by
a defect in the calcium content and also by the irreg-
ular epiphyseal lines and excessive amount of vascular
tissue. " On making a section through the end of the
bone, one sees that instead of the two sides of the
epiphyseal cartilage being parallel to each other, that
next the diaphysis is quite irregular, there are islets
of cartilage extending into the bone, the epiphyseal
line is very much thickened and the ossification is very
irregular" (Cheyne). The result is that at the
epiphyseal lines one can feel a distinct enlargement,
especially noticeable at the wrist, the lower end of the
radius being as a rule the first part affected. Owing
to the softening of the bony tissue, curves and
deviations of the bones of the arms occur in severe
cases in infancy, secondary to kyphosis of the spinal
column, the child tending to assume a frog-like posi-
tion to relieve the spine of the weight of his head and
shoulders. In some instances fractures have been
observed to occur in rickety bones on slight provoca-
tion. The treatment is regulation of the diet and
improvement in the hygienic conditions together
with the administration of tonics. Phosphorus and
the hypophosphites are especially recommended.
Extract of the thymus gland has been shown to exert,
in some cases, an appreciable effect in disorders of the
osseous development. Its use in rickets has been
recommended as a means of promoting the fixation
of phosphorus in the bones, particularly of children.
The radius is a common place for the commence-
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Ann and Fercarin,
and Injuries
Diseases
of
inellt of OSTEITIS DEFORMANS. Here (lie boneS
enlarge and soften, and a distinct bowing is at time
noticed, while from the irregular enlargement of the
articular ends, the hand is often deflected. This
disease, which is also known as Paget's disease of the
bones, is a rare affection, appearing generally after
middle age. The disease is essentially a symmetrica]
one.
The articular ends of the humerus and ulna may
lie involved in the hypertrophy characteristic of
uarie's disease or ostioarthropathie hypertrophiante
lique.
In senile atrophy, osteomalacia and osteopsathy-
rosis, as also in rickets, in syringomyelia, and in
metastatic deposits from malignant tumors, <-. <•
of marked evidences of general sepsis, together with
the presence of similar local signs. In the absence of
pronounced suppuration, we are justified in pursuing
longer, in this form of bone disease than in the other,
our efforts to check the process by means of rest, coun-
ter-irritation, fomentations, etc., but with the advent
of signs pointing to pus formation, free incision and
drainage are as positively indicated as before.
The Joints. — The articulations of the upper ex-
tremities are, like those elsewhere in the body, liable
to dislocation; for discussions of which other portions
of this work may be consulted. It will, however, be
well to call attention here to a somewhat rare affec-
tion of the elbow, occurring exclusively in infants and
young children, resulting from forcible dragging on the
forearm, often by the nurse, or in play. In this con-
dition the forearm is held flexed in a prone or semi-
prone position, and supination is very painful. The
554
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Ann and Forearm, Diseases
ami Injuries of
condition is probably one of subluxation of the radius
,1(H\ award, and the partial escape of its head from the
grasp of the orbicular ligament; the normal laxity of
the ligaments in childhood and the want of full devel-
opment of the head of the radius contributing to
make the condition possible. The signs may be re-
moved by complete supination followed by flexion,
under an anesthetic if necessary. The forearm should
then be placed in a sling and massage and careful ex-
ercise employed.
Of the primary inflammations in these joints,
SIMPLE synovitis is perhaps the most common. The
acute form may be due to trauma or to overuse, and
gives rise to pain on pressure or on movement of the
joint, and to swelling due to an increase in the amount
of synovial fluid, sometimes to an effusion of blood.
A bulging tumor is formed where the joint capsule
is thin; in the elbow joint the tumor is generally shown
i riorly. Purulent infection of the effusion may
take place.
The treatment of simple synovitis consists in rest,
enforced if necessary by fixation of the joint, pressure,
by careful bandaging or by the wearing of a woven rub-
ber sleeve, the application of cold or of heat, the latter
best in the form of the local hot-air bath, and passive
hyperemia. With the subsidence of acute symptoms,
massage carefully regulated active and passive mo-
tion of the joint are always helpful and are frequently
indispensable. Active and passive motion, while
they may be administered manually, are more easily
regulated and are more efficaciously applied by means
of the Zander mcchanotherapeutic machines.
The chronic form of synovitis may date from a
previous acute attack, or may be chronic from the
start. The pain in this form is either small or absent.
I luctuation can usually be elicited, while creaking on
moving the joint may be quite a noticeable symptom.
The treatment here, too, will consist in pressure, rest,
massage, counter-irritation, etc. It is particularly
in cases of chronic synovitis that the local hot-air
bath together with active and passive motion accu-
rately regulated by means of the Zander apparatus
may be relied upon to give the best obtainable
results.
Tuberculosis of the joints is usually due to in-
fection from the bone, though it may in some cases
be primary in the synovial membrane. The usual
symptoms are swelling, due to effusion and to the
thickened capsule; there is always a limitation of
motion, and usually pain, due to the friction of two
roughened joint surfaces, and marked and painful
spasms of the muscles surrounding the joint, while
atrophy of these muscles is generally to be noted.
Immobilization of the j<3int, together with extension,
are indicated as in joint tuberculosis elsewhere. This
is, however, difficult to achieve in the upper ex-
tremity by any portable apparatus, though simple
immobilization at the elbow and the wrist may be
attained by proper splints. For thoroughly satis-
factory extension, the use of the weight and pulley
with recumbency in bed is essential, and even with
these, satisfactory application of this form of treat-
ment to the shoulder joint is very difficult, owing to
the extreme mobility of the scapula. On account of
the imperfection of methods of extension and im-
mobilization in treating tuberculosis of the joints of
the upper extremity, we turn the more readily to the
use of iodoform emulsion and other substances by
injection into the joint cavities, and in severe
cases proceed to resection, typical or atypical. In
conjunction with other methods, general tonic treat-
ment should not be foregotten, including open-air
living and the use of tuberculin.
Acute suppurative arthritis is sometimes found,
due to the infection from a wound, or of hematogen-
ous origin. All the signs of a severe and acute inflam-
mation are present. The treatment is in all cases by in-
ei.sion and drainage and by immobilization of the
joint. The value of bacterial vaccines and of pa ive
hyperemia should not be overlooked in this formid-
able and crippling disease. Ankylosis is often a
result in spite of our best efforts.
Infectious) arthritis is seen following the acute
infectious diseases. It has much the same clinical
character as rheumatism, but it does not tend to
suppurate, nor is it migratory.
The wrist is the most prone of any of the joints of
the upper extremity to succumb to GONORRHEAL
arthritis. Its well-known obstinacy and intracta-
bility have made it an opprobium medicorum. Re-
cently incision and irrigation of the joint have been
made use of with gratifying results in this form of
arthritis. Bier's passive hyperemia will do a great
deal to allay the truly atrocious pains of this form of
infection, and often it will go far toward effecting a
cure. The brilliant results which have attended the
use of antigonocoecus serum and of gonococcus vac-
cines have done much to make the outlook brighter in
this formerly most intractable disease.
In acute rheumatism, besides the systemic mani-
festations, the joints are inflamed, painful, and
tender, and the articular affections tend to migrate.
Rheumatic arthritis is prone to attack the larger
joints. Incases of chronic rheumatism, the joints are
stiff and painful but not always swollen, while on
passive motion a creaking may be elicited. The
muscles may become greatly wasted, and there is
a tendency toward fibrous and even bony ankylosis.
The treatment of the acute form is by means of
alkalies and salicylates and other appropriate drugs,
together with heat, pressure, and rest. In the chronic
forms the best results are obtained from massage
and mechano-therapy, the hot-air bath, the copious
and long-continued use of akaline mineral waters,
and a strict anti-rheumatic regimen.
Rheumatoid arthritis, or arthritis deformans, is
characterized by changes in the cartilages and syno-
vial membranes with periarticular formation of new
bone and great deformity. The cartilage is either
thin or entirely absorbed, laying bare the bone, while
at the ends of the joints osteophytes form that
may cause even complete ankylosis. This is ac-
companied by a thickening and contraction of the
ligaments and great atrophy of the muscles. Hyper-
trophy of the articular ends of the bones is common,
though in some cases atrophy is observed. Neuritis
is prone to occur as a complication.
The treatment is by massage and hot-air baths
together with forced passive motion. Both active
and passive motion must be kept up long enough to
remodel deformed articular ends of the bones to their
normal shape by the effects of use and pressure. The
stiffened joints can sometimes be advantageously
broken down under a general anesthetic, but this
must be promptly and vigorously followed up by
long-continued active and passive motion in which
the mechanotherapeutic machines of Zander are far
superior to manual work. The use of thyroid extract
in moderate doses is useful in some cases, as an ad-
junct to other treatment, and, when possible the pa-
tient should spend the winter months in a warm cli-
mate. The disease has, however, a marked tend-
ency to become progressive, and in severe cases
but little benefit is derived from treatment of
any kind.
The shoulder, the elbow and the wrist occasionally
show a form of arthritis, arthritis sicca vel senilis,
which is much more commonly found in the hips
and in the knees. This is due to atrophy of the syno-
vial membrane, and shows itself practically as a defi-
ciency in the lubrication of the joint. The disease
is rarely extremely painful, is never entirely curable,
but may be helped by treatment applicable to ar-
thritis in general, with the important exception that
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long-continued disuse of the joint, and above all, all
fixation of the joint must be avoided as furthering
the atrophy which is the essential, underlying
pathological lesion.
A spbain is produced when the motions of a joint
are carried beyond their physiological limits, but stop
short of permanent displacement of the articular ends.
With this there is either a stretching or rupture of
portions of the capsule or ligaments, accompanied by
pain, swelling, ecchymosis, and limitation of joint
motion with tenderness over the joint. Sprains are
especially prone to occur at the wrist, though the
elbow and shoulder are frequently affected. It is
important to differentiate a wrist sprain from a
Colles's fracture, and this can generally be done by
determining the absence of crepitation and of an
abnormal point of motion, and also by the fact that in
Colles's fracture the hand is drawn toward the radial
side with a more or less pronounced "silver-fork"
deformity. This last condition is sometimes better
appreciable to firm palpation than to the eye, espe-
cially when some time has elapsed since the receipt of
the injury. The use of the x-ray will, however,
in most cases make the diagnosis certain. It should
not be forgotten, however, that sprained wrist is a
constant, and often a serious complication of Colles's
fracture.
The treatment of a sprain is rest, elevation of the
part, and compression, with the use of cold followed
later by hot applications. The use of massage from
the beginning is quite successful in skilful hands,
while this with passive motion is always indicated
after the subsidence of acute symptoms.
Ankylosis may be due to contractures of the
muscles or to contractures and thickenings of the
ligaments, with or without secondary growths of
impeding osteophytes about the margins of the joints.
The contractures which prevent the joint from
moving may, in turn, be due to disturbed innerva-
tion or nutrition of the muscles, or to myositis
followed by degeneration of the muscle-cells proper
and substitution of fibrous for muscular tissue; but
the commonest cause both of muscular and of liga-
mentous contracture is unabsorbed, and more or
less perfectly organized, inflammatory exudate.
Ankylosis of this type rarely causes complete immo-
bility of the joint; it is termed "false ankylosis"
in distinction from a "true ankylosis," where actual
union, either fibro.us or bony, has taken place between
the opposed articular surfaces. A false ankylosis is the
result of an extra-articular process, while a true
ankylosis is the direct outcome of an acute suppura-
tive arthritis, joint tuberculosis, chronic rheumatism
or rheumatoid art hritis.
The treatment will depend upon the cause, and
may consist of massage and forcible flexion and ex-
tension of the joint. These not availing, more or
less extensive tenotomy and myotomy may be
practised, or the joint itself may be excised. At the
elbow, where, on account of the complexity of the
joint, ankylosis is particularly prone to occur, a
flail joint, the result of an excision, with all its disad-
vantages, gives nevertheless a much more service-
able arm than can be obtained by any other form
of treatment for extensive fibrous or bony ankylosis
of the joint. In ankylosis due to muscular contrac-
ture excision is less to be recommended.
Quite a large number of cases are on record of
loose bodies in the elbow-joint. Their pathological
history is similar to that of loose bodies in other
joints, such as the knee. The only treatment is re-
moval by arthrotomy.
IV. Affections of the Muscles, Tendons, and
Tendon Sheaths.
The Muscles. — In no part of the body are the
muscles and tendons grouped in such numbers about
the bones as in the forearm, and in no part of the body
do the affections of these structures stand out so
prominently as in the upper extremity.
The commonest of all diseases of the muscles, if
indeed the name of disease is applicable, is that con-
dition of the muscles which results from long-con-
tinued use without sufficient repose to which the
name myalgia has been given. The pathological con-
dition present is in the main but an accentuation of
the normal condition of muscular fatigue, and is at-
tended by similar symptoms, namely, tenderness on
pressure, "lameness" in use, and deficient response to
ordinary physiological nerve impulse (i.e. weakness
in action 1 ), and, finally, involuntary and painful spasm,
" twitching." These symptoms in turn are caused by
too great an accumulation in the muscle of the chem-
ical products of muscular activity, and this accumu-
lation, again, may be the result of either or both of
two factors: excessive production on the one hand,
and deficient elimination on the other. As to the
exact chemical bodies involved, the reader is referred
to treatises on physiology; their exact nature is still
a matter of dispute, but one of the best established
of the waste substances is lactic acid, present in suffi-
cient quantity to affect markedly the reaction of the
muscle substance to delicate alkalimetric tests, and
there is little doubt that this changed reaction of the
muscle substance induces in its turn the precipitation
of various ''leucomaines" which it is difficult for the
ordinary blood current to remove promptly. So
long as these decomposition products (uric acid,
xanthin, hypoxanthin, acid phosphates) are not
removed from the muscle the symptoms enumerated
above will continue; with their disappearance the
normal function of the muscle will return.
The exact locality of these morbid deposits is not
entirely settled, but many facts point to the probabil-
ity of their being located rather in the sarcolemma
and in the perimysium than in the substance of the
muscle proper. The facts which would indicate this
are the aggravation of the tenderness at the muscular
origins and insertions, and the spread of the myalgio
affection throughout the fibrous tissues beyond the
points of actual muscular insertion; indeed, in no part
of the body is what passes for myalgic affection, or as
very closely akin to it, more obstinate and trouble-
some than in the fibrous tissues just below the origin
of the erector spina? muscles, over the sacrum and the
sacroiliac synchondroses. It is more than probable
that consecutive upon a pure myalgia may occur a
rheumatic form of periostitis from extension beyond
the point of bony origin or insertion of a muscle by
"contiguity of tissue." This is exemplified with
peculiar distinctness in cases. of myalgia affecting the
muscles attached to the coracoid process of the scap-
ula, where the coracoid process itself may often be
found to retain for a long period a great degree of
tenderness when pain may entirely have left the
bodies, or the tendons of the muscles attached to it.
Excessive formation of waste products comes from
over-use of the involved muscle; deficient elimination
may be caused by use of the muscle under unfavorable
conditions, or by exposing the member to untoward
conditions after its severe use, thus interfering with
its prompt rehabilitation. An amount of muscle
work whose catabolic products would be speedily
provided for under other circumstances may induce
a severe myalgia if performed when the patient was
suffering from want of sleep, as many a weary obstet-
rician can testify; and it is notorious that sitting in
a draught after' active exercise will lead to " cold set-
tling in the limbs."
There is one form of this affection whose sudden and
severe onset may lead to confusion in the diagnosis;
this form more frequently attacks the erector spinas
group of muscles, or those of the abdomen, when it is
known as a "stitch in the side." This form of
myalgia is probably due to a gradual accumulation of
5.J0
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Arm
umi Forearm, Diseases
mid Injuries »>f
fatigue products in the muscle, or possibly only in the
fibers "f a small portion of a muscle, to the point
„f irritating the affected fibers to a sudden, painful,
and protracted involuntary contraction, the patient
ing been unaware of the soreness of that particular
muscle through the accident of not having brought
those fibers into play. When once the painful
traction has taken place, the irritability of the
cted muscle becomes extreme and the whole
muscle is brought more or less involuntarily into
ited action, to "test its soreness," and a more
or less persistent myalgia is found to be established
until driven off by the activity of the circulation or
by the exhibition of suitable remedies. Such a
levelopment of a latent myalgia among the
muscles of the forearm has led in one instance I have
known of to an erroneous diagnosis of rupture or
dislocation of a tendon. The patient was a young
woman engaged in wiping dishes; of a sudden a severe
-hooting through the forearm caused her to
drop the dish in her hand, and certain movements of
the fingers were from that time on, for many weeks
after, painful and feebly executed.
The diagnosis of myalgia, as it appears in the arm
and forearm, is not ordinarily attended with great
difficulty. The history of fatigue, or exposure, or
both, will generally suggest the diagnosis, while the
presence of the gouty or rheumatic diathesis, as condi-
tions under which waste products are imperfectly
removed from the tissues, will be allowed a certain
weight in establishing the probabilities. In the upper
arm the extensors (triceps) are most frequentl}'
affected, in the lower arm, the flexors and extensors
with about equal frequency. Occasionally the coraco-
brachialis or the anconeus may be affected alone,
giving rise to rather obscure pains in the shoulder
and elbow respectively. Such cases are readily over-
looked in a careless diagnosis. Incidentally their
deep location renders treatment more difficult. The
tenderness over the affected muscle, the painful and
imperfect function, and the occasional fibrillary spasm
are the positive factors upon which we base a diagno-
sis, while the absence of fever, swelling or redness, the
absence of tenderness about the joints, along the
course of the nerves, or along the tendon sheaths will
weigh against rheumatism, neuritis, and thecitis
respectively. The absence of fibrous crepitation will
also serve to aid in excluding this last affection.
From painful affection of the bone or the periosteum
it may be extremely difficult to differentiate a deep-
seated myalgia; the absence of pain on jarring the
limb, and its ready yielding, if recent, to the faradic
current will serve to aid in identifying a myalgia.
The prognosis is good if treatment be instituted
earl}-; if treatment be too long postponed, and atrophy
ensue, due partly to disuse and partly to local poison-
ing of the muscular substance by the "materies
peccans" of the disease, the affection may prove very
obstinate and intractable, but will in almost all cases
eventually yield where the persevering cooperation
of the patient can be secured. It is my firm belief,
however, that simple myalgia, if severe and untreated,
can occasion permanent disability.
The treatment of myalgia consists in efforts to
throw again into solution those precipitates in the
muscles whose presence impedes their function and
causes the pain. This we seek to accomplish along
certain rational lines, all tending to this common end.
Probably the first therapeutic efforts of sufferers
from myalgia were directed toward keeping the
affected part warm. The rationale of this lies in
inducing a dilatation of the blood-vessels, which
brings a larger supply of the solvent serum into
contact with the offending precipitates, thus pro-
moting their solution. With the increased advent
of blood follows in turn an increase of heat, which in
connection with the heat added from without induces
an actual rise of the temperature of the part, which
i< likely to promote considerably tie- solubility of any
precipitates. Recently this method of treatment
has had its efficacy greatly enhanced by the devising
of methods of exposing tin- affected limb to dry an-
al very high temperatures. Local hot-air baths may
now be procured from instrument dealers by means
of which an extremity may be exposed, without
damaging the skin, to dry air at a temperature of
300 to 500° E.
Other ways of increasing the afflux of fresh serum
to aid in the solution of precipitates are. first, Bier's
passive hyperemia, by means of a constricting band-
age; secondly, counterirritation, applied to the
overlying skin by the use of iodine or other rube-
facients, cantharidal blisters, or "firing" with the
actual cautery; thirdly, moderate, active use of the
muscles, when practicable without causing too much
pain; every athlete is familiar with the disappearance
of "muscular stiffness" (the mildest grade of this
disease) under fresh exercise; fourthly, massage of
the affected parts is extremely useful, particularly in
the more obstinate and chronic forms of myalgia; it
partly by mechanically dislodging crystals or
amorphous masses of precipitated matters, forcing
them into the lymphatic circulation, and partly by
greatly stimulating the local circulation.
Antirheumatic remedies, and the antirheumatic
regime are also of use in controlling the pain of
myalgia, chiefly by the solvent affect of alkalies and
of the salicylates on the morbid deposits, and of these
measures there is none that compares in importance
with the ingestion of very large quantities of water.
While massage is our best weapon against chronic
forms of the malady, especially in the presence of
secondary atrophy, there is no agent whatsoever that
will give the immediate and lasting relief that is to be
obtained from the application of the faradic current,
and no more grateful patients are encountered than
those who have been relieved from the misery of a
myalgia by the brief application of a mild current.
Within the last few years our armamentarium has
been enriched with a multitude of new and efficacious
means of treating this common and troublesome
malady. Among these are a variety of phases of the
electric current, such as the slowly interrupted gal-
vanic current, the sinusoidal current, the high fre-
quency alternating current and the franklinic spark,
also violet light, and the many candle-power (500 or
more) incandescent light. Perhaps the simplest and
most commonly used of the recent methods of
treatment is the application of mechanical vibration.
One special point it is important to notice in the
treatment of myalgia of the upper arm — namely, this,
t hat the muscles which move the upper arm have their
origin on the trunk; and that their function is twofold,
first, that of imparting voluntary movements to the
upper extremity, and secondly, that of supporting
the weight of the arm. This second function is not
appreciated during health, but in the presence of a
severe deltoid myalgia, the six to ten pounds weight
of the arm dragging upon the lame muscle is a very
considerable factor in increasing the pain and a serious
obstacle to recovery. In all acute myalgias, there-
fore, affecting the muscles which pass from the
trunk to the arm it is necessary to support the weight
of the member by a firm bandage at the elbow-. The
most effective device for this purpose is a Moore's
dressing for fracture of the clavicle, as described under
the head of fractures.
Occasionally one sees cases of what are called
"chronic sprains" or "strains," caused by the overuse
of certain muscles, in which the pain is principally at
the origin or insertion of the muscles. Tenderness
and stiffness are prominent symptoms. Examples of
this are seen in the so-called "base-ball pitcher's
arm," "tennis elbow," etc. Such persistent over-
use of a muscle may give rise to a local periostitis at
one of the points of attachment of the muscle, possi-
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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
bly resulting in necrosis, and occasionally leading to
bony infiltration of the muscle, due to proliferative
periostitis.
In some, rather rare cases of sudden and violent
contraction of the muscles, as, for instance, in throwing
a stone, in swinging on the trapeze and among
washerwomen in wringing clothes, actual rupture of
a part, or even of all the fibers of a muscle may occur.
This accident, which not infrequently befalls the
plantaris longus in the leg, has been seen in the arm
to affect the supinator longus (in a young woman
engaged in wiping dishes), the coracobrachialis (in
wringing clothes), the biceps, and occasionally the
triceps. Subcutaneous muscle-rupture is more fre-
quently, however, the result of direct violence exerted
upon the muscle when tense than the result of pure
contraction. Both the biceps and the triceps are not
very infrequently injured in this way when the front
or the back of the arm, respectively, is struck by a
blunt object, e.g. a base-ball bat. When a consider-
able muscle, like those mentioned, is thus ruptured,
the picture is unmistakable provided the injury is
recent. There is characteristic inability to flex the
arm actively and fully with a ruptured biceps, or to
extend it, with a ruptured triceps, while passive
flexion and extension are unimpeded. There is
furthermore evident and extensive subcutaneous
hemorrhage, and, as a pathognomonic symptom,
there is ordinarily readily discernible a diastasis
between the two portions of the ruptured muscle, and
the proximal portion of the muscle contracts to a
quivering fleshy lump when spontaneous efforts are
made by the patient to contract the muscle. The
diastasis is frequently wide enough to permit the
finger to be laid between the ruptured ends of the
muscle. The I reatment is obviously by suture of the
divided muscle, with the arm put up in flexion, for
injury of the biceps, and in extension, for injury of
the triceps.
Occasionally the flexor group of the forearm, but
more frequently the biceps, and rarely other individual
muscles of the arm will present, either as the result
of an injury with a blunt instrument or missile, or
occasionally spontaneously, a rent, not of the muscle
fibers, but of the overlying fascia or muscle sheath.
Through such a fascial rent the muscle fibers tend to
protrude, forming what is called a muscular hernia.
The effect of such a herniation of the muscle sub-
stance through its sheath is to weaken and impede
in considerable degree the forcible contraction of the
muscle, the patient complaining of insecurity and
uncertainty in exercizing the limb, and occasionally
of pain. Here too the treatment is incision and suture
of the torn muscle sheath, after first undermining it
for some distance from the margins of the rent.
Acute myositis is occasionally encountered in the
muscles of the arm as a result of pyogenic infection.
The pyogenic type of this disease, however, is rare,
and when present is but a secondary accompaniment
to neighboring extensive septic processes. It may
lead to necrosis of the muscles en masse, or to frac-
tional sloughing, and solution of the muscle fibers in
the purulent effusion.
A rare form of myositis is the tuberculous, which
in many respects resembles the gummatous myositis
of syphilis. It bears, however, the characteristic
tokens of tuberculosis, including characteristic reac-
tion to tuberculin, characteristic temperature curve,
etc. It appears generally in subjects presenting
other and extensive tuberculous lesions. Its treat-
ment, in the absence of too extensively generalized
tuberculous invasion to make the operation justifia-
ble, should be by partial or complete excision of the
affected muscle.
The most common forms of myositis are those
whose origin is syphilitic, indeed it is more than
probable that part of the "rheumatic" pains which
precede or accompany the eruption of constitutional
syphilis depend upon a light and acute irritative
myositis.
A commoner form of syphilitic myositis is the
chronic interstitial variety depending upon a
small-celled infiltration rising from the perimysium,
and extending into and between the muscle bundles.
These are destroyed by pressure atrophy, and become
transformed into connective tissue with gradual loss
of the muscle. It is a diffuse process within the
muscle, and is at first generally attended with pain.
Gummatous myositis may develop as a slowly
growing, and perfectly painless infiltrate in the
muscles. Accompanying the gummatous process
there are usually found more or less extensive inflam-
matory changes. More commonly, however, the
growth of the gumma is more rapid, and pain, in-
creased by touch and motion, is a marked symptom.
The muscle in all the more rapidly growing gummata
is in a state of constant contraction, the growth at
first moves with the movements in the muscle. As
it increases in size it becomes softer in consistency,
and the muscle assumes a condition of permanent
contracture.
Gummatous myositis often advances beyond the
muscle, and comes to involve the fascia and sub-
cutaneous tissues. It becomes more prominent,
softer and less movable, and finally breaks through
the skin, leaving a sinuous ulcer from which necrotic
masses, chiefly fascial, are extruded. After healing,
which requires weeks or months, a cicatricial tissue
remains which binds together the muscle, fascia, and
skin (Hartley).
Ischemic atrophy or Volkmann's contracture
is a rather peculiar and an important condition. The
following description is taken from Keen's Surgery.
"The cause is interference with the circulation.
Pressure on the nerves may have some influence. The
circulation may be interfered with by the too tight
application of splints and dressings, by the unduly
prolonged use of the elastic constrictor (tourniquet),
by injury to large vessels, and by exposure of the
part to cold. The forearm is the region most com-
monly involved, the affected muscles become densely
infiltrated. Unless the cause is removed within
twenty-four or forty-eight hours or earlier, the
muscle fibers degenerate. The whole muscle (Fried-
rich) does not become uniformly degenerated, but the
portions attacked undergo contraction.
"According to Dudgeon, pain is absent unless the
disease is accompanied by neuritis; other authors
describe pain as an early and important symptom.
Within a few hours the hand becomes swollen, the
phalanges flexed, and there is paralysis of the muscles.
The muscles are hard, swollen and tender. If pain
is absent, the seriousness of the condition is apt to be
unrecognized. If splints are the exciting cause of the
trouble, their pressure may occasion necrosis and
ulceration of the skin, but these lesions are merely
concomitants unrelated to the muscular degeneration.
When recovery takes place it leaves a permanent con-
tracture. When the forearm is the site of the disease,
the resulting deformity is characteristic. The pha-
langes are flexed on each other, but the metacarpo-
phalangeal articulation remains extended. The pha-
langes cannot be extended while the wrist is extended,
but as soon as the wrist is flexed, the fingers can be
straightened. If the muscular degeneration has
been more extensive, the wrist becomes flexed as
well as the fingers."
Progressive muscular atrophy is a disease
which manifests itself most distinctly among the
muscles of the arm. It is, however, essentially a
nervous disease and not a disease of the muscles; its
consideration here, in connection with the muscle-, is
for greater convenience only. The nerves supplying
558
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Ami and Forearm, Diseases
ami Injuries, of
the atrophied muscles may be affected anywhere
along their course, bul the principal site of the lesion
is in the anterior gray columns of the spinal cord.
However general the disease may subsequently
heeunie.il is at first Idealized, anil t lie upper ex I remit y
I hj far the must frequently involved. Affection of
the right hand is said to he considerably more frequent
than thai of the left, and of the muscles, either the
interossei or those of the bull of the thumb first
succumb. The disease, in fact, at first simulates an
ulnar neuritis, but careful study will indicate the
olvement of certain muscles which are supplied by
er nerves. From the thenar muscles and the
interossei, the disease commonly creeps up the fore-
arm and thenee to the arm. or it may skill the forearm
pass into the arm, although the triceps extensor
muscle is usually spared. It may come to a stand-
Still in either of these two places, but may involve the
muscles of the shoulder, especially the deltoid.
Beginning most frequently on the right side, both
r extremities become involved sooner or later.
In other instances in which the extremities are
lived the atrophy begins in the deltoid (here again
the right first). Succeeding the deltoid, the scapular
and trapezius muscles may be involved in any order,
while a grotesqueness of effect is often produced by
reason of certain adjacent muscles retaining their
natural size or even being hypertrophied. This is
ticularly the case with the anterior part of the
trapezius, which is almost never involved. While the
shoulders remain exclusively affected, the arm and
forearm may retain their usefulness and strength,
I uit the power of lifting the arm from the side, and
especially of raising it above the head, is lost, and if
the patient wishes to lay hold of anything he must
swing his arm forward with a jerk till the object is
brought within reach of his fingers.
The muscles of the trunk become at times involved:
the pectorales, the latissimi, the serrati, and the
intercostales, and even the diaphragm and the
abdominal and lumbar muscles.
The muscular atrophy is generally accompanied by
responding wasting and retraction of the skin, so
that this continues to be applied to the muscles in the
usual manner. In some instances, however, this is
not the case, and in these a baggy condition of the skin
is added which gives its subject an appearance which
has more than once rendered him valuable to the
showman as the "elastic skinned man," etc. It
sometimes happens, on the other hand, that the
atrophy is obscured by an accumulation, between
the muscles and skin, of adipose tissue, and an
appearance of hypertrophy rather than of atrophy
may be produced in consequence.
\ second muscular symptom, more or less distinct,
is fibrillar contraction. This consists in wave-like
ractions running along small bundles of muscular
fasciculi. These contractions occur spontaneously,
or are excited by some slight stimulus, as a breath
of air or a dash of water, or by tapping the patient
with the fingers or passing a galvanic current through
the parts, and this too in any stage of the disease,
except that they do not occur in muscles wholly
destroyed. Sometimes they can be felt by the patient;
at other times he is wholly ignorant of them. They
are not invariably present, and often they have been
seen in muscle atrophy from other causes; they
possess, however, a certain amount of diagnostic
value, especially when spontaneous. Coincident
with the wasting of muscles is their loss of function.
Sensibility is in many cases unchanged, the tactile
sense being as delicate as ever, and pain, except
accompanying the cramps and chronic contractions
of groups of affected muscles, which sometimes
occur, is absent. At times, however, the atrophy is
preceded by painful paroxysms, which may or may
not accompany the chronic, contraction referred to.
The pain is sometimes in the course of nerve trunks,
hut is as often diffu e, ■■> if the muscles themselves
were its seat. At other times it is variously described
as a soreness, an aching or a rheumatic pain. Morbid
sensations, as those of cold, numbness, and formica-
tion may be experienced. Keflex excitability may
be increased, while the knee jerk is said to be absent.
Unusual sensitiveness to cold is sometimes noted, and
SO also is the loss of muscular power under its in-
llucnce, which is again restored by artificial warmth
(Tyson).
The lipomatosis, which has already been alluded to
as affording, in some cases of muscular atrophy,
somewhat the appearance of the pseudomuscular
hypertrophy, may to the casual observer obscure tho
diagnosis of this disease. Pseudohypertrophic par-
alysis, however, almost, invariably first asserts itself
in the lower extremity.
Syringomyelia is another of the central nervous
diseases which finds its most marked expression in the
secondary changes it induces in the sensory, trophic,
and motor functions of the arms. The symptoms
are almost always bilateral, but a few cases have
been observed in which but one side of the body was
affected. The most common type is that in which
the most salient features are loss of perception of
pain and temperature, with retention of the tactile
and muscular senses, combined with atrophy of the
arms similar to that observed in progressive muscular
atrophy. The atrophy usually appears in the small
muscles of the hand and gradually extends upward,
involving consecutively the arm, forearn, and shoul-
der muscles, or it may first appear in the shoulder
and upper arm and later descend to the hand. The
difference depends upon whether the lower cervical
gray matter is first affected with extension upward of
the process, or whether the upper cervical enlarge-
ment, in which are located the centers for the shoul-
der muscles, is first affected.
Corresponding with the atrophy there is naturally
a weakness of the muscles which may go on to com-
plete paralysis. Trophic disturbances are common.
Changes in the joints and bones, very similar to
llio-e observed in tabes, occur in about ten per cent,
of the cases. The joint changes consist principally
of enlargement of capsular ligaments, loosening of the
joints, thickening of the capsule, changes of form in
the ends of the bones, and development of bony
spicule in the capsular walls. The further changes
resemble those in tabetic joints.
Painless fracture of the bones may occur from very
slight causes, as in the case of a man who fractured
the radius while kneading dough. Various atrophic
changes in the skin are frequent, such as herpes,
eczema, and even deep ulceration and gangrene; in
rare cases amputation of the hand may be necessary;
or there may be simply vasomotor changes causing
lividity and coldness of the skin or the opposite, or
edematous swelling of the hand. There may be
sweating or dryness of the skin. The nails may be-
come dry, cracked, and brittle and may drop off.
An obtrusive symptom which is sometimes ob-
served is the painless felon, similar to that which
occurs in Morvan's disease. These felons occasion
deep ulceration and necrosis of the distal phalanges
of the fingers so that they may drop off. Notwith-
standing this extensive ulceration the felons are
painless, owing to the analgesia present (Prince).
For a more accurate differential diagnosis of these
different secondary muscular dystrophies, and for a
more exact discussion of their pathology and treat-
ment, the reader is referred to articles in this work
on diseases of the nervous system.
Spastic rigidity of the arms is often one of the
earliest signs of chronic hydrocephalus, even
before the skull begins to enlarge, and convulsions
may be present from time to time. In congenital
spastic rigidity, due to sclerosis or defective develop-
559
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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
ment of the cortex cerebri, the spastic condition is
usually confined to the legs.
In paramyoclonus mi'ltiplex, as the name of the
disease implies, the contractions of the muscles ap-
pear in paroxysms and the muscles involved are usu-
ally the biceps, deltoid, and triceps in the arms, and
the quadriceps femoris and calf muscles of the lower
limbs. Myoclonus multiplex is a disease of adult
life, and may be differentiated from chorea, which is
usually seen in childhood. Sometimes the muscles
in myoclonus are exceedingly irritable.
Sometimes, as the result of infantile cerebral par-
alysis or from reasons developing later in life, the
muscles of the hand are affected by a slow, constant
movement, so that the fingers assume curious con-
strained and unusual postures, being moved into ex-
treme or forced extension, flexion, pronation, or
supination. This condition is called athetosis, and
is separable from chorea in that the movements are
slower, and are limited to the fingers and wrists, the
arm escaping.
Absolute loss of power in one hand and arm, with-
out the necessary development of subsequent de-
formity, results from cerebral or peripheral lesions as
a rule, being rarely spinal in origin, and is called
brachial monoplegia. Although the onset of a
monoplegia due to cortical, subcortical, or capsular
causes is sudden, the reactions of degeneration do not
come on for a long period of time in such cases, be-
cause the muscles in the paralyzed area are still con-
nected with the trophic centers in the cord, and this
affords us a valuable point in differential diagnosis.
In all cases of brachial monoplegia due to peripheral
lesions we find that atrophy of the muscles comes
on very rapidly from cutting off of the muscles from
their trophic centers in the spinal cord.
The Tendons. — The want of protection of the
tendons in the forearm is the reason of their frequent
accidental division from incised wounds near the wrist .
In the event of such division the proximal end will
retract an inch or more into the tissues of the fore-
arm, and naturally the function of the accompanying
muscle will be totally suspended. Where several of
these tendons have been divided at once, there may
be considerable difficulty in identifying the corre-
sponding proximal and distal ends. In any clean
wound, however, union by suture should be attempted;
nor would the mistaken apposition of the proximal end
of one tendon to the distal end of another prove as
serious a disaster as the failure to unite the severed
tendon ends. In fact an intentional transplantation
of the proximal end of one tendon to the distal end
of another has recently been practised with brilliant
success in some cases of infantile paralysis, with a
view to imparting vicarious function to the paralyzed
members. In uniting multiple sections of the ten-
dons in transverse incised wounds of the wrist and
forearm, it is important that the union should be at
least between tendons traversing the same compart-
ment of the annular ligament.
An occasional result of a severe sprain is the
dislocation of the tendons about the affected
joint. The long head of the biceps is oftenest so
affected, being displaced from its groove in the hu-
merus. The flexor carpi ulnaris is sometimes in-
jured in this way, and the tendon of the extensor com-
munis digitorum, which runs to the index finger, is not
infrequently torn from its bed at the back of the wrist,
owing to the fact that the portion above the annular
ligament stands at quite an angle to the portion be-
low. Its displacement is always to the radial side.
In cases of dislocation of the tendons, the muscles
can still contract, but the tendon can be felt to move
in its abnormal position, while the extremity suffers
a partial loss of function from the mechanical dis-
advantage under which the muscle works.
These accidents may be treated by replacing the
tendon and keeping it in position by a splint. This
not availing, the tendon may be cut down upon and
the torn sheath sutured or a new sheath formed by
dissecting up a band of periosteum.
Among the traumatic affections of the tendons we
occasionally meet with instances of complete rupture.
This occurs either in the course of the tendon proper,
or, more frequently, at the attachment of the tendon to
the bone, but rupture at the musculotendinous junc-
tion is almost unknown. When the tendon is inserted
into a special epiphysis, as the triceps into the olecra-
non process, the biceps into the tubercle of the radius,
and the supinator longus into the styloid process of
the radius, so-called rupture of the corresponding
tendons is usually accompanied with tearing off of the
epiphysis and more or less stripping up of the adjacent
periosteum, constituting what is known as a fracture
"par arrachement." The tendons of the arm most
frequently the subject of rupture are the long head of
the biceps, and the pronator radii teres; the radial
attachment of the biceps, the triceps, the deltoid, and
the pectoralis major have been reported as torn from
their insertions. It is not likely that rupture of a
healthy tendon can occur except when the muscle is
suddenly and unexpectedly exposed to severe ad-
ditional strain when already in a state of contraction.
The accident is generally accompanied by sudden
and violent pain, by complete loss of power in the
muscle, and by considerable impairment of function
in the limb.
The treatment will vary, according to the importance
of the affected muscle and the amount of disability
incurred, from simple rest, with pains to keep the
limb in a position to relax to the utmost the affected
muscle, to more or less elaborate operative procedures
for the restoration of the continuity of the lacerated
tissues by suture. It should be remembered that
contractures may subsequently develop in conse-
quence of muscular or tendinous ruptures.
The tendons themselves are rarely the subject of
disease which does not also involve their synovial
sheaths as well. They may become necrotic in sup-
purative processes which have invaded their sheaths,
and in this case their separation will take place at the
point where their intrinsic blood-vessels have bci n
destroyed. The tendons are sometimes the seat of
deposits of urates, and not infrequently undergo
calcareous infiltration in advanced life. Ossification
of their distal ends is also sometimes observed, and in
some cases there is an anomalous development of
sesamoid bones at the point where the tendons may
form an angle in passing over bony prominences.
Rheumatic deposits are sometimes found near the
proximal end of the tendons.
The Tendon Sheaths. — Much more common
than disease of the tendons themselves is disease of
the synovial membrane which surrounds them. The
exact pathology of the simple irritative form of
tenosynovitis is not very perfectly understood.
From its etiology and course the pathological con-
dition is strongly analogous to that which has been
discussed under the head of myalgia, and is prob-
ably due to an alteration of the synovial fluid and
possibly of the endothelial cells lining the sac. It is
observed to occur under conditions strictly analogous
with those which induce an attack of myalgia i.e.
exposure to cold and overuse of the parts. It is
generally accompanied with lameness and tender:
over the course of the tendon, and characteristic of
the condition is the crepitation which follows contrac-
tion of the muscle. Rest, heat, and counterirrita-
tion are the best means for relieving the difficulty.
In addition to the simple irritative form, a septic, a
rheumatic, a syphilitic, and a tuberculous form of
tenosynovitis are recorded.
The septic form is almost invariably secondary to
septic processes outside of the tendon sheaths, and in
septic tenosynovitis of the forearm the locus of
560
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Arm and Forearm, Diseases
and Injurlrs ol
primary sepsis is most frequently the hands and
fingers. The disease is accompanied with a purulent
effusion into the tendon sheaths, giving rise to tender
oblong swellings, ill-defined on account of the dis-
tention due to accompanying cellulitis, and lying
iilrl with the axis of the limb. The surrounding
tea are usually sufficiently involved in the pyogenic
process to give rise to heat, redness, and swelling of
the surface. Suppurative tenosynovitis has been
known to follow gonorrheal rheumatism of the joints.
The treatment of purulent thecitis consists in laying
open the tendon sheaths freely, though not literally
from end to end lest the tendon escape from its bed.
Only in rare cases would it be justifiable to divide the
annular ligament of the wrist or even to open its
compartments. Great effort, however, should be
made to irrigate the sac most freely with antiseptic
solutions through the liberal incision above and below
the bridge of tissue which it may be deemed wise to
leave to serve as a bridle to hold the tendon in its
bed, and particular pains should be taken to force the
irrigating fluid to pass under this bridge of tissue.
In dressing wounds, whether operative or otherwise,
of the tendons or of the tendon sheaths, it must be
borne in mind that the vascular supply of these
tissues is limited and that in consequence when they
have been exposed to the air it is necessary to provide
carefully against their desiccation in order to avoid
necrosis. In all aseptic conditions of the tendon
•lis this may be accomplished by covering the
exposed tissues with impervious protective strips of
a-percha, rubber, or prepared mackintosh. In
septic processes the use of impervious dressings is
contraindicated, and provision against desiccation
must be made by means of wet dressings, frequently
renewed.
serious and crippling a disease is purulent
tenosynovitis, and so indifferent are the results
obtained by ordinary surgical means, that I have
deemed it not unwise to append a description of the
treatment by passive hyperemia, as outlined by Bier,
in his book "Hyperamie als Heilmittel."
"Incipient phlegmon of the tendon sheaths.
whether accompanied or not by a wound leading
directly to the sheath of the tendon, we never attack
by immediate operation, but, on the contrary the
at tempt is made to abort the process at the outset by
vigorous obstructive hyperemia (i.e. by means of a
firm constricting bandage applied above the elbow).
If we are not successful in this, or if there is already
unmistakably present a considerable accumulation
of pus, the abscess is opened, either through one large,
or through multiple small incisions. We avoid very
long incisions, such as extend the whole length of the
;ed tendons, because they involve the danger of
having the tendon disengage itself from its sheath,
allowing it to lose its proper relations with the sur-
rounding soft parts, and to become desiccated and
necrotic. For the same reason we abstain from the
introduction of any packing or any drainage appli-
ances. Indeed, a most important consideration is
that gauze packing, owing to its capillarity, with-
draws the nutrient fluids from contact with the
tendon and thus favors its desiccation and necrosis.
When, on the other hand, the wound is left to itself,
the exposed tendon presently becomes covered with
granulations pushing in from the sides of the sheath.
Each day the accumulated pus is expressed from the
1 incisions; if necessary, the pus is flushed out
with a stream of saline solution. If fresh abscess -
form they are promptly incised. All operative
measures are conducted under narcosis, for the sake
of more thorough work. Xo splint is used. After
any operation the wound is simply covered with a
copious absorbent dressing, because the obstructive
hyperemia generally evokes a very abundant secre-
tion. The dressing must be applied very loosely, so
that the limb underneath may have ample opportun-
Vol. I. — 36
it v to swell under the influence of the constricting
bandage, and so that the patient shall not be impeded
in malting active movements of tin- fingers. From
the very first day, tin- surgeon executes daily pa
movements of the fingers in which every joint of each
finger is both Hexed and extended. Only in this
way is it possible to obtain full restoration of function.
Occasionally, even in twenty-four hours, the tendons
will have contracted adhesions with die surrounding
parts, and under the passive flexion and extension,
the tearing loose of these adventit i<>us attachments is
accomplished only with a very perceptible cracking.
These maneuvers, which under other conditions would
be cruelly painful, are relatively easily borne owing to
the conspicuous analgesic effect of the obstructive
hyperemia. A further extension of the suppuration,
v. Inch one would perhaps not unnaturally dread, we
have not encountered as the result of such passive
movements. The constricting bandage is removed
from above the elbow a certain length of time before
beginning the passive movements, to avoid bleeding
of the granulations. The best time to undertake the
passive movements is in the pause between two
periods of hyperemization. (The general recom-
mendation in the treatment of acute septic processes
is to leave the constricting bandage in place, above
the elbow, for from twenty to twenty-two hours a
day.) The patient, furthermore, is urged to perform
active movements of the fingers at frequent intervals."
The results which Bier has attained under this
method of treatment are most satisfactory, and are
far in advance of any attained before his method of
passive hyperemia was introduced.
It is likely that still better results can be obtained
by combining with the treatment by passive hyper-
emia, the use of bacterial vaccines. This would
necessitate a careful determination of the nature of
the infecting germ, and the application of a corre-
sponding vaccine. If the streptococcus were found
to be the cause of the septic process, such a vaccine
would probably- prove more efficacious if grown from
autogenous cultures.
Like all diseases of the fibrous system, tenosynovitis
is very prone to occur in arthritic subjects, and the
rheumatic form of texosyxovitis has a very
disagreeable tendency to become chronic. In the
acute stages alkalies and the salicylates will afford
relief to the patient. In the later stages lithia and
the iodide of potassium are the most servicable drugs
available; while the exposure of the limb to high
temperatures in the hot-air bath, together with
massage, and active and passive motion carried on in
spite of the soreness, will do much to restore the
supple action of the arm.
The tuberculous form of tenosynovitis begins
in a very insidious fashion. It may be primary in the
tendon sheath, but is frequently secondary to a
tuberculous process in the adjacent joints. It is,
like most tuberculous processes, of very slow growth,
covering a period sometimes of years, with times of
improvement under rest, but with great proneness to
recur as soon as the limb is again put to its customary
use. It develops frequently after some traumatism
such as a sprain or a contusion, and the differentiation
from the simple irritative or from the rheumatic form
is not at first easy. After a while there will almost
always be developed along the course of the tendon
the characteristic flat or oval swelling, caused by
eTusion into the sheath and thickening of the walls
of the sheath itself. This swelling may take on more
or less of an hour-glass shape from confinement of
the tendon beneath the annular ligament. The
disease may remain confined to one portion of a
single tendon -heath, but tends to extend both
upward and downward; also to attack neighboring
tendons and even to invade underlying joints.
According to Park, there are two pathological forms
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of the disease: one is a fungous form distinguishable
by the growth of exuberant granulation tissue of a
gelatinous appearance surrounding the tendon on the
inner side of' its sheath. In the other form, known as
hygroma, the inner surface of the tendon sheath is
covered with small growths, which become detached,
forming small, hard kernels known as rice bodies.
These rice bodies are the result of fibrinoid degenera-
tion, i.e. the degenerated villous growths which are
fibrinous in character become loosened, forming free
kernels. Until recently, this form of disease was
supposed to have no connection with tuberculosis.
It is now distinctly established that these bodies con-
tain tubercle bacilli. The same condition may be
found in tuberculous joint disease where they develop
from a fibrinoid degeneration of tuberculous granula-
tions on the synovial fringes. If the disease is allowed
to run its course, suppuration ensues, forming sinuses
involving the skin which eventually breaks down.
These with the resulting cicatrices greatly impair the
use of the hand.
The treatment of tuberculous tenosynovitis is
essentially the same as that of tuberculous joint
trouble, and consists at first in the immobilization of
the arm by suitable splints, with moderate pressure,
together with the administration of appropriate
tonics and careful attention to hygiene. It is essential
to differentiate positively the tuberculous form of the
disease from the simple irritative and the rheumatic
form. Massage so preeminently useful in the treat-
ment of the two latter forms, is absolutely and
positively contraindicated in tuberculous synovitis.
The possible usefulness of dry heat, by means of the
hot-air bath (active hyperemia), is not altogether
settled, though it would seem to be a rational thera-
peutic measure. Less doubtful is the beneficial
effect of "obstructive" or "passive" hyperemia by
means of a constricting bandage above the elbow.
The application of this method of treatment to
tuberculous lesions demands, however, considerably
more care, judgment, and circumspection than its
application to ordinary septic processes. Three
points are insisted on by the advocates of passive
hyperemia in applying it to all tuberculous lesions:
first, the bandage must be very lightly applied, so as
to induce but a mild degree of venous obstruction, as
opposed to the much firmer application of the
bandage in ordinary forms of sepsis; secondly, the
bandage should remain in place a much shorter time,
from one to two hours a day, instead of twenty to
twenty-two hours; and, thirdly, the treatment must
be patiently continued for a long period, several
weeks or months. Where this method of treatment
is applicable, it has the further great advantage that,
at least during the time that the constricting bandage
is in place, both active and passive movements of the
fingers can safely and advantageously be carried out
with comparatively little pain. Such active and
passive exercise of the fingers naturally very greatly
favors complete restoration of function after eventual
recovery from the tuberculous process in the tendon
sheaths. Without the use of passive hyperemia,
such movements of the fingers are counterindicated
in tuberculous tenosynovitis, until after complete
subsidence of the infectious process, and their use at
so late a date can, in the nature of the case, yield only
indifferent results. Failure to secure improvement
by the above means would justify us, as in cases of
joint tuberculosis, in proceeding to operative meas-
ures. The simplest of these consists in aspirating the
fluid contents of the tendon sheaths and in injecting
into them a tcn-per-cent. emulsion of iodoform.
Should this fail to control the process, the tuberculous
area should be cut down upon, the blood-supply to
i lie .inn being first cut off with an Esmarch bandage,
and any suspicious granulation tissue scraped away
with a small curette. At any point where the
tendon itself seems hopelessly affected, it should be
freely resected and an effort shoiuji be made by
splitting and grafting the tendon to compensate for
the defect. Even should this be impossible, the
function of the tendon may better be sacrificed than
to expose the patient to danger of loss of the limb
or even of life.
Syphilitic tenosynovitis may exhibit itself in an
acute and chronic form, not easy to differentiate by
symptoms alone from simple and rheumatic inflamma-
tion of the tendon sheaths. Both of these forms of
syphilitic thecitis are seen in early syphilis, and I
have myself observed one marked case ending in
resolution after some months of treatment, in a case
of hereditary syphilis accompanied with syphilitic
pachymeningitis.
The gummatous form is almost invariably very
late in development, occurring often fifteen or twenty
years after infection. It is recognized as a round or
spindle-shaped swelling involving the tendons. It
grows slowly and painlessly, remaining as a gumma-
tous swelling becoming calcareous, or extending to the
surrounding tissues, the fascia and the skin.
Synovial cysts of the tendon sheaths, other-
wise known as weeping sinews or ganglions, occur
with greatest frequency about the wrist, whether
just above or just below the annular ligament.
There are cases met with, however, in the lower part
of the forearm, both on the flexor and on the extensor
tendons. Their exact pathology is a matter of
dispute, but it is fairly well established that they
rarely communicate with the synovial sac proper.
They not infrequently contain rice bodies such as are
found in the synovial sac in cases of tuberculous
disease, but their almost invariably benign course
would make it seem improbable that their origin
should be tuberculous. These little cysts frequently
disappear spontaneously, and often their disappear-
ance can be hastened by moderate pressure long
continued. More obstinate cases can be dealt with
by free subcutaneous puncture with a sharp bistoury
or tenotome and the expression of their contents by
digital pressure into the surrounding cellular tissues.
Some cases may demand free incision and extirpation
of the cyst walls, an operation which must be con-
ducted with careful antiseptic precautions, on
account of the close association and occasional
continuity of the cyst with the tendon sheath proper.
V. Affections of the Blood-vessels.
The Arteries. — The blood-vessels of the arm
are subject to the same diseases as the blood-vessels
elsewhere in the body. The anatomical position
of the radial artery is important from its frequent
use for taking the pulse, and it should be remembered
that it may be absent in rare instances; or it may
be much smaller than normal, terminating in muscular
branches above the wrist; or it may lie upon the deep
fascia instead of beneath it; or it may be covered by
fascia so thick and hard that the pulsation cannot
readily be transmitted to the finger tips; finally, it
may turn backward beneath the extensor muscles of
the thumb. When in its normal position it is easily
felt, pulsating almost subcutaneously over the bones
of the wrist.
Atheroma of the arteries manifests itself
through thickening of the vessel wall, either localized
or diffuse, and often accompanied by the deposit of
calcareous salts until a condition of the vessel is
produced well expressed by the term "pipe-stem
artery." It is most readily appreciable in the radial
artery near the wrist. Its chief importance in this
connection is not with regard to the function of the
vessels of the arm, but as an indication of the condi-
tion of the vascular system throughout the body.
The vascular sclerosis will often be found more
marked in the right arm than in the left, in individuals
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RKl-'KKKXCK HANDBOOK OF THE MEDICAL SCIENCES
Ami and Forearm, Diseases
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such as stone cutters and blacksmiths who habitually
perform much heavier labor with that arm than with
the left. When this condition of arteriosclerosis is
found to be present, it is an important guide to the
surgeon in leading him to make a guarded prognosis
aa to the result of severe operation anywhere in the
body.
Aneurysms occur in the vessels of the arm as
They may be present at any age; indeed
Schmidt reports' an aneurysm of the radial artery in
an Infant of eight weeks.
The traumatic forms affecting the arm are chiefly
■ springing from the axillary artery and showing
in the arm pit. The arteriovenous form of an-
eurysm was formerly quite a common occurrence
v. lien venesection was more generally practised.
The adjacent artery being wounded by the incision
,-ii opened the vein, adlie-ions form Viet ween the
two vessels and part of the arterial blood is thrown
into the vein at each pulsation, the vein greatly dilat-
ing under the strain.
iiD aneurysms are occasionally met with on
t he forearm. They are formed of dilated and tortuous
arteries. In a ease that came under my observation,
tumor extended from a little below the elbow
almost to the wrist, and was about three inches wide.
On operation a mass of dilated arteries was found
lying in the superficial fascia, fed by numerous branches
"rating the deep fascia from below. The treat-
ment of this form of aneurysm, which stands on the
der line between tumors and malformations, con-
in thorough extirpation, approaching the mass
of pulsating vessels from the periphery and tying all
the feeder- at their point of emergence from the deep
ia. With careful dissection, working from the
- toward the center of the tumor, dangerous
hemorrhage can usually be avoided. The diagnosis
of aneurysm can usually be made by observing that
the tumor has an expansile pulsation which ceases on
application of firm pressure on its proximal side. In
the case of cirsoid aneurysm in which the feeders are
numerous and come from the parts directly under-
neath the tumor, pressure on the proximal side will
not suffice to interrupt the pulsation of the mass. A
characteristic bruit, can in most cases be heard over
the tumor. The treatment of aneurysm of the upper
extremity does not differ from the treatment of the
condition elsewhere.
The Veins. — The veins of the upper extremity
are subject to the same affections as those elsewhere
in the body; such as 'wounds, phlebitis, thrombosis,
and varices.
The condition of the veins of the hand and fore-
arm is a valuable index of the condition of the general
circulation as regards aeration of the blood and pos-
olistruction to the venous circulation. These
veins dilate when the heart is weak, or when there is
any impediment to the return circulation in the do-
main of the vena cava superior.
Phlebitis may be caused by inflammation near the
vessel, by thrombus formation, by traumatism, or by
direct infection. It gives rise to pain and tender-
ness in the course of the vessel, to edema and discolo-
ration of the skin, and if at all extensive, systemic
symptoms occur which are those of mild or severe
sepsis.
The treatment of simple phlebitis consists first of
all in rest, which should be insisted on as most im-
portant to prevent the detachment of emboli. Next
it is necessary to secure as near an approximation to
asepsis of the intestinal tract as may be practicable,
and finally some benefit may be expected from the
use of antiseptic and stimulating substances applied
along the course of the affected vein, such as a fifty-
per cent, ointment of ichthyol or Crede's silver oint-
ment; the object of the treatment being to maintain
the intergrity of the thrombus within the inflan
el until such time as .shrinking of the coagulated
fibrin may allow a partial restoration of the vascular
■ ■anal, and to stimulate the absorptive function of the
perivascular lymph channels. Upon the first in-
dication of septic infecti f the thrombus, as
denced by chills and septic fever, or by local abscess
formation, it is proper and necessary to incise the
tissue- freely over the affected vessel, to clean out the
septic clot, and establish free drainage. During
such an operation it may be possible to restore the
patulousness of many adjacent veins which may
have become thrombotic, by extracting from their
lumen long, more or less linn clots oil coagulated
blood and fibrin. Great care, however, must Be used
in manipulation of the affected limb to avoid break-
ing loose portions of the blood clot within the vi
which might be carried as emboli to the lungs or to the
brain, and give rise to dangerous or even fatal in-
farctions.
Thrombosis is due to conditions that slow the
blood stream associated with abnormal condition- of
the endothelial coat. It gives rise to sudden and
severe pain and to edema on the distal -ide of the
coagulum. The treatment is essentially that of the
phlebitis, which is an almost invariable attendant.
Varices are rare in the upper extremity, owing to
the less unfavorable action of gravity as compared
with the lower extremity, but they may occasionally
be found.
VI. Affections of the Lymphatic Vessels,
Glands, and Burs^e.
The Lymph Vessels and Lymph Glands. — In con-
sidering the affections of the lymphatic system of
the arm, one anatomical peculiarity should be borne
in mind — namely, that the greater part of the lym-
phatic current from the hand and forearm passes
directly to the axillary and subscapular nodes with-
out traversing the epitrochlear gland and the other
lymphatic nodes at the bend of the elbow. The
importance of this course of the lymphatic canals
is indicated in cases of septic and malignant disease
of the hand, as some cases on record tend to prove that
the lymphatic vessels, as compared with the lymphatic
nodes, may with considerable impunity serve in the
transmission of both septic and malignant particles.
Thus in cancer of the hand, with more or less extensive
involvement of the axillary nodes, it has been recorded
in some cases that amputation of the hand and
radical extirpation of the axillary lymphatics has
succeeded in leaving the patient free from recurrence
of the disease, and in a similar manner we frequently
find the axillary glands fatally compromised and
breaking down into abscesses with the lymphatic
vessels, by which infection from the hand must have
travelled, remaining to all appearances intact. It
behooves the surgeon in all cases of disease of the
distal part of the upper extremity to examine with
care the condition of the cubital and axillary glands
and to palpate also the course of the deeper lymphatic
vessels, which is to all intents and purposes that of the
main arteries.
The epitrochlear node is situated in the bicipital
sulcus just in front, of the inner epicondyle of the
humerus. It is one of the first glands to become en-
larged and indurated in the general adenitis of
syphilis.
Elephantiasis appears occasionally in the arms,
but more rarely than in the lower extremities.
Lymphangioma is also rarely met with, but may
occur, particularly along the course of the deep
lymphatics. Lymphadenitis may of course affect
the nodes of the arm as those elsewhere, and is due
either to infection in the acute form from some focus
of sepsis on the line of drainage, or, in the chronic
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form, is usually due to tuberculous or syphilitic dis-
ease. As in all cases of adenitis, it is important to
study the anatomical distribution of the lymphatic
vessels which center in the affected node with a view to
determine the portal of infection. The axillary
glands may be involved as a result of disease of the
upper extremity, but more frequently as a result of
disease of the thorax and of the neck.
The Bursa-. — of the bursa? of the arm that most
frequently diseased is the one over the tip of the
olecranon process. This bursa when inflamed and
distended gives a characteristic alteration of the
contour of the arm. It is sometimes present as an
occupation lesion, and is known as "miner's elbow."
The type of inflammation present may be either a
simple traumatic bursitis, a septic bursitis, or in some
cases a gummatous bursitis. In addition to these
are the various forms of secondary bursitis due to
extension of disease of the bone or of the joint. The
only ease in which the diagnosis of bursitis is likely
to offer any difficulty is in its earlier stages before
effusion in the bursal sac has taken place. In this
case it may be difficult to differentiate it from perios-
titis and perhaps from rheumatism.
The treatment of simple bursitis should be direct-
ed either toward causing absorption of effused fluid, or
in default of this, toward the obliteration of the sac.
To this end it is wise in the acute form of the disease
to try the effect of heat, compression, and the use of
various agents such as iodine and ichthyol, whose
function it is to stimulate lymphatic absorption.
Later in the disease a different form of therapeutic
effort will be more likely to be successful, ranging
from tapping alone, to tapping followed by the
injection of irritating fluids, if necessary to incision
and packing, or even total excision of the walls of
the bursa.
In the septic form of the disease the contents of
the bursa will probably be purulent and the surround-
ing tissues will be angry and inflamed, and what was
in the simple form of the disease a painless fluctuating
tumor may take on all the characteristics of an acute
abscess. In this case no treatment is of avail which
does not involve prompt and free incision and the
evacuation of the pus. It is particularly in septic
cases that the danger of joint involvement by con-
tiguity of tissue must be considered. In the other
forms of disease of this bursa, the liability to second-
ary joint involvement is slight.
As already stated, the bursa frequently becomes
sympathetically involved in any of the diseased
processes of the joint (rheumatism, tuberculosis,
syphilis, etc.) ; and in view of this we are not surprised
to find occasionally an acute syphilitic bursitis over
the olecranon appearing at the time of the severe
joint pains which characterize the earlier stages_ of
secondary syphilitic invasion. This type of bursitis
tends to spontaneous amelioration and subsides
pari passu with the joint affection.
A more characteristic form of syphilitic bursitis
occurs in this region as a late secondary lesion (second
or third year). This difficulty is independent of the
joint itself and consists in the development of gum-
matous nodules in the wall of the bursa, presently
enlarging and becoming confluent until the whole
bursa represents one large gummatous mass. The
process soon extends beyond the walls of the bursa
and involves the skin in gummatous infiltration.
When the skin has become involved, this vulnerable
mass is very prone to pyogenic infection and second-
ary ulceration of an obstinate and destructive
character. Like syphilitic affections elsewhere, in
the absence of special constitutional depression the
m will yield readily to the combined use of anti-
syphilitic ami antiseptic measures, neither of which
may suffice for a cure.
There are two other bursa? connected with the
upper extremity whose surgical importance was not
564
fully appreciated until recently emphasized by the
work of Goldthwait, of Boston, from whose work on
"Diseases of the Bones and Joints" the following
paragraphs are largely taken. These two bursas, the
subacromial" or "subdeltoid" bursa and the
"subcoracoid" or "coracobrachialis" bursa, are both
functionally connected with the shoulder joint. The
subacromial bursa is situated under the acromial proo
cess, outside of the capsule of the shoulder joint, and
extends over the greater tuberosity of the humerus
and out under the upper part of the deltoid muscle.
In raising the arm from the body at the side (abduc-
tion), the surfaces of this bursa glide over each other,
and if for any reason the bursa becomes inflamed,
this motion will be attended with pain, and if such
inflammation exist or adhesions have formed, motion
will be limited, and the extent of the limitation will
depend upon the. extent of adhesion formation. If
the cavity of the bursa is wholly obliterated, all rota-
tion and nearly all abduction at the shoulder joint
will he impossible. Pain is usually referred directly
to the location of the bursa or over the situation of
the deltoid muscle, frequently, likewise, to the
attachment of this muscle to the humerus.
The subcoracoid bursa is situated betweed the tip
of the coracoid process and the outer surface of the
shoulder joint as it extends to and over the lesser
tuberosity of the humerus. As the result of a posture
such as occurs when the shoulder is habitually carried
forward (the round-shouldered or stoop-shouldered
attitude), the lesser tuberosity of the humerus rests
against the tip of the coracoid process, and so too in
many occupations the arm is used so that these two
bones are in contact more constantly, or with more
force than is normal, under which circumstances the
subcoracoid bursa becomes inflamed. If such an
inflammation occurs, there will be pain and sensitive-
ness with limitation of motion. This limitation of
motion at the shoulder joint, when caused by adhe-
sions between the two layers of the subcoracoid bursa,
is such as one would expect if the anterior part of the
capsule of the joint were attached to the coracoid
process. Such an adherence of these structures
would not materially interfere with flexion or exten-
sion of the arm, as long as motion was made in the
anteroposterior plane, or with raising the arm from
the side, provided the motion was made in a purely
lateral plane, because in all these motions the sub-
coracoid bursa is comparatively little used. If,
however, rotation is attempted, either with the arm
at the side or when the arm is raised, limitation is at
once apparent, because in rotation the lesser tuber-
osity of the humerus must either glide over (in inward '
rotation) or move away from (in outward rotation",
the coracoid process. It is this limitation that makes
difficult the putting on of a coat or similar garments,
the dressing of the hair, the fastening of the bands of
shirts, etc., all of which involve movement of these
bones in rotation one upon the other. If the sub-
coracoid bursa is inflamed, pain is usually located
just outside the tip of the coracoid process. At times
pain is referred to the deltoid region or down the
arm, t lie region of the attachment of the deltoid to
the humerus being a common place, or along the
course of the ulnar nerve. Occasionally the whole arm
and hand are painful, and associated with this there
may be disturbances of circulation, the whole condi-
tion appearing like a true neuritis.
The treatment of subacromial bursitis is practically
that outlined above for bursitis of the elbow, with
this addition that the weight of the arm must be
supported by a sling, either a "mitella" or the more
satisfactory Moore's dressing for fracture of the
clavicle. The special treatment of subcoraci
bursitis should be based on the etiology of the condi-
tion, as explained above, and should include proper
means, either by gymnastics or by shoulder-brai
to do away with the causative round-shoulders. Its
REFERENCE BANDBOOK OF THE MF.DICAI. SCIENCES
Arm and Foreamii Diseases
and in j uries ol
general treatment is by heat, rest, counterirritation,
etc. When extensive and firm adhesions have formed,
these can sometimes be broken up by forced manipu-
lation under an anesthetic. In sonic cases it \\ill be
fouml that the cavity of the bursa; lias become so
completely obliterated that in spite of all manipula-
tions the adhesions re-form, and improvement is
impossible from such methods. Under such circum-
uces an operation should be performed and the
bursa' removed. Both of these bursa? are easily
hed, and following the complete removal of the
bursal tissue, normal function is often obtained, the
nee of the bursa; seemingly being of little im-
portance.
VII. Affections of the Nerves.
The nerves of the arm and forearm are liable to the
usual forms of disease of these tissues elsewhere
(neuralgia, neuritis, etc.), with similar symptoms and
demanding similar treatment. The main interest
hing to disease of the nerves of the arm is due
anatomical distribution, giving motor and
iiv disturbances in certain well-defined regions.
The three- chief types of such lesions are exhibited
ectively in interference with the function of the
ulnar, of the median, and of the musculospiral nerve.
In ulnar paralysis, the muscles affected are the
ulnar half of the deep flexor of the fingers (perforatus),
the ulnar flexor of the wrist, the hypothenar muscles,
the two external lumbrical muscles, all of the interos-
adductor pollicis, and the inner head of the
Bexor pollicis brevis. The position assumed by the
hand, due to the unopposed action of the antagonist
muscles, is characteristic. The hand becomes more
-- law-shaped and the condition is known as
■'main en griffe. This typical position is assumed
by the hand only when the paralysis has lasted some
time (three or four weeks or longer). The wrist is
slightly bent backward and to the radial side of the
irm by the unopposed action of the extensors and
flexors of the radial side of the wrist and of the extensor
carpi ulnaris. It is the defect of the interossei which
gives, however, the most marked and characteristic
deformity of ulnar paralysis. The fingers cannot be
Hexed at the first phalanges nor extended at the
md and third, and in consequence of this, through
the continued action of the extensor communis digi-
torum, the first phalanges are markedly over-extend-
■ wing to the w-ant of opposition from the lumbri-
cales and interossei, while the continued action of the
flexor sublimis and the unparalyzed portion of the
flexor profundus digitorum bring the second and
third phalanges into extreme flexion. The loss of
ation in ulnar paralysis varies considerably: in
some eases the sensation is lost in the little finger and
the ulnar portion of the ring finger, also throughout the
ulnar portion of the palm and the dorsum of the hand.
In other cases there is but little attendant anesthesia.
The second marked picture of nerve lesion in the
forearm is found in paralysis of the median nerve.
Destructive injury to this nerve above its muscular
branches causes paralysis of the flexors of the fingers
excepting the ulnar half of the flexor profundus, and
Of the other muscles to which the median is distrib-
uted: to wit. the pronators, the flexor carpi radialis,
the two outer lumbricales, and all the muscles of the
ball of the thumb, except the abductor pollicis and the
inner head of the flexor pollicis brevis. The flexion
of the wrist and of the hand, and the pronation of the
forearm are very greatly impeded but not altogether
abolished by the loss of function in these muscles.
The flexor carpi ulnaris is still in action and
■ pronation is possible thourgh the weight of the
hand when the supinators are relaxed. The extension
and abduction of the thumb are characteristic, and
the thumb cannot be made to touch the tips of the
fingers. Flexion of the two distal phalanges is no
longer possible, though thi Si I phalanges are flexed
by the interossei. The loss of sensation i- again
variable; the most characteristic distribution ol
thesia being the thumb, index and middle' fingers,
and the radial side ol the ling finger with the radial
side of the pal f t he hand. 'I a< ton of t he
dorsum of the hand is not greatly affected. Again, a
characteristic appearance of the hand and forearm is
produced, with great atrophy of the forearm on the
radial side and in front . I he wrist is inclined ti
ulnar side, and the thumb, whose flexor and adductor
muscles are wasted, is usually rotated outward so that
its palmar surface is on a plane with that of the wrist
and t he fingers, as in api
The third characteristic picture of injury to
nerves of the arm is thai afforded by paralysis op
hi musculospiral nerve. In paralysis of the
musculospiral nerve loss of power occurs in all the
extensors of the forearm and of the wrist and in the
supinators, with the occasional exception of the supi-
nator longus. The wrist drops and the finger
flexed at their distal joints. Sot xtension of the fin-
however, can be obtained through the action of
the interossei and lumbricales. The typical distribu-
tion of the anesthesia after actual division of the
nerve above its cutaneous branches is along the outer
part of the arm from the insertion of the deltoid to
the lower third of the forearm, and there is more or
less affection of the sensation of the dorsum of the
hand, though in many cases there is little or no involve-
ment of sensation.
The ulnar nerve is more exposed to injury than
any other nerve in the body. In the wrist, at the
elbow, and in the upper arm the nerve is liable to
division from incised wounds, to pressure or contusion,
or to involvement in fractures of the bone. Some-
times an apparently spontaneous ulnar neuritis is
observed in persons otherwise in good health.
One peculiar accident is liable to affect the ulnar
nerve as it passes behind the inner condyle of the
humerus, namely, dislocation from its bed. This
accident is accompanied with more or less neuralgic
pain referred to the region of distribution of its cuta-
neous branches, and with more or less involvement of
the functions of the muscles to which it is distrib-
uted. The pain as well as the motor symptoms
will be most marked when the arm is flexed. In
short there is excited in the nerve at this point
a localized neuritis. The accident, which is rare,
may occur spontaneously during violent use of
the arm, as in ball-playing and gymnastic exercise,
or as the result of a contusion. Pain, numbness,
and tingling along the ulnar side of the forearm and
of the hand will indicate the moment of its occur-
rence and a cord can be felt running along the inner
side of the epicondyle which reveals itself as the dis-
located nerve through the aggravation of all these
symptoms when pressed upon by the examining fin-
ger. To avoid extension of the neuritis and all the
undesirable sequela; of nerve degeneration, it is im-
portant that the nerve should be returned to its bed
and securely fastened there. For this purpose a free
incision should be made over the course of the dis-
located nerve and a firm flap of connective tissue
should be dissected up from the inner side of the
condyle and turned outward over the nerve so as
to bind it in its proper bed. The edge of this flap of
connective tissue should be sutured to the capsular
ligament of the elbow joint or to the periosteum of the
humerus. It is wiser not to allow the needle to pass
through the nerve sheath for fear of exciting neuralgic
pains. The arm should be put up and fixed in ex-
tension and this position maintained until the parts
shall have firmly united. If the symptoms of neu-
ritis in the mean time have disappeared, the limb
should be treated with massage, faradization, coun-
terirritation, active and passive motion, etc.
565
Arm and Forearm, Diseases
and Injuries of
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
The median- nerve is often injured, most fre-
quently in incised wounds of the wrist. In the fore-
arm it suffers in case of fracture of the ulnar and
radius, and just above the elbow its course to the
bicipital groove exposes it to injury. The nerve per-
forates the pronator radii teres, and it is possible
for it to be injured in forcible contraction of this
muscle without direct external violence.
The muscclospiral nerve is generally the sufferer
in crutch paralysis from pressure in the axilla. Its
close connection with the humerus leads to its fre-
quent injury in case of fracture and to its frequent
involvement in the callus or between the fragments.
The most frequent cause of the paralysis is, however,
damage to the nerve during sleep, the patient lying
upon a hard bed with his arm under him. This is
seen particularly in drunkards. In many cases this
injury of the musculospiral nerve is due not so much
to' pressure as to stretching of the plexus by prolonged
extension of the arm above the head. It is important
for the surgeon to bear this in mind, as it is the fre-
quent cause of arm paralysis after anesthesia. The
prognosis in paralysis of this description is almost
invariably good; the most potent therapeutic agent
being faradization of the affected muscles.
Progressive muscular atrophy and syringomyelia,
together with the other spastic and paretic affections
of the arm, though more properly due to nerve influ-
ences than to actual affections of the muscle, have
nevertheless, for the sake of convenience, been treated
above under the head of affections of the muscles.
VIII. Hysterical Lesions.
The elbow is a favorite seat for hysterical lesions,
and the arm as a whole is frequently declared by the
patient to be powerless, or may be held by perverted
volition in some constrained attitude which may be
the more natural one of extension, or of partial
flexion, or again some strange or bizarre position
from which the patient declares herself unable to
move it.
The differentiation of hysterical from organic
disease of the arm may be extremely difficult.
Hysterical affections simulate especially disease of
the joints. The differential diagnosis has been
formulated by Dercum as follows: Hysterical disease
of the joints is not associated with deformity and
shortening of bone, nor with the formation of pus,
nor with the local rigidity, nor with the septic tem-
perature that is seen in tuberculous diseases. The
stiffness is caused by contracture of the_ muscles,
which is usually much more extensive than in organic
disease, and the pain is usually more diffuse and more
spontaneous. There are, moreover, characteristic
mental and physical stigmata present. The hyster-
ical patient dreads to move or assist in the examina-
tion of the limb, and obviously dwells upon each
symptom, while she is very apt to have segmental
anesthesia in the affected limb or even hemianesthesia
of the body. A very significant symptom is paralysis
of the limb, which is never present in tuberculous
joint disease. Finally, under full etherization the
hysterical joint is found to be freely movable in all
directions. It must not be forgotten, however, that
hysterical symptoms may be added to those of
genuine organic disease of the joint.
Hysterica] paralysis may be caused by emotion,
such as fright, anger, chagrin, or disappointed love.
It may vary in degree from slight loss of power to
total palsy. The deep reflexes of the affected side
are usually increased and the skin reflexes abolished.
The tendency to contracture is often marked: some
ca es, however, present a flaccid type. In mild cases
the nutrition of the limb is not affected, but in severe
ca es of long duration slight but distinct loss of
volume may !"■ noted. True atrophy with reaction
of degeneration is practically unknown, and when
present must throw a doubt over the exactness of
the diagnosis. Hysterical paralysis is often accom-
panied also with anesthesia or hyperesthesia. The
anesthesia is likely to be sharply defined and limited
to the paralyzed "part. The boundary of the anes-
thetic area will be at right angles to the long diameter
of the limb. The paralyzed part may become
edematous and blue or mottled. The hyperesthesia
accompanying hysterical paralysis is usually hyper-
algesia. This hyperalgesia may be attended with
contracture. The painful cramp-like state of the
muscles causes the patient to cry out and to shed tears.
Hysterical paralysis is not as a rule confined to the
distribution of particular nerve trunks; in other
words, it is central, not peripheral. Contracture is
very likely to coexist with paralysis in hysteria, still
this is not a constant rule. Neither is the reverse
true: that a contracted limb or muscle is always
paralyzed. Hysterical contracture is most obstinate
and resisting, being very difficult to overcome even
with great force. Moreover, the antagonistic muscles
are involved; in other words, the limb is drawn into
a vise-like immobility. The contracture is sometimes
so persistent that it does not relax even in sleep. It
does relax, however, under ether or chloroform.
The duration of hysterical paralysis may be greatly
prolonged. Some cases recover promptly, but others
persist so long and simulate so closely the effects of
organic disease that even the most careful observer
may come to distrust the exactness of his diagnosis.
The termination of hysterical paralysis is sometimes
sudden, following some shock or strong mental or
moral impression. Sometimes, however, recovery is
gradual under well-directed treatment.
IX. Tumors.
Of the tumors affecting the arm and forearm none
is peculiar to this locality. Keloids following si
of any sort are found here as elsewhere, as are tin
other forms of neoplasm which may develop from the
skin or its appendages. Fibromata may occur on
the arm in the form of painful subcutaneous nodules
over the course of the superficial nerves. Lipomata
are found with considerable frequency upon the
upper extremities. They are most commonly of
the cutaneous variety, and are found chiefly upon
the posterior side of the arm and upon the ulnar side
of the forearm, frequently also upon the shoulders
and over the scapula. They have also been found
burrowing beneath the muscles of the forearm.
Sarcoma sometimes occurs here as a primary
growth, usually in the callus of a fracture or as a
tumor of the bone. Secondary metastatic sarcomata
may of course be deposited from the blood-vessels in
the arm as elsewhere. In this case they are generally
seen as subcutaneous sarcomatous nodules.
Carcinoma very rarely occurs excepting as a
secondary growth from epithelioma of the hand.
Epithelioma of the hand in turn develops with com-
parative frequency in old age from purely benign \\
which are so frequently encountered upon the fingers,
and a case has recently come under observation in
which a verrucose condition existed symmetrically on
the extensor aspect of each elbow, suggesting the
possibility of a primary carcinoma in this region
with a pathological history similar to that of epithe-
lioma of the hand. Leonard W. Bacon.
Army Medical Department.— The Medical Depart-
ment of the U. S. Army received the organizal ion « Inch
it has at the present time (1912) by the Act of April 23,
190S, by which it was largely increased and greatlj
improved in status and efficiency, ruder the Army
Regulations "The Medical Department is charged
with the duty of investigating the sanitary condition
566
REFERENCE HAND ROOK OF THE MEDICAL SCIENCES
Army Medical Department
of tlic Army and making recommendations in refer-
ence thereto, of ad\ ising with reference to I he location
,,i permanent camps and posts, the adoption of
s . tenia of water supply and purification, and the
,li |„,sal of wastes, with the duty of caring for the
sick and wounded, making physical examinations of
officers and enlisted men, the management and con-
trol of military hospitals, the recruitment, instruction,
and control of the Hospital Corps and of the Nurse
I lorps, and furnishing all medical and hospital supplies
except for public animals."
The organization of the Medical Department is as
follows:
ill I he Surgeon-General, who is chief of the
Department;
the Medical Corps;
The Medical Reserve Corps;
The Dental Corps;
The Army Nurse Corps;
The Hospital Corps;
7) The clerical force and other civilians employed
from time to time under the authority of the annual
appropriation acts.
To these might be added the civilian physicians
employed under contract, once a large and important
class who supplemented the commissioned medical
ris and made good the deficiency of numbers of
the latter in time of military exigency. Since the
lion of the Medical Reserve Corps, however, it is
as commissioned officers of this corps that civil
physicians are called into the Army when their
services are needed in time of war or other necessity
only a few contract surgeons are now employed
for duty of a special character or at special localities
h as arsenals and remount depots.
The status, duties, and responsibilities of these
several classes will be stated in order.
(1) The surgeon-general has the rank, pay, and
.inres of a brigadier general and is the Chief of
Medical Department. As the head of a bureau
of the War Department he is charged with the
supervision of the expenditure of the Medical Depart-
ment appropriations and is the adviser of the Secre-
tary of War and the Chief of Staff upon matters
ins; to the health, sanitation, and physical fitness
of the Anny. and the administration of the medical
service in all its branches. He exercises military
control over the general hospitals, medical supply
lots, hospital ships and trains, but not over the
medical personnel and medical units which are under
command of officers of the line of any grade,
ept in so far as relates to duties, reports, and
supplies of a purely professional nature.
The Surgeon-General is not only the ranking officer
of the Medical Corps and Chief of the Medical Depart-
ment, but is also at the head of the Surgeon-General's
office, a bureau of the War Department, which latter
is one of the great executive departments through
which the government is administered. The War
artment is not a part of the Army, although the
ruing power for it, and containg many army
officers among its higher personnel, and in the same
way the Surgeon-General's Office is a civil bureau,
imed by a permanent clerical force belonging to
the civil service and paid from another appropriation
than the Army, although several medical officers are
on duty in it in charge of divisions of the office.
Surgeon-General's Office. — This office being the ad-
ministrative agency by which the Surgeon-General
rcises his authority and his advisory functions
i- the medical service of the Army, a brief descrip-
tion of it is appropriate, although as above shown it
is not strictlv speaking a part of the Medical Depart-
ment. Besides the medical officers detailed for duty
therein, and the Superintendent of the Nurse Corps,
the personnel of the bureau consists of ninety-eight
clerks of various grades, seven specialist- connected
with the library and the museum, and some mechanic-,
messengers, laborers, et C.
As shown by the diagram the office is divided into
five divisions:
The first under the Chief Clerk, a civilian, has
charge of the general correspondence, the records,
the disposition of the mail, the examinations of
property and money accounts, the preparation of
plans lor t he const ruction and repair of hospitals, and
the control of the clerical force.
The second, the Supply Division, is under a medical
officer, anil has charge of the purchase and issue of
medical supplies and equipment of every sort, and
their accumulation for war, the administration of the
depots for medical supplies, and the disbursement,
of the medical and hospital appropriations, and those
for artificial limbs and apparatus for pensioners.
Commissioned medical officer
■ Civil official or clerK",
Secretary of War
Chief of Staff J
Surgeon General
Fia. 317. — Diagram of the Divisions of the Surgeon-General's Office.
The third, the Sanitary Division, is under a medical
officer and passes upon all medical questions which
come to the War Department, including the recom-
mendations made by medical officers in their sanitary
reports. It handles also all questions of physical
fitness for the military service in officers and enlisted
men and reviews the proceedings of retiring boards.
It tiles and collates the records of sick and wounded,
tabulates the vital statistics of the army and prepares
the annual report of the Surgeon-general.
The fourth, the Personnel Division, is under a
medical officer. It keeps the personal records of, and
conducts the correspondence relating to the stations
and duties of all individuals of the Medical, Medical
Reserve, Dental, Nurse, and Hospital Corps, in all
about 4,3(10 persons in time of peace.
The fifth, the Museum and Library Division, is
under a medical officer with several assistants, of
which two are permanent civil appointments con-
nected with the library, and another, a medical officer,
is curator of the Medical Museum. This division
occupies its own building at the corner of Seventh and
B streets, S. W., Washington, D. C. The Museum
was established during the Civil "War and contains
in all more than 34,000 specimens. It is particularly
rich in specimens illustrating gun-sliot injuries of the
skeleton; in colored representations in wax of skin
diseases; in specimens snowing the historical develop-
ment of microscopes, ophthalmoscopes, stethoscopes;
and in specimens illustrating the development of
surgical apparatus. It has also a large collection of
medals celebrating medical and hygienic subjects
and events.
567
Army Medical Department
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
The library was developed in the years succeeding
the Civil War from a small collection of books for the
use of medical officers on duty in Washington into the
great national institution which it is at present. It
has over 175,000 bound volumes and 310,000 pam-
phlets and theses. Its collection covers the literature
of medicine since the invention of printing. Besides
the fact that it is the largest medical library in the
world its distinctive feature, which has made it
famous, is the index catalogue which covers the en-
tire range of medical subjects, being arranged both
by subjects and authors. Osier says with reference
to it "While there is not in American medicine much
of pure typographical interest, a compensation is
offered in'one of the most stupendous biliographical
works ever undertaken. The Index-Catalogue of the
library of the Surgeon-general's office atones for all
shortcomings, as in it is furnished to the world a
universal medical bibliography from the earliest times.
It will ever remain a monument to the Army Medical
Department, to the enterprise, energy and care of Dr.
Billings, and to the scholarship of his associate,
Dr. Robert Fletcher."
(2) The medical corps consists of the following
grades and numbers of medical officers besides the
Surgeon-general, all of whom have the rank, pay,
and allowances of officers of corresponding grades in
the cavalry arm of the service:
14 colonels;
21 lieutenant-colonels;
in") majors;
300 captains and lieutenants; the officers of the
latter grade being promoted to the former after
three year's service, provided that they have
been proven proficient by passing the pre-
scribed examination for such promotion.
Appointments in the Medical Corps are mad. • by the
President and confirmed by the Senate upon the
recommendation of the Surgeon-general after the ap-
plicant has passed the prescribed physical and pro-
fessional examination. These examinations are rigid
'and the success of the candidate depends upon his
own merits and qualifications alone, official and
political influences being powerless to make good
deficiencies. The candidate must be a citizen of the
United States, between twenty-two and thirty years
of age, must have satisfactory general education,
must be a graduate of a reputable medical school
legally authorized to confer the degree of doctor of
medicine, and must have had at least one year's
hospital training, including practical experience in
medicine, surgery, and obstetrics.
Th.' examination consists of two parts, a prelimi-
nary and a final or qualifying examination. The
former is held by boards convened at convenient
places, usually military posts in various parts of the
country, which make the physical examination, and
then conduct the professional examination which is in
writing and by questions sent to the board from the
office of the Surgeon-general. Qualified applicants
are then appointed to the Medical Reserve Corps,
with the rank of First Lieutenant, and ordered to
Washington for a course of instruction in the Army
Medical School. They receive the pay and allow-
ances of that grade for the journey and during the
session of the school, which lasts from the first of
i ictober to the last of May.
This school was established in 1893 by Surgeon-
general Sternberg in the City of Washington. It
gives advanced and very practical courses in hygiene,
sanitary chemistry, clinical microscopy and bacteri-
ology, tropical medicine, the military aspects of
medical and surgical practice, ophthalmology and
optometry, Roentgen-ray work, medical department
administration, and the military duties of medical
officers, hospital corps drill, and first-aid. Lectures
are also given in psychiatry with clinical instruction
at the Government Hospital for the Insane, and a
short course in military law by the Judge-advocate
General. Instruction in horsemanship is given by
officers of cavalry at Ft. Myer. The laboratories of
the Army Medical School are equipped for research
work as well as clinical instruction, and the facilities
of the Army Medical Museum, and the Library
of the Surgeon-general's Office are available for its
teachers and students.
Candidates who fail to reach a satisfactory standard
at the qualifying examination or whose conduct or
scholastic standing is not satisfactory during the
term, are discharged and returned to their homes.
Successful candidates are at once given commissions
in the Medical Corps, if, as is usually the ca~c,
vacancies exist therein, and are at once assigned to
duty with troops.
The pay of a First Lieutenant, Medical Corps, is
$2,000 a year. He is also, as are all medical officers,
furnished with a house, furniture, fuel, lights, horses,
forage, and professional books and instruments. He
is permitted to purchase government supplies at cost
and when he travels under orders his expenses are paid
and his personal property transported free of charge.
At the end of three years' service he is promoted to
Captain, Medical Corps, provided, however, that he
passes satisfactorily a prescribed examination which
is intended to demonstrate whether or not the young
officer has made good use of his time and opportunities,
In ease of failure in this examination the proceedings
of the examining board are reviewed by a special
board and if their findings are confirmed the officer -o
failing is given an honorable discharge from the
service with a donation of a year's pay.
In this and subsequent examinations for pro-
motion, if the officer is found to be physically unfitted
for active service because of a disability incurred in
the line of duty he is promoted and retired. In less
than two years after receiving his promotion as
Captain the medical officer has completed his first five
years of service and becomes entitled to an increase
of pay of ten per cent, and for each additional term
of five years a further increment of ten per cent, is
added to the pay of his grade up to forty per cent, at
the end of twenty years service. These increments
are colloquially known in the Army as "fogies." Pro-
motion to the next grade of Major depends upon the
occurrence of vacancies in the upper grades, and is
theoretically assumed to occur after from fifteen to
eighteen years of total service, but of late years, owing
to increases in the Medical Corps from time to time,
the period has in most instances been much less.
The promotion to the grade of Major is after an ex-
amination under similar conditions but differing
in scope from that for the grade of Captain, and failure
is followed by a like penalty. When the medical
officer reaches" the top of the list of majors he under-
goes the third and last examination for promotion,
but as the duties of the next grade of Lieutenant-
colonel are mainly of a supervisory and administra-
tive nature, this examination is not professional
in character except as regards the applications of
preventive medicine and general and military hygiene,
but deals largely with the important duties of Chief
Surgeons. Because of the age and length of service
of officers of this rank the penalty of failure is some-
what different, being suspension from promotion for
a year and a second trial at the end of that time. If
then successful the promotion accrues, but if the
officer again fails he is placed on the retired list with
three-fourths of the pay of the grade of major. _
Promotion to the grade of Colonel is by seniority.
The Surgeon-general is appointed by the President
by selection from the officers of the Corps, but usually
from the two upper grades, for a term of four years
and may be reappointed for a second or third term
provided he does not meanwhile reach the age of
.Vis
REFERENCE HANDBOOK OF THE MEDICAL SCIENI I 3
Army Medical Department
(sforty-four, at which retirement from active service i
compulsory by law for all offii
From tin' Colonels and Lieutenant-colonels are
selected tin' Chief Surgeons of militarj - and
departments, tin' Chief Surgeons of the larger military
commands of tin- mobile army fur sen ire in the Geld,
tho commanding officers of general hospitals, and
other like positions of importance and responsibility.
Tin' salary of medical officers of the several grades
depends somewhat upon the length of service i> i
[e lint the follow inn table represents what may
insidered the normal rates of pay:
< ! . .riers With quarters
Grade, furnished. commuted.
First lieutenant V $2,432
in -'.400 2.976
in, five years' service 2,640 3,216
in, ten years' service 2,880 3.456
lin, fifteen years' service.. . . 3,120 3,696
fifteen years' service 3,900 4,620
ir, twenty years' service .... 4.000 4,720
mant-colone] 4,500
id 5,01 i 6,008
Burgeon-general 6,000 7, 1 52
Fuel and lights are furnished in kind, the allowance being
iberal and increasing with each grade.
The distinguishing color of the Medical Depart-
ment was formerly green, but after the Spanish War
in 1902 maroon was adopted because, being the dis-
tinctive color of the medical service of most of the
great military powers, its advantages in war were
obvious. This color appears in the uniforms of all
commissioned officers of the Medical Corps, Medical
Reserve Corps, and Dental Corps on the shoulder
straps, the collar of the full dress coat, and the band
of the dress cap. The distinctive badge of the Medi-
cal Department is the caduceus which is worn on
each side of the collar of the service and dress coats,
on the sleeve cuffs of the full dress and special evening
dress coats, and the overcoats of all commissioned
officers of the Medical Department. In the case of
the Reserve, Dental, and Nurse Corps, the caduceus
is surcharged with the monogram appropriate to each.
W^
Fig. 318. — Badge oi the Medical Corps.
(3) The medical reserve corps was created 1 ty t he
reorganization of April 23, 1908, to take the place of
the Acting Assistant Surgeons and Contract Surgeons
of former days, who were civilian physicians attached
to the Army but without a definite military status
and authority, an anomalous and trying position,
which was most unsatisfactory to members of a
dignified and learned profession. They have the
rank of First Lieutenants, and their commissions
"confer upon the holders all the authority, rights, and
privileges of commissioned officers of the like grade
in the Medical Corps of the U. S. Army except
promotions, but only when called into active duty
and during the period of such active duty.''
An applicant for appointment in the Medical
rve Corps must be between twenty-two and forty-
five years of age, a citizen of the United States, and
a graduate of a reputable medical school, and must
pass a satisfactory physical and professional examina-
tion. Examinations for appointment are held from
time to time, and at lea year al convenient
localities throughout the country.
I he number of officers commissioned in the Medical
Reserve Corps is not fixed by law and the inactive
lis) is an unlimited one from which the Secretary of
War may call to active duty as many as the emer-
gencies of the quire. They cannot be com-
pelled to accept active duty, bul should it be declined
by a reserve officer his commission will lie vacated.
receive 1 1 I [tenants of the Medi-
cal Corps, viz., $2,000 a year with an additional $200
for each live years of active service. They receive also
fuel, lights, horses, horse-equipmen) and fori
when necessary, travel allowances, professional luniks
and instruments, and quarters in kind or commuta-
tion therefor at the rate of $36 a month. It i- tin-
policy of the Medical Department to appoint each
year a number of young physicians who have just
pleted their medical education into the Reserve
- and to give them at once a tour of active service
of from six months to two years in order that they
may become familiar with the conditions and admin-
istrative methods of the Army medical service. De-
tailed information as to the physical and professional
requirements for appointment can be obtained upon
request of the Surgeon-general.
The uniforms, side arms and equipments of Medical
Reserve officers are like those of the .Medical Corps
with the difference only that the caduceus bears the
letters " R. C." superimposed in monogram.
Fig. 319. — Badge of the Medical Reserve Corps.
(4) The dental corps was created by the Act of
March 3, 1911, and consists of Dental Surgeons and
Acting Dental Surgeons, the total number of which
together cannot exceed the proportion of one to each
thousand of the actual enlisted strength of the Army.
All original appointments to the Corps are made as
Acting Dental Surgeons after passing a satisfactory
physical and professional examination before a board
composed of a medical officer and two dental surgeons.
Applicants must be citizens of the United States
between twenty-one and twenty-seven years of age
and graduates of a standard dental college. Acting
dental surgeons who have served in a satisfactory
manner for three years are eligible, after passing a
satisfactory professional and physical examination,
to be commissioned as First Lieutenants in the Dental
Corps. Lieutenants of the Dental Corps rank next
after the Medical Reserve Corps and have the same
pay and allowances as the latter, including the quin-
quennial increase for length of service, in computing
which service as an Acting Dental Surgeon is counted.
Dental Surgeons on attaining the age of sixty-four
are retired from active service with the pay of three-
fourths of their grade including the increase for length
of service. Their right to command is restricted to
the dental corps.
The uniforms of commissioned dental surgeons are
the same as those of medical officers of like grade,
with the exception that the caduceus bears the letters
" D. C." superimposed in monogram. Acting dental
5G9
Army -Medical Department
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
surgeons are not required to have the full dress uni-
form but only the dress, service, and white uniforms
which conform to those of medical officers, but with-
out the shoulder strap or other insignia of rank.
Their pay is at the rate of $150 a month with fuel,
lights, quarters in kind, and travel allowances. They
do not receive the increase of ten per cent, for each
five years of service but as above stated their service
counts therefor when commissioned.
Fig. 320. — Badge of the Dental Corps.
(5) The aemt nurse corps was created by the act
of February 2, 1901, and amended by that of March 3,
1910, by which a definitestatus was given to graduate
female nurses who before had been employed under
contract for service in the Army but had not been an
established part thereof. At its head is a superinten-
dent who, under the direction of the Surgeon-general,
has general supervision of the Corps, her office being a
part of the Personnel Division of the Surgeon-general's
Office. The Corps is composed of Chief Nurses,
nurses and reserve nurses, in such number as may be
needed for the military service. The number of
Chief Nurses and nurses in active service is 125.
They are stationed only at General Hospitals and a
few of the larger post hospitals. Chief Nurses are
appointed from members of the Nurse Corps by the
Surgeon-general, upon the recommendation of the
Superintendent, and after a satisfactory examination,
one being stationed at each hospital or station where
nurses are on duty.
Applicants for appointment in the Nurse Corps are
required to be graduates of acceptable training schools,
having a theoretical and practical course of not less
than two years and attached to a general hospital of
not less than 100 beds. They must pass satisfactorily
a physical examination, preferably made by a medical
officer and a professional examination conducted by
the Superintendent. Appointments are made for
three years and are renewed upon application by the
nurse if her service has been of a satisfactory char-
acter.
The list of Reserve Nurses of the Army, contem-
Fig. 321 — Badge of the Red Cross Nurses.
plated by law, and consisting of honorably discharged
our es, has not been carried out, because one of the
functions of the American Red Cross is to furnish
the Medical Department of the Army in time of war
or other emergency with nurses and other personnel.
In order to be able properly to meet this obligation
the Red Cross has enrolled an eligible list of over 3,000
carefully selected graduate nurses, and these now
constitute the reserve of the nurse corps. They will
be called into service through the central office of the
Red Cross with their own consent, and will then be
subject to the same regulations and receive the same
pay and allowances as permanent members of the
Nurse Corps.
The pay of the Superintendent is $1,S00 a year, with
the same allowances as other nurses. The pay of
nurses begins at S50 a month when serving in the
United States and increases at the rate of ten per cent,
for each three years of service up to $05 for over nine
years' service. To this is added .$10 a month for
service outside the continental limits of the United
States. Chief Nurses receive $30 a month additional
when in charge of the nursing service at general and
base hospitals, and in hospital ships. Other chief
nurses get $20 a month in addition to their pay
except when on duty where special skill and capability
are required, when the Surgeon-general may increase
the amount to $30 a month. Thus while a nurse who
has just joined at a hospital in the United States gets
$50 a month, the Chief Nurse at the base hospital at
Manila may receive $105 a month. They receive
also quarters, subsistence, travelling expenses when
travelling under orders, leave of absence on full pay
for thirty days in each year, which may be cum-
ulative up to four months.
The quarters provided for nurses are usually
detached from the hospital, and include a sitting-
room, dining room, kitchen, the necessary toilet
rooms and a separate bed room for each nurse.
When more than five nurses are on duty at a hospital
the Chief Nurse is entitled to an office and a separate
sitting-room. The furniture, equipment, and service
of nurses' quarters is furnished by the Medical Depart-
ment, which also provides the laundry service for
table and bed linen and nurses' uniforms. The
uniform of the Nurse Corps which is always worn when
on duty consists of a waist, belt, and skirt of suitable
white material, bishop collar, and a white cap made
according to specifications prescribed by the Surgeon-
general. The badge of the Corps which is worn on
the left side of the collar is a caduceus of gold or gilt
with the letters "A. N. C." in monogram super-
imposed in the center.
Fia. 322. — Badge of the Army Nurse Corps.
The history of expert nursing in the Army is of
recent date, since trained nursing as a profession was
not introduced into this country until 1S73. Women
have since the early days of the republic been em-
ployed in the care of the sick, but the duties of the
humble predecessors of the present nurse corpswere
quite different from those of their accomplished sisters
of to-day, and are now relegated to the hospital
orderlies'. The Army Regulations of 1S14 provide
" (3) Every regimental hospital shall be supplied with
570
IM'.FERENCE HANDBOOK OF THE MEDICAL SCI] NCES
Army Medical Department
one or more fciiialc attendants; it shall he the business
df these lii scour and cleanse the bunks and II -s of
the rooms or tents, to wash the blankets and bed sacks
and clothes of the patients, to cook the victuals of
the sick, and to keep clean and in good order the
inn utensils." The functions of the women
nurses in the Civil War were of a much less menial
.ntcr and except for lack of .scientific training
approached those of the graduate nurses of a later
day. An authority* on this subject slates thai
"the Civil War marks the beginning of all organized
concentration of women in this country in public
duties." It is estimated that 2,000 women were
engaged in nursing ami hospital administration
during the Civil War. Miss Dorothy L. Dix was
lOinted superintendent of women nurses in general
hospitals in 1862, and it was ordered that except in
emergency no women should be employed as
nurses without her approval. No candidate for
position as nurse was considered unless she was
between the age of thirty-five and fifty; matronly
us of experience and those of superior education
and superior disposition were to have the preference.
Habits of neatness and order, sobriety and industry
were essential. Medical officers were required to
organize their hospitals so as to have one woman
e lor every two men nurses or attendants.
In the forty-three years between the termination
of the Civil War and the outbreak of the Spanish War
nursing as a profession had become well established
in the United States and trained nurses of excellent
attainments were employed in large numbers by the
Medical Department of the Army. Through a
miscarriage in the legislation authorizing the calling
out of volunteers, authority was not given for the
enlistment of a volunteer hospital corps, and it was
impossible to obtain a sufficient number of men of
good character and capacity by enlistment in the
Hospital Corps of the regular army. The vacancies
were filled, therefore, by the clumsy expedient of
transferring the least desirable men who were not
desired by their company and regimental commanders
from the volunteers to the regular hospital corps.
The results were most unsatisfactory until the
employment of trained nurses in large numbers
brought order, neatness, and efficiency into the wards
of the general hospitals.
At the beginning of the Spanish War the Surgeon-
general was authorized to employ nurses under
contract and an appropriation was made for their
pay. No restriction as to sex was made but as the
supply of trained nurses in the country was almost
entirely female and as their services were intended to
be restricted to the general hospitals, where proper
provision for the comfort and privacy of women
could be made, the number of men nurses employed
instead of being double that of the other sex, as in the
Civil War, was so small as to be negligible. At the
beginning a few untrained women were employed
especially for the purpose of getting immunes to care
for the cases of yellow fever which had occurred in the
Army in Cuba, but soon thereafter the national
society of the Daughters of the American Revolution
offered to take charge through committees, of the
selection of those of proper qualifications and char-
icier, and this offer was promptly accepted by the
^con-general. Dr. Anita Newcomb McGee was
appointed director of the board designated for this
purpose and was later appointed an acting assistant
surgeon, and assigned to duty in the office of the
Surgeon-general to act upon all matters relating to
Army nurses. The committee of women which was
auxiliary to the American National Red Cross Relief
Committee of New York also examined and certified a
large number of nurses as suitable for employment
in the Army, besides paying the expenses incident
* A History of Nursing, by M. Adelia Nutting and Levina A.
Dock.
In their arrival al their places of assignment to duly.
More than 200 sisters of charily were also furnished
by religious orders. One thou and live hundred and
sixty-three nurses in all were employed under con-
tract by the Medical Department.
(0) The hospital coeps. of the Army was created
by the Act of March 1, ls.sT (24 Stats., 135), before
which lime the attendance in military hospitals was
supplied by details from the line of the Army and by
hired civilians. The unsatisfactory character of
this service will be referred In later. The act above
referred to provides: "That the Hospital Corps of the
United States Army shall consist of hospital stewards,
acting hospital stewards, and privates; and all
necessary hospital services in garrison, camp, or
field (including ambulance service) shall be performed
by the members thereof, who shall be regularly
enlisted in tin; military service; said corps shall be
permanently attached to the Medical Department,
and shall not be included in the effective strength of
the Army nor counted as a part of the enlisted force
provided by law." This law was amended by the
Ad of March 2, 1903, so as to increase the number of
grades in the corps and alter their titles from hospital
stewards, acting hospital stewards, and privates to
sergeants, first class, sergeants, corporals, privates,
first class, and privates. This act also authorized the
organization of companies of instruction, ambulance
companies, field hospitals, and other detachments in
the Hospital Corps as the necessities of the service
may require. Acting cooks and lance corporals have
been also added as separate gradings.
The corps is recruited by enlistments therefor and
by transfers from other branches of the service.
All first enlistments and transfers are to the grade of
private. The strength of the Hospital Corps is not
limited by law, but the Secretary of War is authorized
to enlist or cause to be enlisted as many privates of the
Hospital Corps as the service may require, it being
clearly the intention of Congress to place upon the
War Department the responsibility for any suffering
which may be caused to the sick and wounded, or any
inefficiency of the medical service, which may result
from a deficiency of enlisted personnel.
The numbers and pay of the various grades of the
Hospital Corps are shown in the following table:
Sergeants, 1st Class
Sergeants
Corporals*
Acting eooksf
Privates, 1st Class..
Privates
Num-
bers.
330
350
50
100
1,867
963
Enlistment.
1st,
IM.
S50 $54
If re-enlisted within
three months.
3d. HI.
$58 Sr,L>
5th. J6th. 7th.
Sfifi S70 S74
42
36
42
30
24
4S
4 J
48
36
26
If discharged at termination of enlistment and re-enlisted after
three months the soldier is only entitled to pay of second
enlistment.
It is required that the proportion of privates, first
class, to privates shall not exceed two to one. Cor-
porals are appointed for duty in ambulance com-
panies, and in the larger hospitals for duty principally
of an outside character. Promotion to the grade of
sergeant is made after an examination by a board of
* Lance Corporals are not properly a distinct grade, being simply
privates who are given the temporary duties and authority of
corporals, without any increase in pay.
t Acting cooks are detailed from privates, first class, and
privates.
571
Army Medical Department
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
medical officers, which reports upon the candidate's
qualifications as to his physical condition, character
and habits, discipline and control of men, knowledge
of regulations, of nursing, of dispensary work, of cleri-
cal work, of the principles of cooking and mess
management, of hospital corps drill, and of minor
surgery and first aid work. Married men are not
eligible for promotion. Chief Surgeons are authorized
to hold these examinations without reference to the
Surgeon-general.
Examinations for appointment to Sergeant, First
Class, are conducted by boards of medical officers ap-
pointed by the General Commanding the Division.
The examinations therefor are oral, practical, and
written. They embrace the same subjects as for the
grade of sergeant, but are more difficult. Sergeants,
first class, are required to have served not less than
twelve months as Sergeants before being eligible for
promotion.
The Sergeant, First Class, ranks with the Ordnance
Sergeant, Post Commissary Sergeant, Post Quarter-
master Sergeant, First Class Signal Sergeant, and
Electrical Sergeant, First Class, of the Coast Artillery,
and is only ranked by Sergeants Major, Master
Electricians, Chief Musicians, and Engineers of the
Coast Artillery.
The duties of Sergeants, First Class, and Sergeants
are to look after and distribute hospital stores and
supplies, the care of medical property, to compound
and administer medicines, to supervise the prepara-
tion and serving of food, maintain discipline in hospi-
tals, prepare reports and returns, supervise the work
of their subordinates, and perform such other duties
as may be required of them by their superior officers.
No other noncommissioned officer requires so much
special knowledge for the proper discharge of his
duties or has such a variety of duties to perform as
the Sergeant, First Class, Hospital Corps. Like the
First Sergeant of a company he must be a good dis-
ciplinarian, drill master, and general supervisor of
the duties of the men under his control. He pre-
pares or supervises the preparation of numerous
reports, returns, and other official papers, some of
them voluminous and complicated, which must be
made not only to the Surgeon-general, but to the
adjutant of the command, the Adjutant General of
the Army, and to the officials of the Quartermaster
and Commissary Department. He must keep track
of, and prevent waste of a great number of articles in-
cluded under medical and hospital property; he
must be a pharmacist and have sufficient knowledge
of medicine and surgery to act as an assistant to the
medical officer. It is commonly supposed that skill
in pharmacy is the essential qualification of noncom-
missioned officers of the Hospital Corps, but from the
enumeration above it will be seen that knowledge
of drugs is only one of the many qualifications which
are demanded of them.
One of the most important duties of medical officers is
the instruction of the Hospital Corps to which a certain
number of hours every week throughout the year is
given, and which never ceases so long as the soldier
is in the service, in connection with his daily round of
duties. The instruction of the Hospital Corps soldier
covers the Articles of War, the orders and regulationsin
regard to his behavior and bearing upon all occa-
sions, bearer drill and field work, use of the first aid
packet and other articles contained in the hospital
corps and orderly pouches, methods of transporting
wounded in peace and war, the use and care of the
field hospital equipment, and the pitching, striking,
and packing of tents. All members of the Hospital
Corps arc also instructed in riding and in the care of
animals. They are also instructed in military sanita-
tion, especially in the purification of water and proper
di posal of excreta and wastes, and the care of the
person.
In the field when serving with infantry or other
572
troops not mounted, only the noncommissioned
officers are mounted and the privates who serve as
orderlies for medical officers, the latter carrying in-
stead of the hospital corps pouch an orderly pouch
which contains a pocket operating case, hypodermic
syringe, scissors, catheter, and ligature material, in
addition to first aid dressings.
The equipment of privates of the hospital corps
consists of a hospital corps pouch containing first aid
dressings, a large hospital corps knife, carried in a
scabbard like a sword, and used for various purposes
in the field, a haversack and blanket roll, canteen, cup,
knife, fork, spoon, meat can, and a shelter tent, half
which is on the march rolled about the blanket and
in camp is joined to the tent-half of a comrade to
make the shelter tent for the two men.
The clothing allowance of the Hospital Corps is
liberal, amounting to $142.44 for the first enlistment,
and $103.61 for each subsequent enlistment. The
value of all clothing not drawn is paid to the soldier
upon his discharge. They are required to have four
uniforms: a field uniform of khaki and one of olive
drab; a dress uniform of dark blue, to which is added
on occasions of ceremony a maroon breast cord, and a
blue and maroon cap band; and a uniform of white
duck, to be worn by men on duty in the wards, dispen-
saries, operating rooms, mess rooms and kitchens, and
by privates who are detailed as assistants to dental
surgeons. The overcoat is of olive drab like that of
the line.
The distinctive color of the facings of the Hospital
Corps is the same as for the other personnel of the
Medical Department, maroon, which is however piped
with white to distinguish it further from the shade of
red adopted for the artillery, which is scarlet. The
maroon facing appears on the chevrons and trouser
stripes of the noncommissioned officers, on the piping
of the dress coat and mixed with white in the breast
collar, and the dress and the hat cord of the service
uniform. The corps insignia are worn on the coat
collar, and the dress and service cap. They are:
For the dress coat a caduceus of yellow metal,
similar to those for officers, worn on the collar on each
side in the same manner as by officers;
For the service coat a caduceus of dull bronze worn
as above stated;
For the dress cap, for Sergeant, First Class, a cadu-
ceus of white metal enclosed in a wreath of gilt metal,
and for all other men of the Hospital Corps a caduceus
of gilt metal without the wreath;
For the service cap these insignia are of dull bronze.
Fig. 323. — Chevron of a Sergeant, First Class, Hospital Corps.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Army Medical Department
7 The clerical force at large ami other civilians
attached to the medical corps includes the clerks,
engers, mechanics, and laborers employed al I he
ii.-al supply depots in Washington, New York,
Louis, San Francisco, and Manila, the clerical
force of the offices of the Chief Surgeons, Headquar-
ters of the four great territorial divisions, and the
mechanics and laborers, with a few clerks, at the
eral hospitals. It will be observed that the clerical
force of the Surgeon-general's t Iffice is not included, as
it is, as stated above, a part of the War Department,
which is one of the executive departments and quite
distinct from the Army. The total number of clerks
employed at the stations above named is forty.
ging in salary from $'2,000 to $(>()(). There are
employed sixteen packers and four mechanics
al annual salaries ranging from $1,200 to $780, The
■I number of employees, including the variable
number of laborers, was on January 1, 1912, two
hundred and thirteen, with a total pay roll of
about $140,000.
Historical Resume. — The Medical Department of
the United States Army had its beginning on July 27,
177", when the Colonial Congress at Philadelphia
1 a medical establishment, or as it was then
railed, "an hospital," for the Army. Prior to this
tment the surgeons of the forces before Boston
been appointed by the colonels of regiments, with
the wise proviso, however, on the part of the Provin-
cial Congress of Massachusetts that they should be
examined by a medical board named by the Provincial
gress. That there was nothing pro forma in
these examinations is shown by the fact that no less
than six of a group of fourteen were rejected on
account of failure to come up to the standard. After
the battle of Bunker Hill a field hospital was estab-
I at Cambridge for the care of the wounded.
Subsequently general hospitals were established at
Ticonderoga, X. Y., and at Williamsburg, Va. To
provide these with the requisite medical officers
surgeons were appointed who belonged to no regi-
ment, but to the hospital department in general as
staff surgeons. Tills arrangement aroused a strong
feeling on the part of the regimental surgeons who
protested against the removal of their sick, and their
reduction to the level of dispensary surgeons for the
-lighter ailments of camp. They claimed the right
to take care of their own sick and they were supported
in this by a majority of the regimental and company
officers. It is interesting to observe how mankind
'ts its experiences. More than 120 years after-
ward during the Spanish-American War the same
clamor was raised by regimental surgeons of volun-
teers, their colonels and company officers, against
the establishment of division hospitals, and the
necessary disestablishment of regimental hospitals
as incompetent to meet the exigencies of active field
service, although this incompetency had meanwhile
been proved during the long years of the Civil War.
Of course, among these surgeons there could be no
-ion or effective cooperation, and, as General
Washington wrote to the Congress at Philadelphia,
affairs were in a very unsettled condition. "There is
no principal director nor any subordination among
the surgeons; of consequence, disputes ami conten-
tions have arisen, and must continue until it is
reduced to some system."
The first department consisted of the director
general and chief physician, four surgeons, twenty
surgeons' mates, an apothecary, a clerk, two store-
keepers, and a nurse to every ten sick. It may be of
interest to mention that the pay of these officers was
as follows: The director general, $120; the surgeons,
the surgeons' mates. $20; the storekeepers, $4,
and the nurses, $2 a month.
Dr. Benjamin Church of Boston was elected
director general, and he was given the appointment
of all the personnel of the hospital, except the
surgeons' males, « i,,, were appointed by I he surgeons.
Dr. church had a reputation for culture and profes-
sional skill, but was a few month- after hi- appoint-
ment detected in treasonable correspondence with the
enemy, deposed and thrown into prison. He was
succeeded by Dr. John Morgan of Philadelphia a
man of much energy and administrative ability as
well as professional skill. He soon gained I he friend-
ship and support of General Washington, and the B
he always retained.
Willi the extension of the theater of war, the
number of surgeons was increased, and Drs. Skinner
and Shippen were named chief surgeons for the
northern department and the forces on the west bank
of the Hudson. The organization was, however,
too loose to secure efficiency or concert of action.
The relations of the regimental surgeons to each
oilier and to those in charge of the general hospitals
were entirely undetermined, and the department
surgeons refused to admit the authority over them of
Dr. Morgan. There was beside no well-arranged sys-
tem of medical supply, and in consequence there was
much suffering, and complaints multiplied. As has
happened since, more than once, Dr. Morgan was
punished for the very shortcomings for which he had
in vain asked Congress to provide a remedy, and he
was dismissed in January, 1777. Congress' the next
year exonerated him from all blame, but did not
reinstate him.
A complete and elaborate organization of the
medical department, modeled on that of the British
tinny, was adopted in April, 1777, and Dr. William
Shippen was elected director general of the new
establishment. Deputy director generals were pro-
vided for the northern and southern departments, and
under these a physician general and surgeon general
in each district, "whose business it shall be to super-
intend the practice of physic and surgery in all the
hospitals of the district." This separation of the
practice of physic and the practice of surgery, which
obtained in Europe at that time, and has fasted in
civil life in England until the present dav, neces-
sitated a most cumbrous and awkward dual organiza-
tion, which soon disappeared under the rudely prac-
tical test of war. It is probable that most American
physicians at that time outside the larger cities
practiced surgery to some extent, in addition to the
practice of physic. The regimental surgeons seem
from the first to have combined the two arts, and we
find in the bill, which in 1780, reorganized and
simplified the medical establishment, an explicit
provision that "there shall be three chief hospital
physicians who shall also be surgeons, one chief
physician, who shall also be a surgeon, to each
separate army, fifteen hospital physicians who shall
also be surgeons," etc. But although the medical
officers of the army thereafter appeared to have been
both physicians and surgeons, the former title seemed
to have been rather reserved for the higher grades,
while the title "surgeon" became bv the end of the
Revolutionary War generic for alPmedical officers.
At the end of the Revolution the Army was dis-
banded, except fifty-five men at Ft. Pitt and twenty-
five at West Point to guard the military stores at
these places. The officer highest in command was
a captain, and the medical department was reduced
to the vanishing point. The Revolution had pro-
duced a number of distinguished military surgeons,
among whom were Cochran, John Warren, Craik, and
Tilton, in addition to those already named.
The pressure of Indians on the western frontier
after a few years prevailed over the morbid fear of a
regular army with which our ancestors of a century
ago were possessed, and in 17X0 a regiment of regular
infantry and a battalion of artillery were organized,
with a medical service of one surgeon and four sur-
geons' mates. This small force was divided up into a
573
Army Medical Department
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
number of small commands at scattered posts along
the frontier and the regimental surgeons were entirely
too few in number to supply them. In 1802, there-
fun-, a new departure was taken in the employment
of post surgeons in addition to the regimental medical
officers. If general hospitals were established sur-
geons of a higher grade and rate of pay than the
regular post surgeons were appointed for temporary
service. In this way the medical department was
enlarged to meet the necessities of the Army in the
year 1912.
The War of 1S12 brought an army again in the
field, but as the medical department was without a
head and the surgeons had not even assimilated rank,
good medical administration was impossible. In
March, 1S13, Congress created the positions of
physician-and-surgeon-general and apothecary gen-
eral, the latter to act as assistant to the former, and
as medical purveyor. The surgeons were divided
into hospital and regimental surgeons, of which the
former were superior in rank and pay. Both had
mates and assistants, and there were in addition post
surgeons who ranked with the mates. Dr. James
Til ton who had been a hospital surgeon during the
Revolution was appointed physician-and-surgeon-
general in 1S13. His management of affairs during
the war appears to have given universal satisfaction.
Many hospitals were established and broken up during
the course of events, but all appeared to have been
well administered and well supplied and competent
for the work thrown upon them. Some indeed as
that at Burlington, Vt., under the superintendence
of Surgeon Joseph Lovell, Ninth Infantry, appear from
the reports to have been model establishments.
The title of surgeon-general appears first in the
Act of May 14, 1818. Joseph Lovell was appointed
to this position, and in that year he made the first
annual report of the surgeon-general to the Secretary
of War, and also drew up a set of regulations for the
medical department. He remained for eighteen
years at its head and during that time by his ability
and force of character shaped and organized the corps
of army surgeons into a coherent and efficient
medical staff. In 1821 a further advance was made
in the organization of the department by consolidating
the regimental surgeons with the staff surgeons so
that the corps consisted simply of one surgeon-general,
eight surgeons with the rank and pay of regimental
surgeons, and forty-five assistant surgeons with the
pay of post surgeons. This number, however, was
insufficient to provide one medical officer to each of
the military posts, and so the system of employing
certain physicians under contract was instituted.
Surgeon-general Lovell died in 1836.
The medical department was fortunate in having
so able a man as Dr. Lovell appointed as its chief. He
defined the duties of his subordinates, established an
excellent system of accountability for property,
improved the medical reports, inspired his officers
with the idea that as sanitary officers they had
greater responsibilities than mere practising physi-
cians and surgeons, and labored earnestly to have
their pay increased and their official status raised in
proportion to his views of the importance of their
duties. He also established an equitable system of
exchange of posts so that no officer would be retained
unduly at an undesirable station.
He was succeeded by Thomas Lawson, a man of
strong character and fine professional and administra-
tive abilities, and withal a brave and ardent soldier,
and a most original character. He entered the Navy
in 1809 as surgeon's mate, but left that service for the
Army in 1811. His service as a medical officer of the
Army covered the remarkable period of fifty years and
three months, and included active and distinguished
set-vice in the War of 1812, the Indian Wars, and the
Mexican War. At the outbreak of the latter he
turned over the office in Washington to an assistant
and joined his old friend Gen. Scott with whom he
made the campaign, performing the duties of Chief
Surgeon in the field, for which his long experience so
eminently fitted him. When he became surgeon-
general, in 1S36, medical officers were without mili-
tary rank, and in addition to the great disadvantages
of such a status, suffered frequently from the insolence
and contempt with which the line officers of that day.
following the traditions of the British service, were
inclined to regard the medical profession. Surgeons,
for example, were not entitled to a salute from enlisted
men, and when serving on boards were ranked by the
youngest subaltern in the service. In the new uni-
form, adopted in 1839, they were allowed a s^ord,
but not the officer's epaulettes, an aiguilette being
prescribed instead; "a piece of tinsel on one shoulder,"
as Lawson contemptuously described it.
To establish and maintain the dignity of his pro-
fession and his corps, was to Thomas Lawson a
sacred mission, to which he devoted himself with such
courage, pertinacity, and keenness of wit that he
achieved success in all the important claims advanced
in behalf of his corps, culminating in the Act of
February 11, 1847, which conferred on medical
officers the assured and honorable status of definite
military rank. It is a tradition in the service that on
the passage of this act the grim old fighter sent
around to medical officers a confidential circular to
the effect that now that the}' had the status of
officers they must promptly challenge any other
officer who failed to show them proper respect.
During the Mexican War the senior surgeons were
assigned as medical directors and in charge of field
hospitals. Certain of the juniors were on duty at
the hospitals and purveying depots, while others
served in the field as regimental officers with regular
troops. Volunteer surgeons were on duty with their
regiments but some of them were occasionally detailed
to hospital duties.
The medical service of the Mexican War seems to
have been performed with the same efficiency, courage,
and devotion to duty which marked all the operations
of the small but glorious armies under Scott and
Taylor, and such men as Satterlee, Tripler, Simpson,
Cuyler, Wright, Moore and Barnes laid in it the
foundation of reputations which were destined to
grow under the far wider responsibilities of the Civil
War. In the fierce assault of Molino del Rey,
Assistant Surgeon William Roberts was killed and
Assistant Surgeon James Simons was wounded.
Although the Army Regulations for 1S25 contained
a clause that no person should receive the appoint-
ment of Assistant Surgeon until after examination
by a properly authorized board, yet this rule was not
at first carried out on account of the difheultv of
detailing medical officers for this purpose. It is
stated that Dr. Charles Tripler, appointed an Assistant
Surgeon in 1S30, was one of the first officers examined
under this provision. General Orders No. 5S of the
War Department, dated July 7, 1832, reiterated this
regulation and directed that hereafter it should be
strictly enforced, and the regulation has been steadily
maintained since that date, even in time of war.
This regulation was embodied in the law by the Ait
of June 30, 1834, which not only required that
candidates before being appointed, should "have been
examined and approved by an Army medical board,"
but also required that an examination be held prior
to promotion fo the grade of Surgeon.
The thirteen years which intervened between the
Mexican War and the outbreak of the Civil War were
years of activity and progress for the medical corp-.
although the Utah Expedition against the Mormons
in 1858 was the only military event of note. \n
important advance in the standard of the examina-
tion for admission was made in 1849, when a knowl-
edge of Latin, of physics, of practical anatomy inthc
form of dissection, and clinical experience acquired
574
KF.FF.KIMT. HANDBOOK OF Till: MFDIOAL SCIENCES
Army Medical nopartmcnt
cither in a hospital or in private practice were made
prerequisites. In lN;jO tin- Medical Department of
\nny was first formally represented at the animal
ting of the American Medical Association.
Surgeon-general Lawson died in L861, shortly be-
fore the outbreak of the Civil War. From the calls
fur large levies of troops and the feeling North and
h thai a desperate struggle was before the eoiin-
ii was evident that without la rue reinforcements
the medical department would be unable to do its work
icessfully. At this time it consisted of one sur-
Q-genera] with the rank of colonel, thirty .surgeons
• ill the rank of major, and eighty-three assistant
eons with the rank of first lieutenant and of
tin after five years' service. In August, 1861, the
1 1 in n of ten surgeons and t wenty assistant surg s
authorized. Some 1 of this small staff corps look
irge, as medical directors, of corps and armies,
ructing the volunteer officers in the duties per-
taining to camps and field hospitals; others acted as
medical inspectors, aiding the directors in their work
of supervision and education; some organized general
utals for the sick that had to be cared for on every
of the armies, while others kept these hospitals
and the armies in the field provided with medical and
iial supplies. The remainder were assigned to
service with the regular regiments and batteries.
Bach volunteer regiment brought with it a surgeon
and two assistants appointed by the governor of the
e after examination by a State medical board.
The senior regimental surgeon of each brigade became
invested with authority as brigade-surgeon on the
staff of the brigade commander, but as seniority in
many instances was determined by a few days or
-. it often happened that the best man for the
don was not secured by this method. Congress
•fore authorized a corps of brigade surgeons of
volunteers, who were examined for the position by a
hoard of regular medical officers. One hundred and
ten of these brigade surgeons were commissioned.
The Civil War was the first in which large armies
made their appearance on American soil, and in these
army corps of volunteers many of the glorious
raditions and hide-bound prejudices of the old Army
disappeared along with its regiments and batteries.
Yet it was none the less the leaven hid in three meas-
ures of meal, which leavened the whole lump, and
this is true not less of the Medical Department than
of the line.
On January 1, 1861, the Army numbered 16,400
and the medical officers 115, or seven-tenths of one
per cent, of the whole — a considerably greater propor-
tion, by the way, than exists to-day. In April, 1862,
a bill was passed by Congress to meet the pressing
needs of the medical department. This gave the
regular army an addition of ten surgeons and ten
assistant surgeons, and provided for a temporary
i lease in the rank of those medical officers who
were holding positions of great responsibility. It
gave the surgeon-general the rank, pay, and emolu-
ments of a brigadier general; it provided for an assist-
ant surgeon-general and a medical inspector general
of hospitals, each with the rank of colonel, and for
eight medical inspectors with the rank of lieutenant
colonel. These original vacancies were filled by the
President by selection from the army medical officers
and the brigade surgeons of the volunteers, having re-
I to qualifications only, instead of to seniority or
previous rank. At the end of their service in these
positions, officers of the regular force reverted to their
former status in their own corps with such promotion
as they were entitled by the casualties of the service
during their temporary occupancy of these war posi-
tions. About the time of this enactment Surgeon-
general Finley, Lawson's successor, was retired at his
own request after forty years' service, and Assistant
Surgeon William A. Hammond was appointed the
first surgeon-general with the rank of brigadier gen-
eral, in December following eight more inspectors
were authorized. Their duties were to supervise all
that related to the sanitary condition of the army,
whether ill transports, quarters, or camps, as will as
the hygiene, police, discipline, and efficiency of field
and general hospitals; to See that all regulations for
protecting the health of the troops and for the careful
treatment of the sick and wounded were duly ob-
served; to examine into the condition of supplies
and the accuracy of medical, sanitary, statistical,
military, and property records and accounts of the
medical depart nieut ; to invest igate t he causes of dis-
ease and the met hods of prevent ion. They were re-
quired also to be familiar with the methods of the
subsistence' department, in all that related to the
hospitals and to see that the hospital fund was
judiciously applied. Finally, they reported on the
efficiency of medical officers, and were authorizci to
discharge men from the service on account of
disability.
Shortly after this the corps of brigade surgeons
was reorganized to give its members a position on the
general staff similar to that of the army medical
officer and to render their services available to the
surgeon-general at any point where they might be
most needed, irrespective of regimental or brigade
organizations. They henceforth became known as the
corps of surgeons and assistant surgeons of volun-
teers; and the appointment of forty such surgeons and
one hundred and twenty assistants was authorized.
The medical history of the Civil War marks an
epoch in military sanitary organization even greater
than was made in the art of war by Sheridan's use of
cavalry or the hasty entrenchments of Lee. It is a
glorious chapter of American history, but the full
story of the ability and devotion of the surgeons of the
Civil War, regular and volunteer, must be sought,
not in the limits of an article, but by those who have
industry and good eyesight, in the ponderous volumes
of microscopic print which make up the " Medical and
Surgical History of the Rebellion."
For many years, during and after the revolution,
the selection of the personnel of hospitals was left to
the surgeons in charge. The stewards and ward
masters, nurses and cooks were either detailed
soldiers or civilians at the option of the surgeon.
The Army Regulations of 1S21 for the first time
distinctly provided that cooks and nurses in hospitals
should be taken from the privates of the army,
although such had doubtless been the usual practice
before that date. During the Civil War civilians,
both men and women, were largely employed as
nurses, especially in the general hospitals. They
may also have been employed to a limited extent
in the war with Mexico. With these exceptions,
hospital attendants were obtained, from 1821 until
the organization of the hospital corps in 1887, wholly
by the detail of soldiers of the line, an arrangement
which was always unsatisfactory, for it was difficult
to secure the best men of the command for such duty,
and the length of the detail being uncertain and pro-
motion practically unknown, there was little to
stimulate the ambition of the attendant.
The employment of civilians as hospital stewards
for post and regiments, as well as for general hospitals,
was still authorized in 1821; but as in the Indian
wars which resulted from the spread of civilization
westward, the activity of the army was transferred
to the frontier, it no doubt became increasingly
difficult to hire suitable civilians, while experience
showed that it was desirable that the incumbent of
this position should be amenable to military discipline
and held to a definite term of service.
It therefore soon became the rule that hospital
stewards should be detailed from the line, as is shown
by the fact that in 1S33 an order from the War
Department gave authority for the enlistment of a
hospital steward at posts where a suitable man
575
Army Medical Department
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
could not be obtained from the command. But
even though specially enlisted as hospital steward he
was still mustered with a company and regarded as a
detailed soldier of the line, and in 1842 the adjutant-
general decided that in case of emergency he could
be required to perforin military duty as such. Since
the hospital steward could be returned to the line at
any time at the caprice of the commanding officer,
the necessity of securing for him a more permanent
status was felt, and Congress in 1856 authorized the
appointment of hospital stewards from the enlisted
men of the army who should be permanently attached
to the medical and hospital department. Command-
ing officers were, however, still permitted to detail,
upon the recommendation of the medical officer, a
soldier to act as hospital steward for field duty or at
stations where there was no hospital steward. These
men were at first known as acting hospital stewards.
After 1S64 they were called hospital stewards of the
second class if detailed for duty at posts of more
than four companies, and hospital stewards of the
third class if at posts of four or less companies.
In 18(52 the employment of civilians as cooks and
nurses in the general hospitals having been authorized,
the surgeon-general published regulations for the
"Hospital Corps, U. S. Army," which was to be
composed of civilians hired under contract for the
period of one year, unless sooner discharged. Except
in name this organization bears no resemblance to the
present hospital corps, which was created by the act
of Congress, March 1, 1NS7.
The idea of medical organizations in the field, drilled
and trained to gather up the wounded from the battle-
field, transport and care for them, developed by
Larrey and Percy in the Napoleonic wars, had
perished with the armies of the First Empire under
the retroactive prejudices of the old monarchies, and
the military taboo of even republican America forbade
a physician to exercise the sacred function of "com-
mand over trained enlisted assistants of his own
department or even to have a permanent and un-
questioned jurisdiction over the mules and drivers of
the medical ambulances. He controlled in battle his
own two hands, and these only, unless the colonel saw
fit to give him the uncertain and doubtful assistance
of the regimental band.
The following letter taken from the files of the
Surgeon-general's Office permits a glimpse of the
tragic results of this lack of an organized enlisted
personnel for the Medical Department:
SfrtGEON-GENERAL's Office, Sept. 7, 1SG2.
Honorable Edwin M. Stanton,
Secretary of War.
Sir:
I have the honor to ask your attention to the
frightful state of disorder existing in the arrangement
for removing the wounded from the field of battle.
The scarcity of ambulances, the want of organization,
the drunkenness and incompetency of the drivers,
the total absence of ambulance attendants are now
working their legitimate results, results which I feel I
have no right to keep from the knowledge of the
department. The whole system should be under the
charge of the Medical Department. An ambulance
corps should be organized and set in instant operation.
I have already laid before you a plan for such an
organization, which I think covers the whole ground,
but which I am sorry to find does not meet with the
approval of the general-in-chief. I am not wedded
to it. I only ask that some system may be adopted
by which the removal of the sick from the field of
battle may lie speedily accomplished and the suffering
to which they are now subjected be in future as far
a |i< issible avoided.
I p to this date six hundred wounded still remain
on the battlefield in consequence of an insufficiency
of ambulances and the want of a proper system for
regulating their removal in the Army of Virginia.
Many have died of starvation, many more will die in
consequence of exhaustion, and all have endured
torments which might have been avoided.
I ask, sir, that you will give me your aid in this
matter, that you will interpose to prevent a recurrence
of such consequences as have followed the recent
battle, consequences which will inevitably ensue on
the next important engagement if nothing is done to
obviate them. I am, sir, very respectfully,
Your obedient servant,
William A. Hammond,
Surgeon-General.
Yet even this picture of the COO men who had lain
ten days on the battlefield of Second Bull Run could
not bring the commanding general to lift the taboo
and approve of enlisting men for the Medical Depart-
ment. But while the Surgeon-general was vainly
struggling with the prejudices of Gen. Halleck, light
had broken in another quarter. July 1, 1862, Surgeon
Jonathan Letterman reported to General McClclIan
to be medical director of the Army of the Potomac
He was only thirty-eight years old, having entered
the service in 1849, and had just received his pro-
motion to major. The Army of the Potomac was at
this time crowded with sick and with the wounded of
the seven day's fight, and in the retreat to Harrison's
Landing most of the medical equipment and supplies
had been lost or expended. In the course of a
month he brought order out of this chaos, and at the
same time drew up a plan for an ambulance corps —
simple, far-reaching and effective — which General
McClellan was quick to adopt. The personnel for
this corps was obtained by transfers of officers and
men from the line, and they, as well as the ambulances
and other transportation, were placed entirely in the
hands of the medical directors of the several army
corps. A distinctive uniform and a simple drill were
prescribed. This organization was announced in
orders apparently without reference to Washington
on August 2, and was soon followed by a scheme for
regimental medical service and the establishment of
division field hospitals in October. These taken
together made a complete workable system, which at
once made a new epoch in medical organization, and
placed the Army of the Potomac far ahead of any
military establishment in the world in this respect.
Meanwhile the system had its first trial at Antietam
September 7, 1862, when the wounded of the Army
Corps from the Army of the Potomac were promptly
removed from the field and cared for, being in marked
contrast with the experience of the wounded of
the other wing made up of troops from Pope's army.
In the bloody battle of Fredericksburg, where, in
addition to the great number of wounded, was added
the confusion of a defeat, the ambulance companies
nevertheless did their work with smoothness and
dispatch, and the wounded were transported without
confusion or delay to the division field hospitals. As
reported by Surgeon Charles O'Leary, medical
director of the Sixth Corps, it "afforded the most
ploasing contrast to what we had hitherto seen during
the war."
This medical organization soon spread to the other
armies of the United States, and was formally adopt-
ed by Congress in the spring of 1864. It was not
copied from European models, but, on the contrary,
has been, in its essential features, adopted by all
civilized nations, and it is probable that the name
and fame of Jonathan Letterman are better known
to-day to the military surgeons of Europe than in lii- 1
own country. Nor during his lifetime did this great
and beneficent genius receive any promotion or any
reward other than the commendation of his general
and the admiration of his professional comrades.
This splendid constructive work was done, and the
vast responsibilities of chief medical officer of a great
576
REFERENCE HANDBOOK OF Till'. MEDICAL SCIENCES
Army Medical Department
Flo. 324. — Dr. Jonathan
Letterman.
army were me( and surmounted by a man who s
■riven only the rank and pay of a major. When the
Surgeon-general proposed thai the medical directors
of the armies under McClellan and Halleck be given
the temporary rank of colonel, which was enjoyed
by other staff officers, the War Department returned
the ungracious and fatuous reply: "Refused unless
ui be shown that the skill and efficiency of sur-
is arc increased by an increase of rank and paj ."
This rank was afterward given to the medical direc-
of armies in the field by the Act of February 23,
li is not surprising that Letterman, broken
in health by his great labors ami disgusted at the
blind ingratitude of those
in authority, resigned
from the service in De-
cember, 1864, and died
in San Francisco some
years later.
The Army General
Hospital in San Fran-
cisco, which receives the
sick and wounded com-
ing from the Philippine
and the Hawaiian
Islands, and which is the
largest general hospital
at present in the Army,
has recently been named
the Letterman General
Hospital, in memory of
this great organizer for
whom it is hoped that
some day the medical
profession will demand
official recognition which was denied him in his life-
time, by the erection of a statue in Washington.
The end of the Civil War found no less than 204
general hospitals containing 136,000 beds in opera-
in the territory of the United States over an area
extending from Maine to Florida, and westward be-
yond the Mississippi. The Medical Department
during the Civil War disbursed over 847,000,000, and
id for 1,057,423 sick in its general hospitals alone,
without counting those that passed through the field
regimental hospitals. Of the medical staff,
ll."> were shot in battle, of whom 42 died, and 2bo
died of disease.
This great struggle has left behind it as monuments
of the labors of the medical profession, the Army
Medical Museum and the great national institution
known as the Library of the Surgeon-general's office.
The record of their professional work is given in
the "Medical and Surgical History of the Rebellion,"
which in spite of the advances in professional knowl-
edge since that time, remains an inexhaustible mine
of statistical information, while the reports of medical
directors in the appendix are of permanent value
and interest to all who are interested in the great and
ever-recurrent problems of medico-military ad-
ministration.
The following remarks from an address made in
1879 on infectious diseases in the Army by the great
German military surgeon Rudolph Virchow, show an
appreciation of the accomplishments of the medical
department of the Army during the Civil War far be-
i what is common to members of the medical pro-
fession of our own country:
"It has been sharp necessity, this keenest of
monitors, which has opened men's eyes through the
heaviest visitations, so that they are compelled to
notice what, to speak accurately, they would not see.
Yes,, it is astonishing, what schools of suffering the
armies have had to pass through before the truth
line commonly acknowledged! Thus in the Cri-
mean war, the French army lost one man out of
every three, in their wholearmy, and it is calculated
that of the 96,615 men who forfeited their lives,
Vol. I.— 37
only Hi.Jlo fell before the enemy; about on equal
number of wounded died in the hospitals. The
re l, more than 7.~>.(H)(l men, f,-|| a sacrifice to dis-
ea e. In the American civil War, 97,000 men died in
battle, and 184,000 from epidemics and sickni
What a huge ma "f pain and suffering, what a sea of
blood and tears stands revealed in these figures I Hut,
also, w hat a heap of fallacious regulat ions, of prejudices
and misunderstandings. It is necessary to lav bare here
the long list of these -ins ami mi-iakes; fortunately
it is sufficiently well known in order to serve as a
warning for others. But it must also be said that it
was not necessity alone which exposed the evil and
brought redress. That the French learned little or
nothing in the Crimea, and the North Americans so
much in their Civil War, that from that date onward
begins a new era of military medicini — this depends
not on the magnitude of the necessity which the
Americans had to Undergo, which in truth was not
greater than the French underwent in the Crimea.
It was far more the critical, genuinely scientific
spirit, the open mind, the sound and practical in-
telligence, which in America penetrated step by step
every department of army administration, and which
under the wonderful cooperation of a whole nation
reached the highest development that, relative to
humane achievements, had hitherto been attained in
a great war. Whoever takes up and looks into the
comprehensive reports of the military medical staff
will be again and again astonished at the richness of
the experiences chronicled therein. The utmost
accuracy of detail, painstaking statistics embracing
the minutest particulars, an erudite exposition com-
prehending every aspect of the practice of medicine,
are here united in order to preserve and transmit to
contemporaries, and to posterity, in the most thorough
way possible, the wisdom purchased at so tremen-
dous a price.
The admirable medical organization of Letterman
disappeared with the armies of Grant and Sherman,
and Congress, weary of war, could not be induced to
take interest in any military matter, except in the
direction of reduction and economy. While all other
nations made haste to apply 7 the lessons of our war
and to remodel their medical organization in accor-
dance with them, our own Medical Department
reverted to ante-bellum conditions and went back-
ward. The hospital stewards were the only perma-
nent enlisted personnel, and all nursing and other
work about the hospitals was done by an uninstrueted
and constantly changing personnel of men detailed
from the companies.
No worse system could have been invented, and
yet it lasted twenty-two years, until, in 1SS7, the
first step toward a modern organization was made by
the establishment of a hospital corps consisting of
privates and two grades of noncommissioned officers.
The medical officers then began the systematic train-
ing of the personnel and the study of modern medical
organization with a view to war conditions. This
movement unfortunately was misunderstood by the
officers of the line and met, especially at first, with
much ridicule and covert opposition, the use of
military titles by medical officers being especially
resented.
The outbreak of the Spanish War in 189S found the
Medical Department with a personnel of 177 com-
missioned officers and 750 enlisted men. This
number was barely sufficient to perform the medical
service of the regular army of 25,000 men in time of
peace. When a volunteer army of 250,000 men was
mobilized, and at the same time an expedition em-
bracing practically the entire regular army was
organized to attack Santiago, it was immediately
evident that if the regular regiments were to be cared
for by regular medical officers but few would be left
to organize the medical service of the volunteer
armies. Each of the volunteer regiments brought
577
Army Medical Department
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
with it into service three regimental surgeons and
three hospital stewards, but no privates. The regi-
mental and field hospitals had to be organized at the
expense of this regimental medical personnel. The
enlisted strength of the regular hospital corps was
inadequate for "25,000 men, and as Congress failed to
authorize the enlistment of volunteer Hospital Corps
men, the situation in this respect became at once
acute, and was only partially relieved by the clumsy
expedient of authorizing the transfer of men from
volunteer regiments to the regular Hospital Corps.
We have seen how this emergency was relieved in
great measure in the general and stationary hospitals
by the employment of female trained nurses in large
numbers. This assistance, of course, could not have
been employed in the regimental and field hospitals.
which marched with the troops and performed the
service of removal of the sick and wounded from the
front, but fortunately the short duration of the
Spanish War made but small demand upon the
activities of these mobile organizations. The volun-
teer surgeons, though in many cases appointed with-
out effective examinations, were, as a rule, capable
and efficient physicians but were lacking in admin-
istrative experience, and in practical knowledge of
military hygiene. The troops were, in most cases,
kept for long periods of time in their camps of mobili-
zation and so the typhoid infection, which almost
every regiment brought with it from its state camp,
had good opportunities for dissemination. It was
the accepted belief of military surgeons, as of the
medical profession at large, in 1S9S, that the principal
and almost the only method of dissemination of
typhoid fever was by polluted water supplies, and the
typhoid epidemic that swept through all the camps
in the summer of 1S9S, regardless of the fact that for
many of them the water supply was artesian, created
consternation and surprise. The true conditions
under which typhoid fever is spread as a camp disease
were not understood until the publication, some years
later, of the remarkable study of these epidemics
made by Major Reed of the Medical Corps, and Majors
Vaughan and Shakespeare of the Volunteer Medical
i.e. which covered 20,738 cases of typhoid fever
among 107,973 officers and men in ninety-two
regiments.
The military and sanitary lessons of this war were
most instructive. They were studied with much
and patience and every facility for arriving at the
truth by a commission appointed by President
McKinley to investigate the conduct of the War
Department in the war with Spain, commonly known
as the Dodge Commission, from the name of its
chairman. Their conclusions were as regards the
Medical Department:
What is needed by the Medical Department in the
future is:
1. A larger force of commissioned medical officers.
2. Authority to establish in time of war a proper
volunteer hospital corps.
3. A reserve corps of selected trained women
nurses, ready to serve when necessity shall arise, but,
under ordinary circumstances, owing no duty to the
War Department, except to report residence at
determined intervals.
4. A year's supply for an army of at least four times
the actual strength of all such medicines, hospital
furniture, and stores as are not materially damaged
by keeping, to be held constantly on hand in the
medical supply depots.
5. The charge of transportation to such an extent
ill secure prompt shipment and ready delivery
of all medical supplies.
G. The simplification of administrative "paper
work," so that medical officers may be able to more
thoroughly discharge their sanitary and strictly
medical duties.
7. The securing of such legislation as will authorize
all surgeons in medical charge of troops, hospitals
transports, trains and independent commands to draw
from the Subsistence Department funds for the
purchase of such articles of diet as may be necessary
to the proper treatment of soldiers too sick to use the
army ration. This to take the place of all commuta-
tion of rations of the sick now authorized.
To these should have been added the creation of
a corps of medical inspectors with adequate rank and
powers.
In the reorganization of the Army by the Act of
February 2. 1901, no attention was "paid to the
recommendations of this commission or to those of
the surgeon-general, and the proportion of medical
officers was not only not increased but was greatly
reduced, while their prospect of promotion was
taken away by disproportionate increase in the lower
grades.
The injurious effect of this legislation soon became
apparent and it was found impossible to fill the
vacancies created by the act or, without a lowering
of the standard, to get more recruits for the medical
corps than were sufficient to replace the annual 1.
by death and retirement. Surgeon-general R. M.
O'Reilly therefore, on December 24, 1903, placed in the
hands of the Secretary of War, Elihu Root, a memo-
randum in which the defects of organization of the act
of February 2, 1901, were carefully and fully diseu-
and a reorganization proposed which would earn,' out
the recommendations of the Dodge Commission >u
far as specific legislation was necessary to that end.
The scheme proposed was finally enacted into law
on April 23, 190S, and has resulted in the excellent
organization of to-day. Meanwhile the Surgeon-
general has kept constantly in view the recommenda-
tions of the Dodge Commission so that all have been
carried out with the exception of No. 2 — authority to
establish in time of war a proper volunteer hospital
corps. This has been for some years before Cong
as part of a general law proposed by the War Depart-
ment for the raising of volunteer armies, but remains
without favorable action. Jeffeksox R. Kean.
Army Medical Field Service. — Where any large
number of men are to be employed in a given task,
their organization into suitable groups is essential to
the accomplishment of satisfactory results. \
machine must be created, each part of which works
in harmony with the others and all are domina
by a single will. No more complete and intricate
machine exists than that found in a modern army,
and that part of the mechanism relating to the
functioning of the Medical Department is one of great
and essential importance. This point has been too
often overlooked; and the first years of our Civil War,
with a sad experience which only lack of time and
opportunity kept from being duplicated in the Spanish
War, clearly demonstrated that zeal and patriotism
cannot make up for defective organization and ab-
sence of team work. It has been said that the best
preparation for war is war itself. This is but a half
truth. Ultimate good results may proceed quite as
578
KJEFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Army Medical Field Service
iiucli f'"«' -original ii ii^i akes recognized and sub-
ie q U entJj ftwciided as from .successes achieved at the
,„,„,,( '\,>i- is training in the routine duties of
ieaoe from its entirely different character, any
eparation for Che new parts and changed
cenery staged by war. We can. by studying in
dvance the matter of medical Held service from the
tandpoiat of theory, make our mistakes largely
inder conditiaaiLS when knowledge is not, bought by
Wood, suffering, and tears. It is easy enough
: to care for wounded actually under his
ands, bul I u problem in war is to bring the wounded
irgeon, and the surgical supplies together
i a suitable way and without undue interference with
uiitary purposes. Not all these facilities can be
rough! up I" the wounded under the limitations of
ce the problem becomes largely one of
vacuatiorj of the wounded from the zone of casualty
i where fixed hospital establishments admit of
ivision of every facility that ingenuity can
.mil money can buy. The problem of medical
irk, before being one of purely professional
is thus first of all one of transportation of
ats.
■neral way, there are three zones whose borders
it overlap, and through which severely
ounded will pass from front to rear, viz., collecting,
ing, and distributing. Each has its specific
•lief formations in which convalescing cases will be
d and returned to the front. The whole
is to pass the cripple back as quickly as pos-
:i point where he will be out of the way, while
■turning the sound man without unnecessary delay
i service with the colors.
loses of the Medical- Department in War. — These
EBcially l:nd down as follows:
: The preservation of the strength of the
)rces in the field (o) by the necessary sanitary
res, (6) by the retention of effectives at the
oat, and the movement of non-effectives to the rear
obstructing military operations, and (c) by
ie prompt succor and removal of wounded.
Second: The care and treatment of the sick and in-
ed :it the front, -on the lines of communications,
ad in home territory.
The primary purpose thus relates to military
tonomics in the prevention of waste; only secondarly
■i ^derations of humanitarianism enter.
The specific duties of the Medical Department in
ar are included in the following:
1) The initiation of sanitary measures to insure
ealth of troops.
_ I The direction and execution of all measures of
ublic health among the inhabitants of occupied
ory.
(3) The care of the sick and wounded on the march,
in camp, on the battle-field, and after removal there-
1 1
ill The methodical disposition of the sick and
wounded, so as to insure I lie retention of those effec-
tive ami relieve the fight ing force of tin' aon-i ffecti re.
The transportation of tin' sick and wounded.
(Ii) The establishment of hospitals and other
formations necessary for the care of the sick and in-
jured.
(7) The supply of sanitary material necessary for
the health of the troops and for the care of the sick
and injured.
(8) The preparation and preservation of individual
records of sickness and injury, in order that claims
may l>e adjudicated with justice to the Government
and the individual.
The Sanitary Personnel. — A very large person-
nel is necessary to carry on the work of the Medical
Department in war. It is drawn from:
(a) Medical officers of the regular army, 450 in
number. Also from the officers of the Medical
Reserve Corps, both on the active and inactive lists.
The organized militia of the States, on mustering into
tin' service of the United States, brings its own medical
officers; while in the organization of any volunteer
foi'res provision is made for the necessary attached
sanitary personnel.
(b) Physicians employed under contract, but not
commissioned as officers.
(c) Members of the Hospital Corps, as existing in
the regular army and organized militia and as ex-
panded to meet war conditions.
(d) Members of the Army Nurse Corps (female).
(e) Officers and soldiers of the line or staff detailed
for duty with the Medical Department.
(f) Civilians employed as clerks, drivers, laborers,
scavengers, etc.
( noncommissioned officers, and seven
privates take part at the aid station and keep in
touch with the firing line. The equipment of the aid
station is very simple, merely boxes of dressings, and
light nourishment with facilities for preparation.
This is an advantage, since it is no great task to
establish or break up such a station, which may need
to go into operation in more than one location during
a tight. The first consideration is protection from
fire, and usually the nearer the aid station is to the
front, the safer it is from dropping projectiles. The
aid given on the firing line will consist of the applica-
tion of dressings, the stanching of hemorrhages, and
the immobilization of fractures where practicable.
It must be confessed, however, that the actual results
accomplished on the firing line will probably be not
great, and that sanitary assignments thereto are
largely to encourage the soldier in a belief that, if hit,
his injuries will be promptly attended to. With
such encouragement lie will stand longer and fight,
better. When troops are advancing by rushes across
an open country, it is clear that to attempt san-
itary work under such conditions is to invite useless
destruction.
The treatment at the aid station will usually be
limited to first aid for wounded coming from the front
who have not already received it; and to the readjust-
ment of dressings, if necessary, of those who have.
Fractures, if not previously immobilized, are here put
in splints. Restoratives and analgesics are given as
required. If practicable, stimulating food and drink
are prepared. In general, as much as possible will be
done here to reduce the burden of work which other-
wise would subsequently fall on the dressing stations
ami field hospitals, as well as relieve the sufferings of
the injured. As a rule, no operations will be done
here except such as are urgently needed to save life,
as the ligation of an artery or performance of trache-
otomy. It must be remembered that the further to
the rear, the better the facilities provided and the
greater the chances for successful surgical work.
Prompt occlusion of wounds, in preventing infection,
is the great thing. By great attention to this last
point, the Japanese are said to have had a third of
all their wounded back on the firing line within a
month.
The regimental surgeon must not permit his station
to be overcrowded. All able to walk will be promptly
started back to the next relief point in the sanitary
chain which has in the meantime been established
to the rear. Those unable to walk are turned over
to the ambulance company bearers as soon as they
arrive. The regimental surgeon therefore must make
every effort to get into touch with the ambulance
company, charging the wounded he is starting to the
rear to report his location, or even detaching one of
his sanitary personnel as messenger. Frequently a
rough position sketch should be scut showing the
location of the station and the best means of access
to it.
Darkness affords a convenient opportunity to evac-
uate the aid stations and search the more advanced
581
Army Medical Field S.-rvii ■<■
REFERENCE HANDBOOK OF THE MFDtCAL SCIENCES
positions. This work at night is very difficult and
ar d , ' 1 ous. If his regiment moves, the surgeon closes
his aid station and follows, never permitting himself to
get out of touch with his organization. ( ttherwise an
advance might leave an aid station so far behind thai it
would not be able to fulfill its purpose. Any wounded
thus left behind on moving the aid station would
probably be taken over by an ambulance company, or
some of the regimental sanitary personnel may be
detached to remain with them. Similar action is
taken in case of retreat.
It appears from the foregoing that the first brunt
of sanitary work is done on the firing line and at the
aid station. The volume of casualties developing in
a very short time will sometimes be tremendous, and
sanitary assistance must be promptly rushed up
from the rear. This is done by appeal of the regi-
mental surgeons to their colonels, and by the latter
to higher authority. Regiments have not rarely lost
from one-half to two-thirds their strength in a single
battle. Larger forces lose less in proportion; but a
division may well lose a third, and in five great battles
of the Civil War the winning side lost twenty per cent.
or over. These losses do not fall equally on organiza-
tions, but some are shot to pieces, while others in
reserve may have lost scarcely a man. To meet the
needs of such diversified casualty, the regimental
sanitary service is not, by itself alone, sufficiently
elastic, and further formations, about to be described,
are necessarily brought into play.
The Ambulance Company. — There are four am-
bulance companies to a division. Like the field
hospitals and reserve medical supplies, they are
divisional troops, and subject only to the commands
of the Division Commander and the Chief Surgeon.
A Director of Ambulance Companies, with the rank
■of major, and with a sergeant and private of the Hospi-
tal Corps as assistants, directly conducts ther manage-
ment under the Chief Surgeon.
The personnel of an ambulance company is as fol-
lows: 5 medical officers, 1 captain and 4 first lieuten-
ants; 9 noncommissioned officers, 2 sergeants, first
class, and 7 sergeants; 1 acting cook; 69 privates, first
class, and privates. In order to keep the organiza-
tion as elastic as possible, for the reasons which appear
elsewhere, specific assignments to duty are not made
except in the personnel to accompany the wheel
transportation, which is as follows: 1 lieutenant; 1
sergeant, first class; 1 sergeant; 1 acting cook; 2
musicians; 1 farrier; 1 saddler; 15 drivers.
As to mounts, of the above company personnel the
following are mounted: five officers, thirteen enlisted
men.
For transport of sick and wounded an ambulance
company has twelve ambulances, each drawn by
four mules. The official capacity of an ambu-
lance is four recumbent and one sitting case; or
two recumbent and five sitting cases; or nine sitting
cases. For short distances, good roads and great
emergency, these figures for sitting cases may be
slightly exceeded.
There are also four collapsible travois, one of which
is carried on every third ambulance. These may be
used with the pack mules, cavalry horses, or public
or private mounts. Automobile ambulances will
probably find a place in the military service.
Each ambulance company carries twenty litters,
beside which there are four on each ambulance. The
latter, however, are needed as cots for the recumbent
cases and are intended to be exchanged for loaded
litters brought to the ambulance. For moving sup-
plies, each company has three four-mule wagons. Two
of these chiefly carry rations, forage, kitchen outfit,
bedding rolls, officers' baggage, etc., and belong with
the field train. The third wagon carries the equip-
ment for the dressing station — a load of about 1,300
pounds. For use in country not practicable for wheel
vehicles, or under exposure to fire, this dressing
station equipment is loaded' on: fotnr pack mules
which form part of the company transport.
The supplies entering into the dressing statioi
equipment are simple yet sufficient far their purpose
They consist chiefly of an abundance of dressings
an operating case, commode set,, detached servici
medical chest, simple fo>tos, a couple of rolls ol
blankets, a water filter., two tent flies, buckets
basins, and lights for night work.
The general function of ambulance companies is tt
collect the sick and wounded of the mobile fo. ci
transport thera to field hospitals. More specifically
their_ duties in battle are to establish and operati
dressing stations, help the regimental sanitary person-
nel at the front, and collect audi remove the wounded
by litters and ambulances, to the field hospitals
They therefore bridge the entire gap between tht
regimental sanitary service and the field hospitals.
Generally speaking, an ambulance company ordereci
into action proceeds about as follows:
The company moves as a whole to th<> last point
sheltered from fire. Here the wheel (transport i
left behind under cover to await orders. Th*
ninainder of the company, with its dressing station
equipment carried on pack mules, moves to the
vicinity designated for a station and locates in a
protected spot, preferably near roads from front to
rear, possessing a water supply aard, if possible,
buildings. The latter are not only shelter, but
convenient landmarks to which to> direct wounded.
The company probably leaves her* about two medical
officers and about nine enlisted men. This personnel
at once establishes and prepares the dressing station
to receive and care for patients. The remainder ol
the company, consisting of, say, twenty litter squads,
under two medical officers and five sergeants, moves
forward either as a single detachment or several
smaller groups to get into touch with the several
regimental aid stations in the sector of the line they
are ordered to handlo. As soon as they get into
touch with these stations, they start the flow of
wounded back to the dressing station, which is a
variable distance — perhaps half a mile — further to
the rear. As the wounded accumulate at this point
faster than they can be cared for by the original
dressing station personnel, the latter is reinforced
from time to time from the litter bearer section.
Ultimately, most of the latter may have been ab-
sorbed into the dressing station and the work of
collecting largely turned over to the regimental sani-
tary service.
The time when ambulance companies ought to go
into action is decided by the chief surgeon on the
number and location of wounded. They go in only
when the local regimental personnel can no longer
handle the situation. The same factors decide
number and location of the stations to be openi d. As
soon as the advance of troops or other factor has
caused the enemy to so modify his field of fire as to
enable the fairly safe approach of the wheel transport,
it is sent for to come up to the dressing station.
The dressing station is marked by Red Cross
guidons and camp colors. If off the road, the way to
it is indicated by these colors stuck in the ground as
markers at convenient intervals. The dressing
station itself is divided into the following depart-
ments: Dispensary, kitchen, receiving and forwarding
section, slightly 7 wounded section, seriously wounded
section, and mortuary. Within ten or fifteen minutes
after being ordered to establish, the stores should
be unpacked and the kitchen in operation and ret
to supply liquid nourishment. All wounded pass
through the receiving section. Trivial injuries, after
treatment, are sent back to their organizations with-
out delay. Those disabled from fighting, but able to
walk, may be sent to the station for slightly wounded,
a field hospital or the advance base, as the Chief
Surgeon may direct; they are usually organized into
.".XL'
ki:i i:i;i:\< i: handbook of Tin: mi.dk \i. SCIENCES
Army Medical I leld ><n pounds; surgical dressings, 5,991 pounds;
official blanks, etc., 492 pounds; instruments, 4o0
pounds Most of the articles carried are expendable.
These articles are largely contained in standard
size boxes with hinged lids. The wagons are packed
under a definite scheme to tacilitate getting at their
Contents. Three wagons are SO packed as each to
cany practically a month's allowance of medicim .
hospital stores, and dressing materials for one field
hospital. The fourth wagon carries equipment;
the fifth, baggage, tentage. and forage; and the sixth
a general supply wagon largely carrying bedding.
By having these reserve supplies available with the
division, the deficiencies resulting from the expendi-
tures depending upon action may be promptly re-
moved and the sanitary organizations as well supplied
in a few hours after action is over as they wen:
before it began.
Sanitary Tactics. — With comprehension of the num
ber, size, and functions of the various mobile sanitary
formations, as briefly outlined above, must come
appreciation of the fact that their direction and
management to good advantage is a task of great
magnitude and much difficulty. The .Medical Depart-
ment has a well defined system of tactics of its own,
based upon and coordinating with general military
tactics as a whole, under which its formations are
handled, moved about, and administered to best
advantage. To learn this properly is a study by
itself, and one absolutely outside the sphere of
education of the civil physician, who is largely help-
less in such an administrative position. A mere
professional training is only one of several necessary
qualifications, among which a knowledge of the
elements of strategy and military organization, pur-
poses, and methods are paramount. In this sense,
the term "Chief Surgeon is a misnomer, for he is an
administrative officer rather than a professional
attendant. The responsibilities of such an officer
with troops in the field are tremendous; and after a
severe action, with wounded by the thousands to
handle under conditions which always partake of an
emergency, they are greater than those of almost
every other officer. He must be an organizer and
executive of a higher degree of ability, so that the
best possible provision to meet sanitary need may
always be available at the right time, in the right
place, and in the right way. Appreciating that a
modern army is the most elaborate and complex
human machine ever devised by man, he sees that the
Medical Department functions as part of the general
mechanism in a way best to promote the military
welfare and to interfere least with the movements
and disposition of troops. But to do this he must be
informed of the plans of his commander and be able
to apply this knowledge to suitable modifications in
the management of the Medical Department.
Under modern military organization, the infantry
division, of almost 20,000 men, is regarded as the
smallest tactical unit possessing the elements to cope
with ordinary conditions and emergency. With such
a force, the sanitary personnel at the front is very
great, as already mentioned, and as adding to the
difficulties of administering it, is very scattered.
And the division is a small force for modern war. In
any great battle, at least a dozen such divisions would
probably make up one of the contending armies, and
such a force would occupy a wide frontage. It is
said that the Japanese had over 400,000 men before
Mukden, with a battle line sixty miles in length. To
control, direct, and smoothly operate the vast sanitary
personnel required at the front, scattered as it must
be and in each of its elements required to play a
different but coordinating part under dissimilar
environment and conditions, in the accomplishment
of a single common purpose, is a task to which all but
the best administrative capacity, fortified by special
training, must prove unequal.
Briefly, the great problem to be solved at the front
with fighting troops is one of transportation and con-
centration of the disabled. Conditions are utterly at
variance with what they are in civil life. Through
every problem runs the dominant requirement that
585
Army Medical Field Service
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
everything — humanitarianism included — shall yield to
matters of military efficiency. Hence the army sur-
geon must regard his military obligations required
under his commission, as an officer, of greater effect
than his Hippocratic oath as a physician; and to
acquiesce, if need demands, in the subversion of the
personal interests of the sick and wounded in the
achievement by the nation of the common ultimate
purpose of military success.
The disposition of sanitary personnel and organiza-
tions in marching columns is of material importance
in respect to the provision of suitable sanitary
assistance when and where needed, but with the
reservation that the assistance thus made available
shall be supplied with the least interference to military
purposes and methods. The tactical formation of
the column — particularly as to whether advance or
rear guard formation — is always a controlling factor.
There are no hard and fast rules as to the distribution
of sanitary personnel, transport and supplies through
the column, but there are certain general principles
relating to these points, the observance of which will
contribute greatly to having sufficient sanitary
assistance available at the right time and place. In
these principles, the factor of distance, or its equiva-
lent in marching time, is basically important. To
better appreciation of the matter, a little knowledge
of the common dispositions of the combatant forces
within the column is essential, and is given here as
follows:
For all practical purposes, we may consider that
marches are to be classed as (a) route marches, in
which troops are being moved from one place to
another and under conditions in which encounter
with an enemy is not to be considered; (b) marches
with an advance guard formation, in which an
enemy is being sought out and will be attacked or
opposed; (c) marches with a rear guard formation, in
which the column is retiring from a nearby enemy and
is endeavoring to evade a general action.
In route marching, the component units march in
closed column, without any special intervals or dis-
positions for offense or defense. In such case, the
regimental and other sanitary detachments accom-
pany the organizations to which they are assigned.
Their exact disposition is a matter of no great im-
portance, except that sufficient of the sanitary
personnel must be assigned to the rear of each or-
ganization to pick up and care for any exhausted or
disabled therefrom. In practice, the great majority
of the sanitary personnel would be aggregated at
the rear for facility of control. TV'ith a detached
battalion, all its sanitary personnel marches here.
With the regiment, probably all except the regimental
surgeon and his orderly, who rides with the colonel,
and the surgeons of the two leading battalions, with
their orderlies and one litter squad each, who march
with their assigned organizations, follow the regimen-
tal column. To each regimental organization is
temporarily assigned for the march one ambulance
with animals and driver. This outfit belongs to
an ambulance company, is only loaned, usually for the
day, and is temporarily under the jurisdiction of the
regimental commander and surgeon. Its function is
to pick up and carry on to camp such sick, ailing,
and footsore as may require transportation. If not
otherwise required, it may carry the belongings or
even persons of exhausted soldiers; but its function is
not to help supply transportation to a jaded army.
Exhaustion in the military organization as a whole
should be avoided by appropriate rests, or met by the
later forwarding at a slower rate of speed, of detach-
ments formed from individuals unable to keep up
with the column. This ambulance on the march is
practically a regimental hospital on wheels, discharg-
ing its cases in the regimental area when camp is
reached, to be there restored to duty, taken up in the
regimental infirmary or transferred to a field hospital
586
as need requires. The medical officer marching ii
rear of the regimental organization limits admissions
to the ambulance to cases of actual necessity. If .
company commander considers that one of his mei
needs medical assistance or transportation, he writes
a memorandum to this effect and gives it to a non
commissioned officer; the latter, with the soldier
falls out of column and waits by tin- roadside unti
a medical officer comes up. The latter authorize;
the admittance of the man to the ambulanci
makes such other disposition of him as seems nec<
sary, sending back to the company commander thi
note, with the action taken by him in the case of thi
soldier endorsed upon it. If more men have to fall
out during the march than can be accommodate
the single ambulance with the regiment, the excess i-
directed to wait at some convenient point beside the
road until the rear of the column as a whole arrives,
bringing the intact ambulance trains with fun
accommodations. This is the plan habitually employ-
ed with troops in advance guard formation and march-
ing to the attack. Any still greater excess of disabled
could await the wagons of the field train, or those of
the field hospitals, next to come up. Where a regi-
ment is operating independently, it is assigned a
total of three ambulances, which follow as a train
at the rear of the regiment.
In the column moving to the attack, special dis-
positions of the sanitary personnel and transpo-t
are necessary, variable with length of column and de-
pendent upon the advance guard formation assumed.
It is of the utmost importance, in controlling danger-
ous hemorrhage and limiting the opportunities for
wound infection, that sanitary assistance shall be
available within a reasonable period after receipt of
an injury. But this is generally practicable only
for the tactical organized units, and the Medical De-
partment gives no assurance that each and every
injury will be reached and handled as promptly and
effectively as might be desired. In its general pla
small groups and individuals have of necessity to be
disregarded, and the purpose is merely to endeavor to
bring about the greatest good to the greatest muni
Assuming an infantry regiment moving toward an
enemy known to be in the vicinity in front, the gem
procedure, somewhat variable with terrain, would be
about as follows:
(1) Six or eight mounted scouts, rapidly recon-
noitering the roads ahead and on the flank, and about
a mile ahead of the leading foot troops.
(2) A "point," of an officer and four men, some
500 yards in advance of the next element.
(3) "Flankers," variable as to number and interval,
and radiating from the "point" out to 400 to 500 yards
on each side of 1he road; thence parallel to it back to ,
the "support" of the advance guard.
(41 "Advance party," probably one company, |i
details as "point" and "flankers," and about 400 yards
in advance of the next element of the column.
No sanitary personnel will usually accompany the
foregoing. If any are wounded, they must dress their
hurts themselves with the first aid dressing carried on
the person, and await the coming up of a formation
large enough to warrant sanitary representation bcit g
assigned to it.
(5) "Support," probably of the remaining three
companies of the battalion. This will march, say,
1,000 yards in advance of the "main body of the
column."
In the rear of the "support" will probably be found
the battalion surgeon, his orderly, a noncommissioned
officer, and two litter squads of the Hospital Corps.
(6) "Main body," consisting of the two remaining
battalions. Each battalion is accompanied by the
sanitary quota just given above. The regimental
surgeon and his orderly ride with regimental head-
quarters, probably at the head of the "main body".
(7) The remaining sanitary personnel, consisting
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
\ i in v Medical Field Service
of the senior noncommissioned officer and four private
Hospital Corps, with litters and park mule, forming
the aid station party.
m Regimental band, carrying company litters,
officially placed under direction of the regimental
.mi and under immediate direction of the senior
sergeant firsl class, II. C, attached to the regiment,
rhe three ambulances, closing in the column.
ini [f the field train is present, it follows the
buiances at a suitable interval, depending upon
circumstances. If a regimental infirmary or regi-
mental hospital is present, its transportation probably
edes the field train.
Communication is kept up between these different
formations by individual soldiers marching at about
100 yards intervals and known as "connecting fil
In this formation the regiment, excluding the
nioiintril scouts, extends about one and one-half
milrs from front to rear. Such an organization will
march about three miles per hour, whence it appears
that if a man in the "point" is wounded and the
'■column" continues to advance, the surgeon with the
support will reach him in about ten minutes, and the
rear of the regimental column and ambulances in
about thirty minute.
In this formation, if the advance is checked, the
'point" is reinforced by the "advance party" and
the latter in turn by the "support.'' The whole
battalion previously forming the advance guard is
now a unit on the firing line, and the battalion surgeon
makes such distribution of his sanitary personnel as
may be necessary. The other battalions successively
arrive, and if necessary go into action. Each has a
.sanitary personnel directly attached to it sufficient
for its immediate needs. The field train is probably
halted a couple of miles back. The ambulances are
halted to await orders at the nearest point to the
my which they could reach while protected from
his fire. The aid station party, reinforced by the
band, is continued on to a convenient point near the
front, probably near the reserve, where it is held in
readiness for movement to the proper place at the
proper time.
It will thus be seen that the military forces arrive
in progressively stronger waves. The sanitary
trees likewise accompany and immediately follow
the latter. If opposition is slight, the column, in
prosecuting the march, soon crosses the zone of
casualty; if opposition is severe, the rear of the column
mines up to the halted head and thus arrives within
the zone of casualty. Either contingency is favorable
to the work of the Medical Department. The
wounded men will not have to march or be carried
back to the surgeon, for the surgeon is himself
normally moving up to him. The contingencies of
tactics here naturally tend to bring the patient, the
.surgeon, and the sanitary supplies together at the
earliest possible moment.
A rear guard formation is practically the same as
the advance guard formation, except that the column
is headed the other way. In other words, the situa-
tion is the same as if all combatant individuals,
detachments, and organizations had simply faced
about. But for the sanitary personnel the above
does not apply. In advance guard formation,
reinforcements of combatant troops and sanitary
a^-istanee are steadily moving toward the firing line
ic front; but in rear guard formation the firing
points are at the extreme rear, so that both combatant
and sanitary troops steadily tend to leave the suc-
cessive zones of casualty and widen the distance already
ting between the wounded man and represen-
tatives of the sanitary service. The purpose of the
rear guard formation, moreover, is not to fight but
to avoid fighting and to get away. The correlated
factors of time and distance control the situation.
Whatever is to be done for the wounded must be done
quickly; and to be able to do it quickly sufficient
assistance must !>'• available at tl i in I possible
point in the column. Ami inasmuch a- wounded
must be promptly removed if they an- not '
captured by the enemy, the need for plenty of wheel
transportation as near as possible to the rear is obvi-
ous. Probably half the SS i innel and half
the band will thus be assigned to the rear guard, at
hast two litter squads with t he rear party. One or
re ambulances would immediately precede the
"support" of the rear guard, falling out on ignal
and halting until reached by litter parlies bringing
up injured men from the rear. Theaid station party,
for which there '.'.ill be little use unless tin- "com-
mand" is forced to turn and fight, precedes the main
body. Any hospital supplies arc with the held train
a variable interval in advance of the main body.
The same principles as illustrated lor the regiment
apply to larger and smaller forces. In such ins t a Qi ■ .
the proportionate strength and composition of per-
sonnel, and intervals between formation-, vary. The
location and strength of sanitary personnel likewise
varies. With larger forces than the regiment, ambu-
lance companies, field hospitals, and the reserve sani-
tary supplies have to enter into our calculations in
connection with marching troops. With a brigade
in advance guard formation, an at tached ambulance
company ami field hospital would march at the rear
of the column. As a brigade in such formation
marches about its own length in an hour, it is clear
that all sanitary assistance available can be up in
about an hour after the head of the column is fired
upon, and by this time a general action has been
begun. This time is not excessive for the regimental
detachments to handle the situation by themselves.
In rear guard formation the field hospital would
precede the "main body", together with filled ambu-
lances, while empty ambulances and the ambulance
company personnel would precede the rear guard,
ready to turn and assist the sanitary personnel of
the latter if need requires.
But the infantry division is the tactical unit. It
would normally have a brigade of infantry, with some
artillery, in its advance or rear guard. Its advance
guard is 6,000 yards long and separated by some
2,000 yards interval from its main body. The latter is
10,000 yards long, total 18,000 yards. The trains are
about 10,500 yards, or a total of say 29,000 yards.
But such a column cannot be kept closed up and will
elongate on moving by ten per cent, and probably
more. The fighting column will thus be 20,000 yards
from front to rear — or say about eleven miles long.
The trains will follow the column at a variable interval,
say three to five miles. From a tactical standpoint, it
is important that nothing which can be spared should
have a place in this column and thus interfere with
the deployment of the maximum number of men in
the minimum time. But humanitarian reasons and
the need for getting wounded attended to reasonably
promptly, by reason of its psychological effect on the
uninjured, combine to require that some provision
for the care of wounded be made. The disposition
will be about as follows: one ambulance company,
less all its wheel transportation, or with dressing
station wagon merely, will follow the advance guard.
This position is about 6,000 yards from the extreme
ftont, or about an hour's march. About the time that
the advance guard deploys and gets heavily engaged,
this leading ambulance company will have come up
and be on hand to assist in caring for casualties. No
ambulances are sent with the advance guard, as
these would occupy valuable road space and merely
be in the way. Until the main body is out of the
road, the latter is blocked for removal of wounded.
The three remaining ambulance companies, complete,
and the train of the one sent with the advance guard,
follow at the rear of the main body. They are thus
some eleven miles from the front, where they could
probably arrive in about four and one-half hours as a
587
Army Medical Field Service
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
division can move only relatively slowly; or three
and one-half hours after the first ambulance company
arrived on the scene, and shortly after deployment
was completed and the action become general. The
field hospitals, heading the trains whenever battle is
imminent, would pull on to within half a dozen miles
of the action, and be halted at a convenient place
to await orders. If need demanded, the field hospitals
could reach the field one or two hours after the
ambulance companies, dependent on the length of the
interval between the rear of the column and the
trains. The reserve medical supplies usually bring up
the rear of the supply train. They are about six
miles from the field hospitals at the head of the train,
and could thus arrive on the battlefield about two
and one-half hours later if the sanitary material were
needed. It thus appears that as the casualty situa-
tion on the field develops, a succession of organized
sanitary relief units comes up and thus are sent into
action according to the needs of the situation.
The actual positions of the foregoing formations
with the division after battle is on is wholly variable
with local conditions and terrain. It could, in the
nature of things, practically never be twice alike;
but perhaps some such disposition as follows would
fairly express the situation:
In the First Brigade, the First and Second Infantry
have each the First and Second Battalions on the line
and the Third Battalion under cover within a hundred
yards or so in support. The Third Infantry forms the
brigade reserve, and is perhaps several hundred yards
in the rear of the other regiments. This brigade has
a frontage of, say, two-thirds of a mile.
The Second Brigade is, say, immediately on the right
of the first. Its interior disposition is approximately
the same as with the First Brigade.
The Third Brigade is the divisional reserve, and is
under cover, say, half a mile to the rear and at a
central point whence any part of either the First or
Second Brigade can be quickly reinforced.
Under such conditions, the points of medical relief
in operation might be about as follows:
With the First and Second Battalions of the First
and Second Infantry, sanitary aid on the firing line as
expressed by the presence of a surgeon, orderly, non-
commissioned officer and one or more privates.
Somewhere back of the First and Second Battalions,
as near them as possible but probably near the reserve
battalion, would be the aid stations of the First and
Second Infantry. The sanitary personnel of each of
these is that of the aid station party, plus much of the
sanitary personnel of the nearby reserve battalion,
plus the band. Wounded from the two battalions of
each regiment at the front drain into each of these aid
stations. Several miies to the rear, preferably on a
side road not utilized by the dressing stations and
field hospital, is the station for slightly wounded.
The battalion and regimental surgeons are directing
the slight cases to start there at once.
Back of the two regiments on the firing line of the
First Brigade, preferably at a point near the center
draining both flanks, is located the dressing station.
This brings it somewhere near — though probably in
the rear of — the brigade reserve. Wounded from
the two regiments engaged and their aid station;
converge here. Only very exceptionally would
sanitary assistance be drawn from the regiment in
reserve, which may at any time have to go into action.
The Third Brigade, in reserve, is for the time beipg
inactive. If successful, it will be pushed against the
enemy; if unsuccessful, it will form the rear guard to
hold off the enemy and permit of an orderly retreat.
It is not suffering casualty and has no sanitary forma-
tions in operation. It may not be needed for some
hours. Some of its sanitary personnel may be tem-
porarily detailed by the Chief Surgeon to assist at the
dressing station nearby.
The dressing stations of the First and Second Bri-
588
gades are evacuating their wounded by ambulance
on a field hospital just established some three miles
back at a point readily accessible from both the First
and Second Brigades.
Perhaps near this point are the two reserve ambu-
lance companies, and three field hospitals, packed up
and awaiting orders.
A transport column has just arrived here from the
rear, and will load its ambulances at the field hospital
as soon as the cases are in readiness to be evacuated
farther to the rear.
Back some five miles on the route over which the
division advanced, halted with the trains, are the
wagons of the reserve medical supply.
Eight or ten miles away is a rest station, where the
transport column will halt to rest en route on its
return with wounded from the field hospital.
Fifteen or twenty miles away is an evacuation hos-
pital, located at railhead and serving as a receiving
and forwarding hospital for the sanitary train service
leading to the base.
Nearby is another evacuation hospital, packed in
wagons and in readiness to be pushed to the front
when and where needed. An advance medical
supply depot has been established at railhead.
In the foregoing scheme, the sanitary service with
the cavalry, artillery, and other troops is not con-
sidered, as the infantry furnishes all but a small per
cent, of the total losses.
In the rear of the field hospital above mentioned,
the sanitary formations relate to the line of com-
munications, or zone of evacuation, next to be con-
sidered.
II. The Evacuation Zone. — Prolonging the col-
lecting zone to the rear comes the evacuation zone.
This includes the line of communications, the great
channel through which the military force at the front
is sustained and at the same time relieved of it-
human debris. The sanitary formations for the divi-
sion in this zone are as follows: transport column;
evacuation hospitals; medical supply depots; hospital
trains and boats; base hospitals; base medical supply
depots. All these formations come under the direc-
tion of the Chief Surgeon, Line of Communications.
They are depended upon to take over the wounded
from the division at the front without unnecessary
delay, and thereby free the military force at the front
from an encumbrance which would otherwise largely
paralyze its fighting efficiency. The various for-
mations in the zone of evacuation may briefly be
discussed as follows:
The Transport Column.-. — One such organization is
allowed each division. Its primary function is the
evacuation of field hospitals, and transportation and
care of patients therefrom to evacuation, base or
other hospitals on the line of communications; or to
points with train or boat connection by rail or water
to such hospitals.
The transport column has 4 medical officers, 1
major, commanding, assisted by 3 junior medical
officers; 4 sergeants, first class; 16 sergeants or cor-
porals; 4 acting cooks; 16 drivers; 4 orderlies; and
40 litter bearers. Its transportation consists of
1*2 ambulances and 3 wagons. The supplies are
identical with those furnished an ambulance com-
pany, except that no pack mules or dressing station
equipment are supplied. This organization is weak,
and capable of meeting ordinary conditions only.
However, its work partakes much less of emerge:
than does that of ambulance companies: and tin'
time factor for removal of the disabled, while al v.
important, is here less frequently paramount.
On the march, transport columns or sections thereof
keep in touch with the column and are brought up to
take over patients collected by field hospitals, which
must again be freed. These disabled are removed
to the designated point, and the transport column
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Army Medical Field Service
promptly returns toward the front. Ordinarily ii
will not work in the rear of evacuation hospitals.
Whin battle is imminent, the transport column is
usually heavily reinforced by both vehicles and
bearers. Empty army wagons and hired or iin-
-,.,1 civilian trams, automobiles, etc., are em-
ed, Mini extra sanitary personnel sent up from the
casual camp at the base. Just before battle, all the e
resources should be moved as far to the front as
ticable, so as to be promptly available. As soon
sufficient patients requiring return to the rear
imulate at one or more lield hospitals, the trans-
port column will receive, provide fur, and transfer
them to the rear. It also provides for the slightly
wounded, able to walk, who may have been directed
Rest Station. — When the distance to be travelled
by the column is more than a half day's march, or the
lition of the patients require it, the transport
Mia establishes rest stations at convenient points.
Hours consumed in travel, rather than distance actu-
ally traversed, largely determine location. These
stations may correspond with quartermaster's supply
depots; they certainly will with one of the etapes
established along the line of communications.
Rest stations are formations having no definite
■ unci or equipment. They can usually be
established in houses and can be materially outfitted
local resources. They are intended only for
temporary treatment and care of patients until
they can be moved further. Ordinarily the duties
of the- personnel at these stations are limited to the
readjustment of dressings and the supply of food and
s'n.'lirr to patients. Emergency operations may,
however, be done when necessary.
Tlic personnel for rest stations may very legiti-
ely be drawn from the Red Cross, who can perform
the necessary work to excellent advantage. Some-
times rest stations may be kept up for considerable
periods with the same personnel, or they ma)- be
iporarily created for the needs of a single stop
or night. When patients must be left behind at
I stations, sufficient personnel and supplies are
left with them, and the Chief Surgeon of the Line of
Communications is duly notified. The general re-
lations and functions of transport companies are
analogous to those of ambulance companies.
Evacuation Hospitals. — Two of these hospitals are
mobilized with each division. Each has an official
capacity of 324 patients, or a total of 624. Under
stress of emergency they may be expanded to accom-
modate many more than that, since the nature of
their service will frequently cause their establishment
in communities where buildings are available and
supplies and personnel may be materially supple-
mented from local resources.
The personnel of an evacuation hospital is as
follows: Fourteen medical officers, divided into 1
lieutenant colonel in command, and of the juniors,
I executive officer, 1 quartermaster and commissary,
1 operating surgeon, 2 assistant operating surgeons,
8 ward surgeons; 8 sergeants, first class, of whom 1 is
general supervision, 1 in charge of office, 1 in
charge of quartermaster and commissary supplies and
records, 1 in charge of kitchen and mess, 1 in charge
of detachment and detachment accounts, 1 in charge
of patients' clothing and effects, 1 in charge of prop-
erty and records, 1 in charge of dispensary; 16 ser-
geants, of whom 1 is in dispensary, 2 in store rooms,
1 in mess and kitchen, 4 in office, 2 in charge of
police, 5 ward masters, 1 in operating room; 10 acting
cooks; 119 privates first class and privates, of whom
76 are ward attendants, 1 in dispensary, 3 in operating
room, 10 in kitchen and mess, 4 in store rooms, 5
with transportation, 4 orderlies, 4 in office, and 12 on
outside police.
The evacuation hospital has little transportation.
There are two four-mule wagons for ordinary hauling,
and three ambulances for the movement of the dis-
abled. The latin' is sufficient, as although the num-
ber of patients to i»- moved is large, the distano
are short and the time factor is rarely of importance
Evacuation to the rear of tin- evacuation hospital will
very frequently in- bj rail.
The equipment of an evacuation hospital is prac-
tically that of three lield hospitals — into which it can
be broken up— pin- a considerable amount of heavy
material, such as folding field furniture, etc., not car-
ried by lield hospital-. It is fully provided with
tentage for shelter. It weighs, packed, about 66,000
pounds, and thus requires about thirty wagon to
move it. These wagons are to be supplied by the
Quartermaster's Department as need requires. The
institution is a fairly mobile one, but it does not
ordinarily need to move often, suddenly, or to very
great distances.
The evacuation hospitals form a central point
toward which the collecting zone converges, and from
which tile stream of disabled Hows toward the rear to
diverge later into appropriate relief establishments.
The primary function of the evacuation hospital is to
replace held liospilals so 'hat the latter may move
with their divisions, or to take over their sick with
the same end in view. Secondarily, it is used for
ordinary hospital purposes on the line of communica-
tions. One of those with the division is usually
established at railhead as a receiving and forwarding
hospital, while the other is, if necessary, pushed out
a day's journey or shorter distance nearer the front.
Sometimes an evacuation hospital may be set aside,
in whole or part, for the treatment of infectious
diseases. The military situation controls the location
of evacuation hospitals, but they should, when pos-
sible, be located on a railroad or navigable stream.
The vicinity of a town or hamlet is very desirable;
but access by good roads, good water, and plenty of
fuel are essentials. If suitable buildings are available,
the evacuation hospital is habitually established in
them, and little or no tentage is pitched. Many such
buildings, as hotels, are already supplied with every-
thing for the comfort of patients except medical
supplies; other buildings, as warehouses, schools,
halls, etc., may be readily converted to hospital use
by the supplies and equipment carried.
When a battle is expected, the evacuation hospitals
are cleared, packed, and brought forward to a point
convenient to the scene of expected action. As they
are cumbrous and can only move relatively slowly,
they are not attached to troops, whose movements
they would hamper. They are held in readiness
somewhere conveniently on the line of communica-
tions, so as to open on the spot or move further
forward as the Chief Surgeon of the Line of Communi-
cations may direct. Once established, evacuation
hospitals are not ordinarily moved during combat
unless the troops have advanced so far that the
distance makes it easier to move the institution to the
patients than the patients to the institution; or when
the natural route of evacuation of wounded no longer
passes through them; or when the field hospitals are
so overwhelmed with wounded that it is necessary to
supplement them without delay. After a battle, the
evacuation hospital may move up to or near the field
and take over the wounded from the field hospitals, or
take over the latter, equipment and all, supplying
similar equipment from one of its sections for a new
field hospital which, with the field hospital personnel
thus released, goes forward to rejoin the division.
The duties of an evacuation hospital are much like
those of a field hospital, except that it is not so
governed by emergency and is intended to afford a
longer and better opportunity for treatment than
field hospitals can give. In a general way, the
organization of the evacuation hospital into depart-
ments corresponds with those already outlined for
field hospitals.
589
Army Medical Field Service
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
The character of surgical treatment given wounded
in evacuation hospitals will naturally vary with con-
ditions. When during or after battle very many
wounded are coming in, the treatment which can be
given will not be much more extensive than that
afforded in field hospitals, viz., emergency operations
and those intended to fit the patient for further
transport. But when few wounded are coming in
and an early move is not probable, complete treat-
ment is usually given. Excellent facilities for surgical
asepsis are almost always available. Like all other
medical formations, the evacuation hospital is in-
tended to facilitate the further transport to the rear
of serious cases liable to be permanently incapacitated,
or those calling for more protracted treatment than
the nature of such establishment is intended to pro-
vide; while on the other hand it is intended to re-
tain all cases offering prospect of early recovery and
return them to duty with their organizations at the
front. Every effort is taken here, as elsewhere, that
wounded soldiers shall not separate themselves from
their commands further than is absolutely necessary.
To facilitate administration, two or more evacuation
hospitals establishing in the same town or vicinity
may be combined under one head; or the whole or part
of the personnel of one such hospital which is not
itself established may be sent to reinforce that of
another. Such matters, together with the opening or
closing of these hospitals, with when, where, and how
their patients shall be evacuated, are decided by the
Chief Surgeon of the Line of Communications. Upon
him devolves the responsibility of freeing the forma-
tions at the front of wounded, and keeping the
movement of the latter back to the rear uninterrupted
so that congestion at any point or points may be
avoided. Particularly is it necessary that the non-
effectives shall be promptly removed from the zone
of operations. An appropriate field of usefulness of
the Red Cross is in taking over one or more wards of
an evacuation hospital, or in performing such other
duties in connection with it as the medical officer in
command may deem fit.
Base Hospitals. — These are sanitary formations of
the line of communications. One is mobilized for
each division, and has an official capacity of 500 beds.
It is capable of caring for more than that number of
disabled under stress of emergency; and probably,
as was the case in the Civil War, many would be
greatly expanded.
The personnel of a base hospital includes 20 medical
officers, of whom 1 is a lieutenant colonel in command;
1 major, as operating surgeon; 18 junior medical
officers divided into 1 executive officer, 1 quarter-
master and commissary, 1 pathologist, 1 eye, ear,
nose and throat specialist, 2 assistant operating
surgeons, 12 ward surgeons. There is also 1 dental
surgeon. There are 8 sergeants, first class, of whom
1 is in general supervision, 1 is in charge of office, 1 in
charge of quartermaster and commissary supplies and
records, 1 in charge of kitchen and mess, 1 in charge
of detachment and detachment accounts, 1 in charge
of patients' clothing and effects, 1 in charge of
medical property and records, and 1 in charge of
dispensary. There are 16 sergeants, of whom 1 is
in the dispensary, 2 in storerooms, 1 in mess and
kitchen, 4 in office, 2 in charge of police, and 6 are
wardmasters. There are 14 acting cooks; and 1 1 ~>
privates, first class or privates, of whom 68 are ward
attendants, 1 in dispensary, 2 in operating room, 1 in
laboratory, 14 in kitchen and mess, 12 outside police,
1 dental surgeon's assistant. Also 46 female nurses.
The medical supplies, furniture, and equipment of
a base hospital weigh 92,000 pounds. It might some-
times be established under canvas, and for such con-
ditions 121 hospital tents are authorized as shelter.
But ordinarily it will occupy buildings taken over
for the purpose, or erected in the form of frame
pavilions especially adapted to hospital purposes and
590
built according to the official specifications filed in the
office of the Surgeon General. The base hospital is
provided with 3 ambulances and 2 four-mule wagons
for ordinary hauling. Any additional transportation
required is secured as needed from the Quarter-
master's Department. The base hospital is rarely
if ever moved in wagons, but is habitually brought
up by boat or rail to the point of establishment at the
base from which the military movement is launched.
Its equipment is very complete, and nothing in the
way of supplies or personnel is lacking to facilitate
the recovery of patients.
As troops advance further from their main base,
railroads are repaired and one or more suitable points
become advanced bases. New base hospitals are
established at these points, since those already estab-
lished further back are very likely now too far sepa-
rated from the advancing force. The ones first
established still continue their functions, but as the
line of communications lengthens, new ones are
established to form links in the sanitary chain at
suitable intervals more convenient for the handling
of sick and wounded. Where battle by a large force
is expected, several base hospitals may be opened
and held empty in readiness to receive the wounded
who may be expected — or the personnel of those al-
ready in operation may be augmented by that of those
not yet established
Base hospitals are intended to receive cases from
the field and from evacuation hospitals, as well as
cases originating on the line of communications and
the base. Being completely equipped from a medical
standpoint, it is intended that they shall give com-
plete treatment to the great majority of cases sent to
them, forwarding to home territory only such cases
as require special treatment, are not likely to be fit
for service for a considerable period, or will probably
be permanently incapacitated for further duty.
But where their capacity is being exceeded, or where
heavy fighting is in immediate prospect, they will
either have to be evacuated of suitable cases or rein-
forced by the opening of new hospitals or the expan-
sion of accommodations already existing. These
hospitals send out the necessary personnel to meet
sick arriving from other hospitals or from the trans-
port columns, but such receiving parties will ordinarily
not go further than the adjacent railroad station or
points of debarkation. When evacuating cases
further to the rear from advanced base hospitals, the
necessary personnel and supplies are drawn from the
latter. Several base hospitals in the same vicinity
may be combined under a single head. As frequently
happened in the Civil War, they may be converted
into general hospitals. In a general way, the internal
management of base hospitals conforms to that of
general hospitals. No man capable of further duty
in the immediate future should ever be sent further
to the rear than the base hospital, for experience
amply shows that the services of a great proportion
of the cases getting further to the rear will probably
be lost for the campaign if not for the war. While it
is necessary for the surgeon at every field establish-
ment of the Medical Department to exercise great
discretion as to who shall go further back, who shall
be retained, and who shall be returned to the front,
this perhaps applies with greater force to the base
hospital. It is most important that those formations
shall not become clogged; for if this occurs the more
mobile organizations near the front, having no place
into which they can discharge their patients, must
inevitably become congested and immobilized.
Convalescent Camps. — When necessary, the chief
surgeon of the line of communications may establish
a convalescent camp or camps at the base, or in the
vicinity of base hospitals established along the line.
Such camps are branches of the base hospital near
which they are situated.
The purpose of the convalescent camp is to relieve
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Army Medical Field Service
-Mire in the base hospital by permitting the
therefrom of all such cases as are well on
ecov'i ry, and which rest and time rather than
edical care are needed for a cure. It frees many
beds which would otherwise be occupied,
nl holds under control and for further service
any who, if evacuated further to the rear, would be
radically lost to the army. Held here under
• oversight, th?y can be forwarded to their
ions at the front as their condition and
iportunity warrants. These convalescent camps,
practically emergency formations, have no
i or organization. In the Civil War, thej
metimes grew to such vast size as to be difficult of
lininistration and management. One being now
d to a division, it is probable that a size equal
base hospital which it relieves of a certain
patients will not be exceeded. Uniting
es, closed but healing flesh wounds, cachexias,
lility following any cause furnish legitimate
i such camps. No personnel can be specified
advance for these camps, as it naturally depends'
pon the number and character of cases present in
ii latter. The same remarks apply to the equip-
Facilities for shelter, nourishment, sleeping
ausement are about all that are required.
arge buildings with grounds, located on the outside
towns. ina\ be taken over; or frame partition
uildings may lie specially constructed for the pur-
ose on attractive sites. Tentage would rarely be
sed except for temporary emergency. Super-
v medical officers could be assigned in charge,
ith a necessary sanitary personnel detailed from
ial camp.
Disease Hospital. — One such hospital
iv he established for each division as need demands,
personnel, or equipment is prescribed, as
arily vary with the number and nature
f the cases to be eared for. All large bodies of
■oops not infrequently present cases of dangerous
issible infections, which must be isolated as
on as possible. The contagious disease hospital is
branch of the base hospital whose need- it serves,
cing located conveniently thereto yet far enough
.ay to secure the necessary isolation. The person-
el is assigned by the chief surgeon of the line of
immunications, . who makes the necessary drafts
lereto from the casual camp. The nature of the
luipment varies, but corresponds in a general way
) that of the base hospitals. It would usually be
cured direct from the base medical supply depot.
he use of buildings is preferable, and conditions are
-ually such that these can be obtained. If a large
umber of contagious eases have to be treated, the
i.i.f surgeon of a field arm}' may set aside an evacua-
ion hospital for special service as a contagious
isease hospital. Small hospitals for contagious
.ay need to be established along the line, so
hat these cases need not be moved.
ial Camps. — These camps are designated for
eption, shelter, and control of the unattached
anitary personnel on their arrival and during their
tay at the base of operations. They are established
>y the Chief Surgeon of the Line of Communications,
nd are under the immediate command of the senior
I officer on duty therein. These camps are
I iblished in the proportion of one to each division,
hough several may be merged when several divisions
re operating together as a field arm}-. Sanitary
ecruits, Hospital Corps men discharged from hospital
>r returning from furlough, absentees from any cause,
md special detachments returning from the front
'port here, and are taken up under a company
irganization. From this, drafts are made on request
if the Chief Surgeon of the Division to replenish
anitary organizations at the front weakened by
leath, sickness, discharge or other causes. From it,
he organizations on the line of communications are
manned, and the necessary personnel for any spei ial
put pose is draw n.
Iia*' U. ■ ['he 1 t he point
from which a military force draws it- supplie . a
sufficient quantity of which is rapidly accumulated
to meet pn ,ni and probable needs, lii making
this provision for material, the Medical Department
has its part to play, and establishes a supply depot
thereat for the purpose. The personnel prescribed for
this formation is 2 medical officers, 1 sergeant, first
class, - sergeants, and 12 privates.
The amount and character of supplies to be
carried in stock by the base medical supply depot is
fixed by > : ieneral. However, they must
be ample to constantly meet all requirements of the
sanitary sen ice at the front , on the line of communica-
tions, and at the base. Some elasticity is necessary
according to the needs at the front, the operations
in prospect, facilities for transportation, etc. Among
other items, a large number of iron frames as litter
supports, lor use in fitting up baggage cars for the
conveyance of wounded, are carried in stock. As
the troops advance and the line of communications
lengthens to a degree where it is difficult to make
issue of supplies to the divisional sanitary units, one
or more branches, or advance medical supply depots,
may be pushed to the front. One is usually if not
invariably established at railhead. Issues are made
from these depots to organizations along the line of
communications. Ordinarily, only the divisional
-anitary units will receive supplies direct from the
base medical supply depot. Regiments will replenish
their stock from a designated field hospital or the
reserve medical supply. The base medical supply
depot is habitually established in a building. Its
difficulties are many, for its efficiency largely- depends
upon facility of the transportation of supplies called
for, and transportation is in the hands of another
department.
Hospital Trains. — There are two kinds, regular and
improvised. The regular trains are made up of ten
cars each, of which eight are for patients. The official
capacity is 200 patients. The personnel of such a
train is made up of 3 medical officers; 1 sergeant, first
class; 2 sergeants; 2 acting cooks; 2 orderlies; 20
privates as nurses. The equipment varies with the
special needs of the situation.
In time of emergency, improvised trains for patients
are made up of any available cars and turned over
to the use of the Medical Department. Troop trains
moving up to railhead may have their empty coaches
filled with less severely wounded on the return trip.
Empty baggage or freight cars, made more or less
comfortable with litters, straw or hay, may carry
back recumbent wounded. On many occasions it is
probable that wounded, as in the Russo-Japanese
War and our Civil War, will be sent back in these
trains without any special preparation of the latter,
as a result of unfavorable military conditions. In
ordinary freight or baggage cars, all patients carried
for any distance must be regarded as recumbent, and
the capacity based on twenty-five patients per car.
Special litter fittings for the conversion of box cars
for hospital purposes are supplied by the Medical
Department. They are so assembled as to provide
recumbent transportation for twenty-four patients
per car. They are kept in stock, knocked down, in
the base medical supply depot, and are sent forward
so as to be at railhead on the eve of impending
battle. The personnel of improvised trains depends
on the needs of the situation. It comes either from
the casual camp, or the large hospitals at the base or
on the line of communications. Supplies would
usually come from the base medical supply depot.
Hospital trains and improvised trains for patients
may operate in hostile territory, in home territory,
or both, according to tactical and geographical con-
siderations. Abroad they are directed by the Chief
.391
Army Medical Field Service
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Surgeon of the Line of Communications; in home terri-
tory, by the Surgeon-General. Medical officers com-
mand these trains. In transporting patients, they
are particularly charged to give due warning to the
institution to receive them of the time of arrival and
number of disabled. The schedule of train service
is arranged by the Chief Surgeon of the Line of Com-
munications.
Hospital Slu'ps. — These can only relatively rarely
be used on the line of communications. However,
in the Civil War they rendered invaluable and
tremendous service, particularly on the Mississippi
and its tributaries. Where navigable streams are
available, they will usually offer better opportunities
for the more comfortable and expeditious evacuation
of the disabled than can be had by land, and the
necessary boat service should be at once organized,
the personnel and supplies coming from the sanitary
service of the line of communications.
But in over-sea expeditions, hospital ships and
ships for patients are required; and both are provided
by the War Department. The former are of a
permanent and elaborate nature, while the latter are
usually transports fitted up in emergency for the
return trip to bring back the less severe class of the
disabled. The former are outfitted at home, and the
latter from the main base in foreign territory. All
these ships are under the command of the medical
officers in charge, who have exclusive direction of
all but the technical handling of the ship, which
latter remains vested in the sailing master. The
capacity, personnel, and supplies of ships for patients
naturally varies with availability and requirements.
Perhaps about one-third of its troop capacity may be
regarded as a fair average of the capacity of a return-
ing transport to carry patients of the less severe
class.
Regular hospital ships are intended to have a
capacity of 200 beds, and to carry the more severe
cases. As a matter of fact, since our Government
owns no army hospital ships in time of peace, the
capacity of those in war will vary with the facilities
afforded by the most available ships of the merchant
marine, remodelled for the purpose. In the Spanish
War, our regular hospital ships were the "Relief,"
" .Missouri," and "Bay State, "all utterly dissimilar as
to size, tonnage, and construction. The personnel of
the official hospital ship is 1 major and 4 junior medical
officers; 1 sergeant, first class; 4 sergeants; 5 acting
cooks; 30 privates. The equipment of these hospital
ships is most elaborate and complete, nothing being
lacking which could in any way contribute to the
comfort and welfare of the patients.
III. The Zone of Dispersion. — While this article is
supposed to deal only with army medical field service,
it is impossible to conclude the discussion without
further consideration than that of the zone in which
the patients fall and are collected, and the zone
through which they are removed. Many of the dis-
abled pass into a third zone, or zone of dispersion.
In this latter zone they will be scattered, for conven-
ience and availability of treatment and care, through
various general hospitals and the convalescent camps
attached thereto. All of these are in home territory.
We now have two such army hospitals receiving and
caring for all kinds of cases, one in San Francisco
and one in Washington, D. C. Both are capable of
great expansion. In addition, as many other such
inst itutions as may be needed in any future war would
be established at strategic points, and of a size to meet
necessary requirements. Plans and specifications
for such hospitals, drawn up on the pavilion system,
are already prepared in the office of the Surgeon-
General, and they may be erected out of lumber and
ordinary building materials with great rapidity.
During the Civil War, the Northern forces had at one
time 192 general hospitals, with 118,000 beds. Some
such hospitals accommodated 3,500 patients each, but
it is not now believed to be good policy to have
them of more than 1,000 bed capacity. These
general hospitals are under the exclusive control of
the Surgeon-General, and are set outside the juris-
diction of department commanders. The equip-
ment of the general hospital is varied and elaborate,
approximating, except in the relatively temporary
nature of the buildings, that of high class civil hospitals.
The personnel is very complete, and in these general
hospitals will be found the best expert medical as-
sistance found in civil life, drawn temporarily to the
colors through motives of patriotism.
Receiving hospitals may be established at posts
habitually utilized for the discharge of troop trans-
ports. They may be branches of neighboring
general hospitals; or they may themselves be ad-
ministered as general hospitals.
In time of great stress, or when official hospital
accommodations are insufficient, contracts may be
made with civil hospitals conveniently located," and
patients sent there for necessary treatment. Usually
such cases are supervised by a medical officer, to
maintain some military control and see that the
necessary records are properly kept up. The system
is undesirable, as tending to absenteeism and will
probably not now be employed any more than ab-
solutely necessary, though freely used in the Civil
and Spanish Wars.
In the past, many disabled have been furloughed
to their homes as soon as able to travel, where they
have received private medical attention subsequently
paid for by the Government. This system is highly
undesirable, as letting the patient escape absolutely
from military control, and will probably not be
greatly employed in the future.
Hospitals for prisoners of war are established by
the Surgeon-General at points designated by the
Secretary of War. They have the status of general
hospitals and are managed directly under the Sur-
geon-General, except that the officer charged with
the custody of the prisoners will maintain such guards
over the hospital as are necessary to prevent libera-
tion or escape of prisoners under treatment therein.
A total necessary bed capacity for the entire
force, front to rear, is fixed at the equal of ten per
cent, of the total borne on the muster rolls. This
number does not include the accommodations of the
field hospitals, rightly considered as being unavailable
except for brief emergency treatment.
Edward L. Munson.
Army Medical Statistics. — Broadly speaking, the
main causes affecting the health of troops are the
manner of living, the environment, and the fond
supplied. The first relates to the occurrence of
overcrowding, imperfect ventilation, want of clean-
liness, and inattention to personal hygiene. The
second is typified in the accidents arising from atmos-
pheric or telluric influences, such as rapid death from
heat and cold, the comparatively transient influei s
of the seasons, and the slower and more durable
effects of climate as modifying diseases of a restricted
habitat. The last cause concerns the diseases
brought about directly or indirectly by vicious ali-
mentation. There are no diseases peculiar to the
soldier; but military conditions are frequently such,
particularly during a campaign, that the germs of
disease are widely disseminated among an especially
susceptible body of men — and hence a larger number
are attacked and succumb than would probably have
been the case in civil life. In character, the diseases
developed in the military establishment call for no
remark unless it be their unusually severe type, the
regularity with which outbreaks of some affections
recur, and the frequent tendency of others to become
endemoepidemic. The prevailing diseases in armies
592
REFERENCE HANDBOOK "1 THE MEDICAL SCIENCES
Army Medical Statistics
are, naturally, largely acute; and a large propor-
tion of thein arc zymotic and hence theoretically
preventable.
I he purpose of army medical statistics i- to define
the influence of military life upon health and ti> per-
mit the ready appreciation and accurate comparison
of varying conditions of service and environment
in their relation to the well-being of the soldier.
Since each case of sickness in the military establish-
ment at once becomes a matter of official record at
the hands of competent observers, it follows that
statistics so obtained are not only more comprehen-
bul more accurate than those bearing on the
irrence of disease among civilians. Unfortu-
v tor their general utility, however, they are
i upon a physically superior class, always exist-
under restricted and unusual conditions and fre-
1 1 v in unfavorable surroundings, and hence
ictions which may be drawn from them cannot
legitimately applied outside the limits of the
military service. Unfortunately, also, owing to the
irent systems of nomenclature and classification
eases which have prevailed in the past, as well
other causes which will be referred to later, it i<
not always possible accurately to compare the sickness
and mortality from special causes occurring in differ-
annies, or even for the military establishment
and civilian classes of the same nation. The commit-
on international military medical statistics which
met at Budapest in 1894 has, however, formulated
a plan which overcomes in great measure the difficul-
ties with which army statisticians have had to con-
tend, leads to a common basis of comparison, and
will ultimately be the means of affording a large
amount of information hitherto not available.
In the British army, statistics with regard to sick-
and mortality were first compiled shortly after
the close of the Peninsular war, but were published
at long and irregular intervals. They gave much
information with regard to the healthfulness of
various stations, but the advent of the Crimean war
caused their temporary discontinuance. In 1S59
their publication was again resumed and they have
since been issued annually. Army statistics have
collected in France and Germany since the
Napoleonic wars, but have not been regularly made
available for general use, frequently being issued
only in part or not at all. Of late years, France has
not given out full information as to the occurrence of
ase and death among her military forces. In the
Itiited States army, satisfactory data for the period
prior to 1S40 are not available, and it is only since
Iss-t that figures sufficiently elaborate to be of any
great value to the statistician have been compiled
and published. At present the official returns show
not only the amount of loss the army annually incurs
from disease but also the causes leading thereto as
influenced by race, age, length of service, arm. of
service, season, station, and other factors.
Little information is gained by recording the statis-
tics of disease as a whole, since so many factors com-
bine in the production of the final result that they
must be separately studied to arrive at a proper
^standing of the whole.
The main points upon which army medical statistics
are based are as follows:
1. The number of admissions to sick report as
compared with the number of persons furnishing the
This is accomplished by taking the actual
lumbers in both classes and reducing them to a com-
parable standard in rates per "thousand. The
lumbers furnishing the sick are reduced by those
sick in quarters or hospital; but as a general rule an
equivalent number of men are returned to duty or
1 ulisted to replace the losses through death or
'Usability. In our service statistics are based on
ital strength.
2. The rate of deaths per thousand strength. This
Vol. I. — 38
is obtained by the division of the total number of
CUrring during the year by the mean at Qua]
strength, including the absent as well a rving
with the colors. The figures thus obtained are then
reduced to rates per thousand.
.'). The rate of discharges for disability from dis-
ease, per thousand strength — obtained by dividing
the losses from discharge by the i • ngth and
then reducing to the above standard of comparison.
1. The total ln-rs from disea-e; as determined by
the sum of the rates for mortality and for discharge
for disability from this cause.
5. The rate of constant sickness, or constant ineffi-
ciency. This is given by adding the numbers put
down as remaining under treatment at the end of each
week, or month and dividing by the number of
days, weeks, or months in the period desired, again
reducing to the comparable standard.
6. The number of days of service lost by each
soldier. This is found by adding together the total
number of sick days in a given period and dividing by
the mean strength of the command for that period.
In all computations the figures are reduced to
common terms of one year and one thousand strength.
Comparative Loss in C from Sich d
Wounds. — Since the great military epidemics of antiq-
uity — the destruction of the Assyrians under Sen-
nacherib; the plague described as occurring during
the Peloponnesian war; the pestilences which ravaged
the Roman and Carthaginian armies; the great
losses substained by the army of Severus in the mar-
shes of Caledonia — it has been established as a gen-
eral rule that, in protracted wars, armies suffer much
less from wounds than from disease. The con-
stant advance in sanitation, however, based upon
an accurate knowledge of etiological factors, has
exerted a marked effect in diminishing military mor-
bidity and mortality; and while in the future a com-
paratively high sick and death rate among troops
engaged in war is always to be expected, it is scarcely
possible that such disastrous epidemics as have
prevailed in times gone by could be repeated in
the future. Wars become shorter as they become,
through modern refinements, more expensive; and
troops, particularly in an aggressive and decisive
campaign, are not exposed to unhealthful influences
to as great a degree as was the case when hostilities
were more protracted. With improvement in the
effectiveness of arms, as regards both range and ra-
pidity of action, the proportion of casualty for any
period of action must naturally be increased — and
hence there is a constant tendency toward the
approximation of the rates from wounds and disease.
From the records of the past, however, many valu-
able lessons can still be drawn. In 1809, during the
Walcheren expedition, the mortality in the British
army from disease was 346.9 per thousand effectives,
while only 16.7 per thousand were killed by the enemy.
A few j-ears later the British army in Spain lost three
times as many men by disease as by the result of con-
flict, and the sick rate mounted to such proportions
that more than twice the number of men composing
the army passed through the hospitals during a sin-
gle year. In the Russian campaign against Turkey,
in 1828, it was estimated that SO, 000 men died of
disease and "20,000 in consequence of wounds. During
( teneral Scott's campaign in Mexico the losses from
disease alone exceeded thirty-three per cent, of the
effective strength of the forces under his command,
and in a single regiment of Indiana volunteers
which entered the service 1.000 strong only 400 re-
turned to the State for muster out. Laveran states
that in the Crimean war the allies [osl 52,000 men in
six months, of which number 50,000 men were un-
harmed by the Russians; while during the entire war,
according to Viry, the French lost, in round numbers,
out of a total force of 300,900 men, no less than
95,000, of whom 75,000 died of disease and only
593
Army Medical Statistics
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
20,000 died on the field or succumbed to wounds.
In this campaign nearly one-fourth of the French
medical officers arc said to have succumbed to sickness.
During the war in Italy, in 1859, a period of hostilities
of only short duration, there were from the French
force of 200,000 men. 129,950 admissions to hospital.
In the war carried on by France in Mexico the mor-
tality from gunshot and that from sickness was as
10 to !",).
The mortality among the Fnited States forces in the
Civil war was divided as follows:
Mortality.
White.
Colored.
Total.
42,721
I7.au
157,004
23,347
1,514
1,817
29,212
S37
44 238
19,731
24,184
Total
270,989
33,380
304,369
From the most reliable data available the deaths
in the armies of the Confederate States during this
struggle did not fall short of 200,000, three-fourths of
which number were due to disease and one-fourth
to the casualties of battle.
In 1866, in the war against Austria, out of a total
strength of 437,260, the Prussians lost in an unusually
brief and decisive campaign ii,427 men by sickness
and 4,450 at the hands of the enemy. The Franco-
German war, in 1870-71, furnished the only exception
up to the time of the Russo-Japanese war, to tin'
general rule that more men are killed by disease than
by the weapons of the enemy, since of the German
army 33.7 per thousand strength fell in battle while
only 18.6 per thousand died of disease. This admir-
able result was largely due to the proper observance
of sanitary precautions; assisted, no doubt, by the
brevity of the campaign, the rapidity of the move-
ments, and the fact that active operations were con-
ducted during the most healthful season of the year.
In the Russo-Turkish war of 1878, according to Viry,
the Russians lost 102,799 men, of whom only 10,578
were killed by the enemy. During the Spanish-
American war of 1898, for the five months which in-
cluded the total period of hostilities, of the 274,717
officers and men enrolled in the United States forces
there were only 34.5 men killed by the enemy while
2,565 succumbed to disease. For the whole year of
1S9S the deaths from wounds in our service gave a
rate of 0.G2 per thousand strength, the killed in battle
amounted to 2.79 per thousand strength, while the
deaths from all causes aggregated 30.31 per thousand.
Even in July, the month in which aggressive opera-
tions against Santiago were conducted, the killed in
action amounted to only 1.25 per thousand, while the
deaths from disease were 1.7S per thousand. The
British in the last South African war, had 7411.0
admissions per thousand from disease and but
34.0 per thousand for wounds inflicted by the
enemy; while the deaths from disease were 09.0 per
thousand and deaths of those killed in action or sub-
sequently dying of wounds amounted to but 12.0
per thousand. But the Japanese Army reversed
tliis in the Russo-Japanese war, the best available
statistics giving their killed at 72.0 per thousand
Strength; their wounded at 266.8; and their deaths
from disease at lis per thousand strength.
An interesting side light on the later results of hard
campaigning is given by Rosse, in his statement
thai of the old soldiers carried on the Fnited State.
pension rolls those disabled by disease are more than
four times greater in number than those pensioned
for wounds.
Death Rates in Civil ami Military Life. — The diffi-
594
culties attending an accurate comparison of death
rates for the military service and those of civil 'life
are necessarily very great. Owing to the rejection
of intending recruit- many individuals are at once
returned to private life whose early demise would
otherwise have gone to swell the military death rates
Further, the army is maintained as a s"elect body of
physically sound men, and its weaklings are constantly
undergoing elimination from the service ultimately
to increase the mortality of civil life. Hence
civilian rates are unduly increased, while army statis-
t ics fail to show all the deaths presumably due to mili-
tary service — and it is obvious that the more rigorously
the standard for the soldier is maintained as regard's
physical excellence, the more favorable the showing
apparently made for a military life. Vallin, in France
in L871, placed the probable error due to the above
causes at as much as 9.19 per thousand, thus practi-
cally doubling the figures for the military death ri
of his time. Viry considered this allowance to be too
high, but believed that a rate of 3.60 per thousand, for
such as leave the colors with incurable disease should
be added to the military and subtracted from the
civilian death rates; thus making a difference of 7.20
per thousand. The estimates of Marvaud placed
the probable error at four per thousand. While it is
probably correct for the French service to add 3 60
or even four per thousand to the millitary death rate,
to deduct the same number from the civilian rate
involves the broad assumption that the numbers in
each class exactly correspond. For our own service
the immense disproportion existing between the pres-
ent small army of 75,000 men and the large number
of males of the military age living in the United
States renders the influence of the comparativi ly
small number of soldiers who may be discharged
for incurable disease upon the civilian death rate of so
little importance that it may practically be disre-
garded. The census returns for 1S80 give the an
death rate for disease as 6.97 per thousand for all
males between the ages of twenty and forty-five yi
During the same year the mortality from disease in the
United States army was 5.S8 per thousand — appar-
ently a distinct advantage in favor of the military
service. If, however, Viry 's factor above mentic
be accepted as correct for our service, the true mili-
tary mortality becomes 9.48, or 2.51 per thousand
in excess of the civilian rate for the same period. As
it is probable that since that time the death rate in
the military service has diminished in proportionately
greater degree than has been the case in civil life,
it may be fairly assumed that, under conditions of
peace, the death rate in our army is at present but
slightly in excess of the mortality for the same
in civil life. The results obtained by Farr in his com-
parison of the death rate in the British army with
the corresponding classes of civil life, made a genera-
tion ago, are as follows:
Death rate
Age. per 1,000,
20-25. — Soldiers 17.0
Civilians 8.4
25 30. — Soldiers IS. 3
Civilians . !>.2
30-35.— Soldiers Is. i
Civilians 10.3
35-40. — Soldiers I'LL'
Civilians .11.6
According to Notter and Firth, the present death
rate of the civil male population in England, at the
soldier's age, is as follows:
Morta
Age. per I I
-'11 25 5. I
25-35 7.1
; i 15 i-' 3
Between the ages of twenty and thirty-four the
mortality is in favor of the soldier, but after thirty-
REFERKXCK HAXDBOOK OF THE MEDICAL SCIENCES
Army Medical Statistics
the mortality is reversed and the civil rates are
ower.
[■'or (lie British service I lie death rate for the home
ons was 3.42 per thousand in 1897 and l.iis per
fiousand for the decade IS87-1896. If the civilian
leath rate for all males of the military age be accepted
i- about seven per thousand, the showing made com-
iares favorably with similar figures for the German
in and is superior to the French mortality rates.
I'liis is certainly a great improvement over the con-
ns existing in 1856, when it was shown that the
mortality in the army at large was twice as great as
ong the civilian population, and in the case of the
I luards three limes as great.
gards t he < lerman army, it was recently stated
iv its surgeon-general that during the early part of
century the death rale of the male civil populat-
ion of Prussia, between twenty and thirty years of
. was lower than that of the military death rate,
figures being fourteen per thousand for the army
ind ten per thousand for the civil population. This
lit ion is now reversed, and in 1S93 the death rate
i Prussia for the civil male population from twenty
to thirty years of age was 6.38 per thousand, while at
the same time the mortality for the German army
;.(ili per thousand. While these results are cer-
tainly admirable and are undoubtedly in large part
due to careful observance of sanitary regulations,
u should be remembered that soldiers unable to main-
tain the required physical standard are probably
more thoroughly eliminated in the German army,
and at an earlier period in their military training,
than in other services.
In the French army, on the home stations, the
age annual death rate from 1882 to 1890, inclu-
was 7.88 per thousand strength; while Bertil-
fixed the annual mortality among the civilian
male population, between the ages of twenty and
ity-five at 10.60 per thousand. Marvaud, how-
, believed that the estimate made by Bertillon
was too low, and placed the annual death rate for
civilians of the military age at two per thousand.
nig Marvaud's coefficient of error given above, the
corrected rate for the French military service would
become 11.88, while it would be eight per thousand
for the same class in civil life. Marvaud concludes
"that, in spite of all ameliorations which have been
introduced, chiefly of late years, into the hygienical
Surroundings of the French soldier, his mortality rate
is ^t ill elevated and certainly exceeds that of the
same sex and age in civil life."
Loss of Time from Sickness. — In the United States
service the annual average number of days lo s,-s.
United States
1,043.43
30.74
12.98
3 . 96
16.94
962.05
26 87
1 1 52
.',. 16
111 MS
( lermany . . .
sio, to
24 . 67
13.20
4.11
17.34
907 . 1 1
2 ; 16
12.46
4 . 'J6
16.72
1,033.14
32.81
18.87
4.16
23.03
Scandinavia .
8S6.08
26 - 55
13 3 :
5.17
18.50
Scotland
S52.38
25 64
12.50
1. 17
13.97
Switzerland. .
893.75
27 82
12.31
2 . 90
15.11
Austria
807.1 1
21.63
16.53
2.67
19.20
1 tanmark. . .
s ;r, o:;
26.21
13.33
5 . 55
18.82
t'i
1,049. 13
30.89
in 56
7 04
17.68
Ail others.. . .
821. 12
23 . 90
13.66
3.86
15.70
595
Army Medical Statistics
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
It should be noted, however, that the figures given
fur the countries named in the latter half of the above
table are not to be considered as absolute, since they
are not based upon a sufficiently large number of men
to avoid the possibility of error. These rates are,
however, of particular interest, since, so far as they
go, they tend to bear out the popular belief that the
native-born American possesses a greater proportion
of vital force and greater power of resistance against
death than does the foreigner.
Race proclivity, as regards sickness, is well shown
by the records of the British forces in the West
Indies, in which, for the ten years 1876—1885, the ad-
missions per thousand of strength for the whites were
893.5, colored 1,(174.1; discharges, whites 13.95,
colored 26.79; constantly non-effective, whites 44.68,
colored 58.38; deaths, whites 1.3.42, colored 15.38.
In the United States service, for the decade 1877-80,
the death rate among the whites per thousand was
9.97 and for the colored 12.91. There has been,
however, a constant tendency for the past twenty
years toward the approximation of the rates for the
whites and blacks in our service; and therelative
rates per thousand for the white troops of all nation-
alities as compared with those for the colored troops,
during the year 1S97, were as follows:
Admis-
sions to
hospital.
Constantly
non-
effective.
Discharges
for
disability.
Deaths
Total
losses.
35.72
37.24
11.04
10. S9
9.62
9.51
5.05
5.89
14.67
15.40
But since the Spanish war, new factors of climate,
environment, and race have entered. For the year
1910, some rates per thousand were as follows:
Whites, in United
States
Colored, in United
States
Whites, in Philippines
Filipino native scouts.
Admis-
Con-
sions to
stantly
,n
hospital.
non-
c3
effective
Q
1 lis-
charges.
903.31
827.53
1,242.65
S76.10
34.25
4.25
2.S . 72
7.37
45. 15
5.19
26.01
4.31
15.45
12.39
10.14
6.79
Total
losses.
19.70
19.76
1 J . 23
11.13
The lower rate for losses in the Philippines is ex-
plained by the practice of sending home to the United
States many serious cases for treatment or discharge
for disability.
In the distribution of diseases according to nativity,
typhoid fever and rheumatic fever had their greatest
prevalence in our service, for the years 1890-1S96,
among the Canadians and Scandinavians. The high-
<■ l admission rates for consumption were 5.70 among
the French and 4.76 among the Scotch; the lowest
rates were 1.42 among the English and 1.49 among
the Germans, the rate among the nativesof the United
States being 3.33. Pneumonia was more frequent
among Canadians, 5. IS, and Scotch, 4.76, than in
men of other nativities. The rate for this disease
for the natives of the United States was 3.90.
Venereal disease prevailed more among men born
in the United Stales and Canada than among the
others, the admission rates for these two classes
being 93.98 and 91.92 respectively; the Irish and
Swiss had the lowest rates, 47.00 and 50.90.
The Irish, however, had by far the largest relative
number of cases of alcoholism, 90.96. The smallesl
rales for this cause were given by the Danes, 12.59,
and Austrians, 19.00; the admission rate for the
native-born American soldier having been 28.51 for
this cause.
Sickness and Death Rates as Affected by Season.
.Military morbidity and mortality are to a certain
extent influenced by seasonal changes; varying accord-
ing to the climatic conditions prevailing in each
country or locality, by which the propagation of
certain affections is either favored or retarded. In
the French army the admissions to hospital for disease
in time of peace, reach the maximum of fifty-seven or
fifty-eight in January and fall to the minimum of
about thirty-eight per thousand in September. In
the Italian army, for the period 1872-1S92, the great-
est amount of sickness occurred in March and the least
in November. In the United States service the
midsummer period is the most unhealthful, while the
late fall and early winter gives the least sickness.
The monthly prevalence of disease in our army, in
time of peace, as given in the figures for the year i vi_>,
is shown in the following table:
Total admissions to
hospital, per thou-
sand of mean
strength, for dis-
ease and injury.
Constantly non-ef-
fective, per thou-
sand of in . : .
strength, from dis-
ease and injury.
January. . .
February. .
March
April
May
June
July
August. . . .
September
October. . .
November.
December.
148.65
107. S7
108.03
92 . 53
9S.66
101.94
108.26
108.37
108.57
97.48
91.97
9S.34
49.54
41.69
39.27
37.34
37.67
:;s.3i
37 . 46
36. S6
38. 12
38.79
39.38
111.44
For the year 1898, when the army, if not entirely
engaged in active military operations, was, after the
month of March, still in the field and on a war footing,
the monthly rates per thousand strength were as
follows:
January. . .
February. .
March
April
May
June
July
August. . . .
September
October. . .
\i -\ . ■ T r l I XT,
December.
Admissions
from
disease.
Discharges
from
t year and under. . .
Second year
Third year
Fourth year
Fifth year
Six1 h year
N '. i nth year
Eighth year
Ninth year.
Tenth year
Twelfth year
Fifteenth year and over
,205
,632
,645
,2 I'J
,053
,148
897
629
738
921
,351
,587
2,254
l.t «1
98 1
967
1,064
901
97IJ
1,057
927
991
1,007
823
For the same year the discharges for disability,
divided according to length of service, were as follows:
Discharges for
Service. disability, per
1,000 strength.
Under 1 year 64.9
1 year ... .41.5
2 years .
3 years .
4 years .
5 years
6 years .
7 years .
8 years .
9 years .
10 years .
12 years
13.3
19. 6
2.3.1
15 years and over 22 . 1
For the same year the death rate per thousand
strength, according to length of service, was deter-
mined to be:
Less than one year of service 10.90
One year of service 4. SO
First five years of service 4.54
Second five years of ser\ice 5 . 22
While the absolute number of men in the army of
the United States during the year 1SS5 can scarcely
be considered as sufficiently large to warrant any
exact deductions, it is certainly safe to assume that
the processes of elimination in our army are most
active by far during the first twelve months of service;
after which the total losses fall below the general rate
for the whole army, not to rise again until the more
mature men of ten years' or longer service succumb
to infirmity.
Viry states that in the French service the annual
losses by death and discharge for disability amount
approximately to forty per thousand during the first
year of service, thirty per thousand during the second
year with the colors, and twenty during each of the
subsequent years. According to Ordronaux, sta-
tistics for the French army some years ago showed
the following to be the average annual mortality:
Service.
1 year
2 years
ears
4 years 4.3
5 years 3.0
6 years 2.0
7 years 2.0
In comparing the amount of sickness among French
soldiers of one year of service with those of two or
three, Viry found that in 1888 there were, per thou-
and of each class, 866 admissions among the former
and 132 among the hitter: in 1889 the numbers were
859 and is:;, and in 1890 they were 826 and 5.59
respect ively.
The proportionate mortality in the German army
for the year 1889-90, out of each 1,000 deaths, was as
follows:
Loss per 1 .111)0.
7.5
6.5
5.2
Less than 1 year of service. .
From 1 to 2 years' service. . .
From 2 to 3 years' service. . .
From 3 to 4 years' service. . .
4 years' service and upward,
432.0
248.0
143.8
29.5
146.7
Total 1,000.0
In the discharges for disability in the German army
for the same year, out of 8,740 men so discha
78.3 per cent, owed their incapacity for service to
causes existing prior to enlistment. Hence it is not
surprising that the majority of men so discharged
should have been less than one year with the colors.
The percentage of discharges according to length of
service was as follows:
First year SI. 4
Second ye:tr 8.6
Third year 5.0
Fourth year 2.0
Under conditions of tropical service the raw and
unseasoned recruits are proportionately even more
prone to disease than is the case in temperate cli-
mates, as is well shown in the following rates for the
British troops in India during the year 1897.
bV ■
a
o
GO
'a
CJ
c
—
>
Ratios per 1,000
streng h
Length of service
in India
Admis-
sions.
Deaths.
1 e i
5 to 10 years
10 years and up-
1 1 6 10
11,580
11,368
8.013
8,874
1,806
1.111
21,700
18,795
17,929
14,866
10,548
11,728
1 222
36
311
217
20S
124
131
151
31
8
302
123
477.
446
265
288
59
1857.9 29. 15 25 86
1G23. 1 is. 7 . 16.53
1 77.1 1 ;.30 11.78
1472.0 12. 2S 14.16
1316. 1 16 :;
1321 .6 17.02 32. IS
G76.fi 17. 17
Not stated
32 1 7.20
Total
61,531
96,824
1,214
2.25S
1500.4 IS. SI 31.99
1
Age as Influencing Sickness and Mortality. — In the
United States service, for the seven year* 189(1 IXOfi
inclusive, the relation between disease and age among
the enlisted strength existed as follows:
3 e u4
© © ■£
S S J3
p , ■s
-
« o o u
.£ § H
o>n
7 ' »
c £ a a
■a — a c
u a c
Age.
■ - — - t-
tf
» - *4 £
la -a g-S
i.{ '■*> S z.
ba *i to *J
w a i.
_ i a
— - *-
-.2 3
Admi
hospi
dise
1,000
z
z
-
non-
from
1,000
.£ ' - '- —
- °o
7 S 7S g
Q^q
19 years and less.
2,244.79
69.73
■ 61
5 3 '
20 to 24 years
I. 159 6 :
39 52
11. 12
2 ' :
25 i" 29 years. . . .
S96.6.5
20.06
11.96
: 1 ;
3 i ( " -1 years, . . .
755.64
21 53
l:i 69
:: 7 ;
35 to 39 years. . . .
718.43
21.32
L0.32
4 . 32
40 to 4 1 years. . . .
798.09
24.87
L6 65
7.46
24.11
755.01
21.16
1 5 . 26
10.97
50 to 54 years. . . .
843. is
28 96
31.11
13.18
1
55 i o 59 years. , , .
875.22
34.93
1 5
60 years and over.
1.265.31
72.91
1-'2.01
66.04
188.68
The younger men, both officers and soldiers, appear
particularly susceptible to disease as well as prone to
injury. For the period noted above typhoid ft
v as observed to be much more prevalent among 1 1
under thirty years of age. The rate for this dist B
in men from twenty to twenty-four years of age WM
10.31; from twenty-five to twenty-nine years, .".71;
from thirty to thirty-four years, 2.58. Enlisted men
under twenty-five years of age suffered more from
malarial fevers than did officers of the same age;
but with the advance of years the rates of the
came to differ but little from those of their superiors.
598
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Army Medical Statistics
|,e higher rates for venereal disease were given bj
nder thirty and particularly by those under
i-enty-five years of as;' 1 ; but, on the other hand, the
r alcoholism increased with age. Tuberculo-
: appeared to be equally distributed among men
the ages of twenty and fifty years, hut the
[iarrheal troubles was confined to soldiers
twenty-five years. Rheumatic fever was , H ,t
lly prevalent among young men, susceptibility
eing increased after the age of forty or fifty years.
or pneumonia were considerably larger
five years of age — as were also tho
idney disease.
In the French army, for the decade 1875-1884, pei
trength, the average annual death rate for all
given by Marvaud, was:
Under 20 years <>f age 6.72
oi age 10.92
irs of age 9.38
o 26 years of age 8.59
o 30 years of age 7.14
Fta ■ ears of age 8.51
'he cla.ss less than twenty years old is not only a
iv small one, amounting, according to Bertillon,
• only about three per cent, of the whole, but the
oung men composing it are all volunteers and before
ut are subjected to an exceptionally severe
il examination, so that only the best ii\< - are
ccepted. Hence for the French army at large the
ar of service may be considered to begin at the
iventy to twenty-two years. In commenting
ii the excessive mortality of the younger soldiers,
larvaud says: "It is during the first year of service
mber of deaths attains its maximum, a
act which proves the dangers provoked by acclima-
ion to a military life." The influence of age upon
ickness, in time of war, is even more marked than
luring peace. According to Gayet,. in the cam-
laign of Benin the total losses by deaths and disease
repatriation were as follow-:
Per cent.
Foreign legion 9.7
Artillery of the marine 23.3
21.2
Infantry of the marine 39.0
African battalion 47.9
in the lasl two classes the men were young and
v developed, ranging from nineteen to twenty-two
rears of age; in the foreign legion the men were older,
>eing between the ages of twenty-five and thirty-five
of Military Rank as Affecting Health. —
The report of the surgeon-general for 1897 gives
statistics for our army to include the seven years
1S90-1S96, this being equivalent to a total strength
'or one year of 14,859 officers and 17 1,'Jss enlisted
men. These figures show a sick rate of 76.5.69 per
ad for the officers and 1.25S.90 for the men;
nut the inefficiency rate of the former class was much
than that of the latter, being 44.27 per
nd as compared with 37.63 per thousand in the
t In 1 enlisted force. The average death rate for
was 9.56 per thousand, while among the en-
listed men the annual mortality was only 6.52 per
'»1. Such an unfavorable showing made by
the officers as regards the rates for death and ineffi-
i iency is largely to be explained by the fact that the
military life of the enlisted soldier practically ceases
at the age of forty-four years, only 6.50 per cent, of
this class remaining in service after that ace; while
ii the officers included in the tabulation referred to,
37.25 per cent, were over forty-four years of age.
liter class, then, while sharing largely with the
1 men in the hygienic disadvantages of im-
maturity, had, in addition, the diseases of beginning
'ml age and the results of long years of hard service
tn increase its death rate. It 'is to be noted that
during this same period young officers under twenty-
five years had only 784.20 admissions per thousand
for disease, w here thi id an
admission rate <>f 1,359.63; while the nor
taie oi t he former was 29.61, a- compared with t he rate
of 39.52 for the hitter. This would indicate thai if
the same attention "as given to sanitary details by
the young soldier as by the young officer, hi- rate of
constant -ickness would be corn pondingly reduced.
The influence of petty rank ami length of service
on sickness in the French tinny is shown in the -lib-
joined table, constructei 1 hum data given by Marvaud
covering the year 1S88:
per 1 ,000
i
in
260
567
Men having more than one year of service
Men h:iviiij_' [i 1 yeai of service..
172
2S9
The proportionately large number of non-conn
sioned officers treated in hospital is explained by
Marvaud as being due to lack of suitable accommoda-
tions in the detention rooms for this class.
Health of Troops in Peace. — The individual signifi-
cance of the several factors which, taken together,
determine the sanitary condition of our army in time
of peace will be readily appreciated by reference to the
subjoined table. Venereal affections have the high-
.-t admission rate for sickness, but the mortality from
this cause is not great. Malarial diseases rank second
in frequency, but. as shown by statistics, they tire not
of severe type and are readily amenable to treatment.
Pneumonia occupies third place in importance as re-
gards admissions. Rheumatism and myalgia together
furnish a large proportion of admission- and dis-
charges, as does also bronchitis. The admissions for
alcoholism are slightly above the general mean, but
the rates for death and non-efficiency from this cause
are small. All the rates for typhoid fever are low.
As to injuries, the several figures for contusions and
sprains are all large — those for wounds, excluding
gunshot injuries, being considerably lower than'those
for contusions, but still somewhat in excess of the
general average. But since our Colonial expansion,
our troops have become exposed to many morbid
influences, practically or entirely absent from this
country. The effect of these diseases in altering siek
rates is shown in the following table for the year 1909.
With regard to sickness, deaths, and non-efficiency
in the British service for the home stations, the fact
which at once attracts attention is the high ratio
given by venereal affections; the admissions from this
<• being more than half again as high as from any
other affection or group of diseases. For gonorrhea,
primary and tertiary syphilis, the individual rates for
non-efficiency are much higher than for such disi
as are summarized as affections of the respiratory and
tive systems. The rates for rheumatism and
influenza are high, while diseases of the -kin and of the
connective tissue are common. Alcoholism is a mi-
nor factor in increasing the- rates for sickness, deaths,
and non-efficiency.
Decreast in Rates under Conditions of Peace. — That
improvement in the sanitary administration and state
of armies is constantly being made will be unhesitat-
ingly admitted, but few are aware of the stupendous
progress in this respect which, particularly during the
pasl generation, lias been accomplished by military
hygiene. Not only is this the case in our own service,
but in foreign armies also, and, on reviewing the
sanitary conditions which for their time were consid-
ered to be excellent, it is apparent that -till further
decrease in the several rates may justly be anticipated
for the future.
599
Army Medical Statistics
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Table of Admission's to Sick Report. Discharges. Deaths, and Nov- effectiveness, with Ratio? per 1.000 of Mean-
•Strength, fob the Abut — Officers axd Total Enlisted — For the Year 1909.
Officers U. S. Army.
American troops, army.
Mean strength.
522— A. G.
• >., 74.319— A. G. O.. 75,399.
Causes of admission
to sick report.
Retirement
Admissions, for disa-
bility.
Deaths. Xon-effective. Admissions. Discharges. Deaths.
*" m - Ratio. N ; um - lurio N ; um - Ratio
b3T. ber. *"***" ber.
T" m - Ratio. N ^ m - Batio.
ber. ber.
*" m - Ratio "?° m - Ratio
ber. ber.
Xon-effe<-ive.
Num-
ber.
Ratio.
Typhoid fever, in-
cluding P
phoid fever
Fevers, undetermined
Malarial fevers
Intermittent
Estivo-autumnal
Malarial cachexia,
and undeter-
mined infection.
Smallpox. ...
Measles
Scarlet fever
Diphtheria
Influenza
Cholera nostras
Dysentery
Amebic
Bacillary. .
Mixed infections
and other dys-
enteries
Leprosy
Beriberi.. . .
Erysipelas.. .
Dengue
Mumps
Cerebrospinal men-
ingitis, epidemic
*.
. .
Purulent infection
and septicemia. .
Trichino-i-
Tuberculosis
Tuberculosis, pul-
monary . . . .
Tuberculo-i -
othei
Venereal disei
.Syphilis and its
resu!-.
Chancroid and its
resul'-
Gonorrhea a
r and other
malignant
growths. .
Rheumatism, artic-
ular
Rheumatic fever. .
Rheumatism, sub-
acute and
chronic, artic-
ular. . .
Alcoholism and its
I
Epilepsy
Trachor:.::
earl
Filari.'i-
Chyluria.
11 _
12 3.14 .
102 26.69 .
63 1
S.63 .
6 1.57 .
1
1
-
195 51.02 . . .
18
12
2
4.71
3.14
4 1.05
3 .73
93 24.33 .
7 1.S3 .
12
11
1
3!
18
10
23
2
1
1
11
1
1
3.14 3
2
-
-
-
1.05 .
6.02 .
4.71 ....
2 . r,2
2.09
6.02
-
.26
.26
0.23
.47
:
. 17
2 .47
1 .23
2.53
3.02
1.16
1.43
0.67 267
470
2,855
2,096
560
99
.04
.19
.01
.05
3.61
"
2.65 .69
2.21
.24 .06
580
2
35
2.00S
_
675
319
155
.21
.07
: 88
.29
.02
.49
.08
.01
.24
.001
.07
11.39 2.98
10.96 . 57
.43 .11
3.12 0.82
201
3
31
1,695
72
14
11
1
3."*
:
.40
-
.S9
1. 17
.42
.62
.54
.01
2.44
.50
.02
.23
.10 _ •:
: 'i.090
.2:;
.11
10
.2S
413
.16
1 77"
.14
.
.001
.07
_
.61
^7
.13
9
.004
2
'
3.59
6.32
■ -
29.55
1.33
.03
1
.01
19
2
0.25
.03
.03
.31
.47
27 .
.o:;
-
i
3
1
.11
.01
.04
.01
9. OS
4.20
2.09
:
-
6
5
1
.19
.04
.OS
.07
.01
.01
.04
-
.03
-
1
.01
2
1
.03
.01
9.69
.19
.01
15.20
.15
.01
-
1
.03
.01
S
5
.11
.07
- "
4.00
.71
196.99
30.45
77
n
171
160
1,
206
122
-
-
2.12
- "
1.11
43
35
S
.57
.46
.11
.13
13.1''
.05
.34
.03
5.56
I
1.61
1.74
.43
2.52
.12
.03
.01
24 .32
22 .29
109 1.43
4 .05
.01
.01
69
6
.91
.OS
26
3
.09
.01
.34
.04
47.71 0.64
22 .10
62. 3S .84
42.90 .58
15.00 .20
1.4S
-
36.19
1.90
1.90
31.97
-
57.16
35.05
12.05
10.06
2.13
.50
1.64
30.32
1.57
.42
17.20
1.05
201.93
.06
.003
.49
.03
.03
.43
.0003
"-
1
.16
.14
.03
.01
.02
.40
.41
.02
.01
.01
.004
-
191.0. 2 "
10.91
- -
.. •
134.67
610.75
.15
13.07
3.04
.02
.91
34.46 .46
33.63 .45
21.07
10.46
3.69
24.16
.31
.28
.14
.05
.003
GOO
REFERENCE HANDBOOK "I" THE MEDICAL SCIENi
Army Medical MatlMi«.»
Table or A Repokt, Discharges, Deaths, and X
StBE.VOTH, POB THE ARMY — OpFICERS i
Officers V. S. Army.
Mean strength
. 74.319
Admi -
for disa-
bility.
Deaths. Non-effective Admiasi - I 1 schargi I ■• Non-effe
Causes of admission
port.
Num-
ber.
Ratio. N " um " Ratio N " um ' Ratio N *™-
ber. ber. ber.
S »"'- Ratio. N ; un '- Ratio *"■"
ber. ber.
Num-
ber.
Ratio.
Ly m phalli
eKpli
(ever
Other filai
of the heart . .
Bronchitis. acute
and chronic
Bronchopneumonia
Pneumonia I pneu-
•iic fever...
Diarrhea and en-
teriti-
Tenia
Tenia sohum
Hymenal
nan l
Bothn<>cephalus
latus
ris Jumbri-
. ■
.ris vermic-
ularis
mum
duodenal--
Necaior Aineri-
canus
Other intestinal
parasite-
Inguinal and other
hernia?
Hepatic abscess
Appen-li' -
Climatic bub
Tropical ulcer
\ pene-
-
Pemphigus con-
tagi»- 1~
Dhobie itch
Tenia imbric;
Prickly heat
■ ■-.'■- is
Chronic nephritic. . .
Malingering
External causes,
special.
Fractures, exclusive
of gunshot
Dislf>ca*i ins
Sprains and muscular
strains
Wounds, gui
Wounds, other than
gunhsot
■ ke
Frostbite and general
freezing
Drowning. .
ing, acute
►us bites, etc
- bite
Other venomous
bites, etc
.78
155 40.55
3 .78
1.05
23 1
7 1 .45
1
.26
1
.26
12
3.14
.52
31
S.ll
120 31.40
5 1.31
42 10.99
1 .26
12 3.14
S 2.09
S 2.09
! 1
21 5.49 I
34 8.90
12 3.14
-
.70
.004
.1"
62
.06
.10
1
2.521
21
1.34
.01
.01
2.71
. 55
1.97
. 06
.001
.001
.71
.14
1.30
.07
.64
4.13 1.08
.99 .26
4.1.5 1.09
1.05
.03
.41
.01
.001
4
19
136
127
1
22
■
7
23
10
49
212
10
20
15
70
S04
21d
215
-
7
85
.19
.09
.05
.02
.09 .02
315
86
84
.HI
.28
. i
.54
2.-507
.01
5.21
.002
65
1
31
.12
.03
.05
-.26
.03
1.83
1.71
.01
3.61
.30
!
.09
.31
.13
_
.61
.94
10.82
2.95
56.92
-
43.30
.09
1.14
1.16
.03
1.13
32
1
18
01
.13
24
.21
01
51
7
.32
.09
04
28
11
.1.5
11.79
1 08
. i;
.12
.03
.01
29.13
■
33.58
0004
.16
12.16 .16
52
.10
.01
.01
.002
.0004
.01
.0003
.03
.03
.0001
.40
.06
.4.5
.01
1.11
.02
.21
.003
1 . 55
.02
4.63
.06
. 15
.002
.005
3.6.5
.0.5
7 5
.10
.03
99.33
1.34
10.16
.14
1.20
24.63
.33
79.01
1.06
.36
.004
2.10
.03
.hi
1.50
.02
.09
.001
601
Army Medical Statistics
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Tabls of Admissions to Sick Report, Discharges, Deaths, axd Non-effectiveness, with Ratios per 1,000 of Mean
riTREXGTH, FOR THE AflMY OFFICERS AND TOTAL ENLISTED FuR THE YEAR 1900. Continued.
Officers U
S. Army.
American troops, army.
S. G. 0.,
1,822
-A. G. O., 4.2S3.
S. G
ii.. 74,316-
-A. G.
' ' , 75.399.
Causes of admission
Admissions.
Retirement
for disa-
bility.
Deaths.
Non-effective.
Admissions.
Discharges.
I It'aths.
Non-effective.
to sick report.
Num-
ber.
Ratio.
Num-
ber.
Ratio
N u um " Ratio
ber.
Num-
ber.
Ratio
Num-
ber.
Ratio.
Num-
ber.
Ratio
Num-
ber.
Ratio
Num-
ber.
Ratio.
Diseases find '"-
juries grouped.
Infectious diseases
Other general
Diseases of the nerv-
ous
organs of special
544
439
105
188
102
60
20
59
314
601
52
120
99
142 33
114. S6
27. 17
19.19
26.69
17.27
5.23
15.44
82.16
157.25
13.61
31 . m
25 . 90
S
3
5
15
13
2
13
1.87
71)
1.17
3
3.04
.47
: 04
4
1
::
2
2
.93
.23
.70
. 17
. 17
34 . 03
14.35
19.68
17. I-",
12.70
2.77
1 92
5.11
7.33
19.13
4 . 53
5.89
4.08
8 90
3.75
5.15
4.57
3.34
.72
.50
1.34
1 .92
5.00
1.18
1 . 5 1
1 .07
28,396
10.3S7
IS, 009
2,955
1.253
1,121
5S1
1,681
5,209
14,812
1,050
6,512
2,308
130
1
1,300
382.08
139.76
242.32
39.76
16.86
IS. OS
7.S2
22.62
70.09
199.30
14.13
S7.62
31.06
1 . 75
.01
17.49
476
11
465
2S0
220
32
28
112
33
72
51
9
41
71
6.31
.15
6.17
3.71
2.92
. 12
.37
1.49
. 11
.95
.68
.12
.5 1
-.94
121
60
01
10
10
1.60
.SO
.81
.13
.13
1,612.09
■ . ■ .
1,284. 12
1 5:; . :i i
si. id
39.96
r>g 22
in ;. ill
115.44
317.80
49.63
170.09
80.42
12.84
.02
21.69
4.41
17.28
2.06
Of the nervous
1.13
Of the eye and its
.54
Of the ear and its
.39
Diseases of th
latory system. .
Diseases ol iherespir-
3 .70
33
29
22
12
.44
.38
.29
.16
1.39
1.55
Diseases of the diges-
tive system
Diseases of thegeni t o-
urinary system
Diseases of the skin
and cellular tis-
1
2
2
1
. 17
.17
.23
3
3
.70
.70
4.28
.67
2.29
1 lisea ses of the or-
gans of loco-
1.08
.17
1 suits of
1
.0002
35
9 16
.9.5
.25
1
.01
1
.01
.11
Total f'»r diseases.
2,012
392
526. 13
102.56
46
5
10.74
1.17
15
3
50
.70
98.50 25 77
17.20 4.50
04,354
14,646
S65.92
197.07
1.110
121
15.20
1.61
228
142
3.02
1 . 88
2,647. 19
135.61
35.62
5.86
Total for diseases
and external
2. mi
628.99
51
11.91
18
t.20
115.70 30.27
79,000
1.062.99
1.270
16.84
370
1.91
3,083.10
41. 4S
For the U. S. army the accompanying charts (see
pp. 505 and 506) so well illustrate the remarkable
decrease in sickness and death which has occurred
during the past three-score years that any extended
discussion of the matter would seem to be super-
fluous. Suffice it to say that the death rate for the
five years preceding the Spanish-American war was
about three and one-half times less than that for the
five years preceding the war with Mexico, while the
rate for sickness underwent a diminution of about two
and one-third times during the period included by
these dates. Since 1S72 the death rate from ail
causes has dwindled to about forty per cent, of what
it was at I hat time, while the death rate from sickness
alone has fallen almost as much; and during the same
period tin- rate for admissions to sick report has
diminished more than one-half.
In the German army, according to official figures
recently submitted to the Reichstag, the number of
602
admissions to hospital from disease, per thousand
strength, underwent a decrease from 1,496 in the
year 1868 to 867 in 1894. In 1S6S the annual death
rate per thousand was 6.9, 1.82 in 1S79, 3.24 in 1888,
and only 2.60 in 1896 — a magnificent result, in the
attainment of which the due observance of sanitary
detail, and especially the careful selection of recruits,
were main factors. .Military epidemics, in thia
showing of the German army, have above all lost
ground. Smallpox is rare, and caused only two
deaths during the twenty year.-. 1S73-1S93. Dysen-
tery was reduced from 6.S per thousand strength in
1S74 to 0.39 in 1894. Typhoid fever gave a rate of
sickness of 33.8 per thousand strength in 1868 and 2.4
per thousand in 1894. The typhoid death tale was
2.2 per thousand in 186S and' 0.S1 per thousand in
is'U. Malaria showed a rate of sickness of 27.fi
in 1868and o.sl per thousand in 189 1 : while contagious
eye inflammations fell from 7.0 to 1.5 per thousand.
REFERENCE HANDBOOK OF THE MF.DK'AL SCIENCES
Army Medical statistics
5 10 15 20 25 30 35 40
45 50 55 60 65 70 75 80
1 .1 8 8 11 13 16 18 21 23 26 28 31 33 36 38
1 A 1 ffl 48 i ' B 1 OS ■ n SB 71 7S 76 78
2 4 7 12 14 17 19 22 24 27 20 32 34 37 39
42 44 47 40 B2 -.4 '.7 _fl 62 64 67 E'. 72 74 77 79
1840
1840
1841
1842
1843
1844
1845 r L -LL^
1845
1846
1846
_*7! |WAR W TH MEXICO-
YEAR OF CHOLERA EPIDEMIC
1850
1851
1856 - --■__-
1857 r -■
1858 ----- ,-
186 c, \. c V,L WAR
loee AN ^PIDEvl'lC OFr SMALL-POX DURING THIS
(■EAR FuWhsWeC 877 DEAT HS'. iQfifi
iofi7 A^l :p PEVllC OF ]ch6_.Er|a [FURNISHED hlsiC
' deAths. 1 | — -tTT 1867
iqco lEPICEMIG OF CHOLERa]anD YELLOW _EEY-Ef
-FURNISHED 6G1 DEATHS oc _
1871 — L- I __ — _L 1
1070 _u __L _i__ _' _J _ !
1ft7 o !___/ \__ I 1
18/(3 / ^<
1074 _L J_ ' ^£L _ _ -_-
18/4
I875 ---I L^_L_'
io^ Y£ AR ^FvcJsTER^m'a^SACRE WHEN 2^7 Mb
WE1E KILLED 1876
1879
- -- 1881
1886 ^ \ _____________
1887 ---{
1888 )r- ■ - -- -- -----
1889 -{-£ --
1895 {--- -- -- -- --
1896 j-J.____.--__ - - - __ -.
1897 L-L - _
War with spain
1898
603
Army Medical Statistics
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
^
CM
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1
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to
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it :
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o .
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.... . . ^_ : _. . . ^ ^
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ID » ID » N
t -* tf tf -
ISC'- "J *o -t
- - ,- i.o in in
» S » B K B *
ifi b n a oi o •■
is ji ifi in K THK MKDICAL SCIENCES
\r m\ Medical Statistics
A. — Ratios of Admission to Sick Report, Discharge;, Death, and Constantly Non-Effective of the
United States Army for the Decade L886
'..r the I
I88fi
Whii
Colored.
Indian.
eta strength.. A. G ,24,301 S. G., 22.071 A G ,2,379 S. G.. 2,188 A G , 227. S. G.. 213
J 1,172
of admis-
.. k report
.
Lnia
...id fever.
M :il:uial infect ions
Tuberculosis of
the lui
' - -
irrhea
\ll venerea) dis-
housm and
direct results.
Jgia
Hitis
Colic and consti-
pation
Diarrheal dis-
eases
Diseases of the
heart
-■: ......
lir tnchitis
Pneumonia
ases of the
kidneys. . .
Rheuniaiism and
myalgia
Boils and ab-
Conjunctivitis
AH diseases of the
All diseases of the
ear
Contusions and
sprains
Dislocations
Fractures. not
gunshot
Wounds, not gun-
shot
Wounds, gunshot.
Grouped.
Infectious dis-
general
cal
nutri-
tion, general. .
Di -eases of the
nervous
I 'i lases of the
digestive sys-
if the
circula! ory
:i .
if the
respirat ory
- .
Diseases of the
-urinary
m
if the
lymphatic sys-
tem and
ductless glands.
33.76
0.004
5.94
.01
96 _' i
.09
5.11
.07
1 52
17. IS
1.98
. 26
2.30
42.37
.07
24 69
.16
41.37)
.001
32.10
.02
0.61
.1 I
.02
1.06
.91
.59
; =
& 1
.44 .70
.01' 1.6S
-
.02 5.26
.47
.62
26 .21
2.10 0.50
64.50 0.04 .38
5.76 .04
3.93 1.85 .84
.in
:>2.ll .ii!
7s. is 3.40 .04 5.21
II
76
1
71
"7
7
02
115. 6S
5 . 79
; 56
67 . 9 1
1.72
7 ; 28
43 7 1
11.86
17.95
7.67
130.04
2 . 7.7
50.21
3.30
. 22
1.36
.01
.13
.42
.23
.06
.20
1.59
.02
.06
.9S
.54
.02
.66
.23
.02
.004
.29
1.34
.53
.29
1 37
.41
.21
3.65
99
.32
.78
.34
4. Ml
49.18
99.75
4.94
41.36
69.26
6.90
2 - .
116.33 2
26.51
14.49
26.71 1
3 . 70
.01
.04
.17 .13
18 25
.17
.os 1.7,1
29 .34
02 ...
.04
.21
.23
.11
.01
.004
3.33
.20
.52
.10
1.20
.2'!
.64
.05
.96
1 1-
.57
145.86
1.S7
6S.07
: :
302.66 4.15
2.55 .59
96.67 3.12
278 10
. . •
1.73
.09
.7 '
13.18 276.73
2.10
2. 12
7.14 1.71
.05 4.40
.51 .69
77.07
300.59
.34
ill
.OS
.08
Ml I. (ill
. II
1.14
.30
.30
1.20
.60
.22
4.56
.67
. 15
1.04
.16
3.36
.11
1.99
.•17
5.76
2.14
.04
. 16
.IS
5.30 ! 1.26 .50
.47
2 ■
4 . 2:;
-
1 5 . 5 1 2
98 26 2
4 . 70
15.05
31 .50
45.01
2 . 35
12.09
in 34
5il 7s 1
42.:>l
44.67
62.06
S.46
128 82
6.11
1 1 . 75
91.20
7.05
II 7
64
64
:;j
SS 4
in
9
BE
d
>-
a
1 lischa
a
a
-
~. -
3i
4.14
.iij
.47
.58
3.55
I .76
:;.17
r. . 77
,ii7
.17
.41
.34
.16
.11
.82
.711
0.004 1.06
84
.16 2.40
5.16 .117 .02 58
3.21 1.63
17 75 2.11
!8.6 J I
76 12 2.40
1.54
1.21
1.21
25.70
42. 12
33.62
113.65
5.69
34.08
67.97
4.20
1.S0
76.94
.07
.11
.004
.02
.21
1.34
.54 .75
.02 1.71
J J I
. 1 12 5 . 26
.20
.01
.22
.06
.20
1.63
.16
3.02
.52
42.18
12 -
19.13
7.32
.02
.07
.99
.50
.13
.41
.112
.74
.24
.02
.004
re i . 52
2.10
1.05
84
131.46
.23
.01
2.54
.11
.004
6.S6
.50
.11
52.16
.20
.05
3.69
.66
1.05
.43
.62
.66
.30
1.32
.51
.29
1.35
.43
.21
3.71
.97
.34
.82
.33
3.33
.20
1.7:!
.61
2.40 11.55 350.26 15.41 7.04 17.45 300.76 4.39 1.84 13.09
1.41
1 57 41. 3S
7 IS 4. us 180.54
2.35
1.32 .Ii .us
2 . 57
.lii
--
. !■
2.7.0
.56
94 . 4 1
3.02
.7",
113.1 ! .58 .78 2.49 130.55 .341.81 2.7.7 92.15 1.32 .8S 2.46
11.33 .SI .24 .85 14.49 .97 .31 .93 7. 99 .11 . .21
5.35 .07
.004 .44
6.95
11.28
.'i :
.09 .22
.76 2.24
.62 4.35
6.93 1.66 .51 .66
111.;' .7,1'. .s7 2.50
11.58 .82 .25 .S5
5.54 .06 .004 .45
(a) For 1SS7-95 — nine years of decade; (fe) for 1891-95 — four years of decade.
605
Army Medical Statistics
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
-Ratios of Admission to Sick Report, Discharge, Death, and Constantly Non-Effective of the
■ United States Army for the Decade 1SS6-95. — Continued.
For the Decade
1886-95.
Menu strength.
1 Luses of admis-
sion to sick report.
White.
i 'oli.n.-il.
Indian.
A. G., 24,301. S. G., 22,071 A. G., 2,370. S. G , 2,188
? 8
^
IB
a
oj
>> >
'tn
cc
1
B 1
DQ
8
T3
>.£
Total.
A. G., 26,907. S. G., 24,472
I
B
Is
8!
Diseases of the
muscles, bones,
and joints
Diseases of the
integument
and subcu-
taneous con-
nective tissue. .
Diseases of the
organs of spe-
cial sense
Unclassified
I leneral injuries. .
Injuries to special
parts
Total for dis-
eases
Total for in-
juries
Total for all
causes
79.16
;.07
.01
79.47 .23
27 . 53
2.79
3. 25
245.13
1.65
!o2
.01
.004
1.02
1,005.77
24S . 38
1,254.15
3 . 36 1 . 26
16.34
3.39
1.S4
2.2S
19.72 7.12
3.74
1.27
.07
.08
8. 17
121.-11
31.45
5.21
1.87
2S9.26
3.24
1.39
.111
3. 15
.01
.42
1.08
:i so
8 . 5 1
40.31
1,022.31
291.13
1,313.43
16. 4S 6.05
I
3.49 2.40
19.97 8.45
1.89
1.26
.08
.04
9.35
29.53
9.39
53.60
71.93
72.40
2 . 82
302.30
888.11
302 . 30
3S.92
1,190.41
2.64
21.57
2.61
24.21
. II
. I 1
6.60
1.3S
2.19
2.19
..01
9.76
S2.7H
76.81
28.27
3.00
3.10
249 . 57
2.71 .01
.23
1.62
.03
3.36
9 . 76
1,006.22
252.67
16.39
3.39
16.72 40.03 1,2S8.S9
19. 7S
.02 2.06
.01
.304
.'.ill
1.37
4.99
2.33
7.32
1.28
117
.07
8.S7
,i 62
40.26
(a) For 1SS7-95 — nine years of decade; (6) for 1S91-95 — four years of decade.
Decrease of Rates for the German Army.
Year.
Morbidity
per 1,000.
Mortality
per 1,000.
Invalided
per 1,000.
1879-80
1.174.8
1,136.2
1,135.5
S49.6
S30.1
S50.3
S49.2
808.0
S04.1
758.9
S97.2
4.S2
1 . 82
4 . 53
4.25
1 16
3 . 93
3 . 73
3.79
3 . 2 I
3.19
3.30
1880-S1 ..
18S1-82...
1882 S3
20 6
1883 84
20 7
l.ssi 95
20 4
1885 86
23 'i
lSSli 7
20 6
1887-88...
21 5
188S-89...
19 6
1889-90
25.9
According to Boisseau the mortality of the British
army on the home station prior to 1853 was 17.5 per
thousand strength. After the improvement in the
sanitary surroundings of the soldier in that service
following the Crimean war, the rates for death and
sickness were much diminished, and for the decade
1875-1884 had fallen to 7.20 deaths per thousand
strength. In 1889 the death rate was 4.57, the sick-
ness 730.4. In 1S90 the deaths rose to 5.53 and the
sick rate to 810. For the decade 1887-1896 the
admissions were 735.9 and the ratio of deaths per
thousand strength was 4.68. In 1897 there died only
3.42 per thousand of strength, while the admission
rate had fallen to 640. per thousand strength.
The reduction in the rates for sickness and death
in the Italian army during the past twenty-five years
has been steadily progressive and probably presents
less fluctuation than is the case in any other military
service.
G0C
Admissions r> e . 1 (h Admissions
to hospital rat Year to hospital
or infirmary , n0( . or infirmary
per 1,000. ' I per 1,000.
Death
rate per
I .nun
IS 75
1,031
13.3
1887
760
S.7
1876
1,001
11.2
1SSS
732
8.7
1877
987
10.6
1SS9
7 19
8.0
1878
'.117
10.6
1890
796
7 .7
1879
936
9.9
1S91
811
9.0
1NSO
935
11.0
1S92
758
7.1
1881
928
10.6
1S93
735
e a
1SS2
833
10.2
1894
723
5 2
1883
842
11.8
1S95
713
7.0
1884
779
11.6
1896
711
5.8
18S5
791
10.3
1897
694
4.2
1886
798
9.3
Viry gives the following rates for mortality in the
French army as illustrating the progress of military
hygiene:
Period.
Mortality por -. . .
1,000 strength Pennd '
Mortality per
1,000 strength.
1812
27.9 1873-81.. 9.0
1820- 25
1846
21.4
19
16
13
1SS3 ' 8.15
1S89
1846-58
1862-72
1S90
5.81
Dewey states that in the French service the average
annual death rate was 8.43 per thousand strength
for the seven years 1880-1886, and that it sank
yearly average of 6.63 for the seven succeeding years.
REFERENCE HANDBOOK OF TIIF. MKDK'AL SCIENCES
Army Medical Statistics
his decreased death rate is naturally consequenl to
. d amount of sickness, as the following figures
r om Marvaud illustrate:
Period.
L862
L86
L866 1884
1869 1887.
Amissions t.) hospital per thousand strength
dons to infirmaries and cases treated
lers not included) 264.5J259.5 177.0
ani ni in-effei I i i es pi r thousand
1 2:;.:; 22.1 14.0
Lindley, writing in 1S92, states that during the
ng forty years the death rates in the Prussian
n,l Belgian armies had shrunk to two-fifths, the
inglish ami Russian rates had fallen to one-half, and
he French rate had diminished to one-third. These
igures may probably be accepted as being approxi-
uately correct.
The lamentable conditions revealed by the above
s as existing until even within the present
generation were undoubtedly largely due to ignorance
if first causes of disease, by which measures for its
ion could not be intelligently applied, as well
is to an insufficient knowledge of hygiene and lack of
appreciation as to its value from a military stand-
>oint. An additional factor of no mean importance,
towever, was to be found in the former anomalous
.ml inferior condition of the medical officer, his lack
if authority to recommend in sanitary matters, and
lis powerlessness to control or remedy existing eondi-
ions. It was long held that his duties were merely
,< rare for the sick and wounded, and any recom-
nendations bearing on the general care or manage-
uent of the men were deemed intrusive and as such
usually disregarded and resented. The compara-
ivelv recent conferring of advisory powers upon the
mrgeon lor sanitary purposes has undoubtedly been
i potent factor in the gradual betterment of the
;anitary condition, and hence efficiency, of the
loldier; and when the medical officer is invested
.vith actual authority upon all matters bearing upon
be health of troops, with executive powers as well as
I Ivisory privileges, a still further improvement in
his direction may be expected.
Although during the past one or two generations a
narked diminution has occurred in the sickness,
nortality, and non-efficiency among the troops of the
States and those of European nations upon
!ii home stations, the same unfortunately cannot be
:ii 1 with regard to white troops doing colonial duty
II tropical climates. For them these rates continue
be high, and no great improvement in their relative
sanitary state, as evidenced by statistics, appears to
have resulted for many years. Since the hygienic
requirements for each military establishment, wher-
3 troops may be stationed, must be accepted
1- being the same for all circumstances, the conclusion
is obvious that climatic conditions in the tropics furnish
:i potent obstacle against a constant reduction in
rates proportionate to those which have occurred on
the home stations. While undoubtcdl}- much lias
lone during the past generation to render
military service in hot countries less inimical to life
and health, the fact none the less remains that sani-
i.'.ry progress in the low latitudes has fallen far short
of that obtaining in more temperate climates. It is
that figures illustrating this point are best
furnished by the records of the British service, and
are briefly compared as follows:
a these figures it is evident that while there was
a considerable diminution in the morbidity and mor-
tality rates for the West Indies and Ceylon during the
past twenty years, but little improvement has oc-
curred in the general rates fur China, Egypt, and
Cyprus. In India, a country long occupied b
large military force and one in which the grea
improvement might reasonably be expected to have
occurred, the rate: are practically what they wi
decades before -the death rate of British troo]
home having fallen from 7.20 to 3.58 per thou
while the same rate for India fell only from 17.43 t"
15.29 during the same period. Further, the several
rates f"i' the Straits Settlements have actually in-
creased.
1 leatht
1 lays
Period.
hospital
|„T
per
1,000.
1,111m.
Decade 1S75-S4.
885.0
Decade 1886-95.
111.",. 7
'.1 23
22 67
Year 1S96
1190.2
6.19
28 69
Decade 1875-84.
ins;,. 1
14.51
2U.II7
Decade 1S86-95.
1004.1
11 ,38
21 . 10
Year 1896 .
1321 .1
8 . 23
2:; . 711
China
Decade L87
Decade 1SS6-95.
1030.4
1256.0
10.53
11 .41
18.07
22 . 1 1
Y'ear 1S96
1856 5
7.48
32.05
India
Decade 1875 8 1 .
1 182.9
17.43
23 . 06
Decade 1886-95.
1 153.5
15.52
30.26
Year 1896
1386.7
1 5 . 211
34.35
Egypt and Cyprus..
Decade 1S75 8 1
No fig
ures gi
ven.
Decade 18S6-95.
1069.7
16.30
24 . 56
Year 1896.
822.3
1 3 . 28
23.11
Straits Settlements.
Decade 1875 S 1
X" fig
are- iri
ven.
Decade 18S6-95.
1079.4
7.27
25.58
Y'ear 1896
11171.7
8.88
26.46
In this respect the experience of Great Britain is
duplicated by that of the French service; in which in
1862 the mortality for troops throughout France was
9.42 and for those in Algeria 12.21 per thousand; while
in 1890 the death rate for troops at home was 5.81 and
for those in Algeria 11.94 per thousand.
TFor as Affectimj the Health of Armies. — The rates
of sickness and death of troops in campaign, inde-
pendently of the circumstances which accompany
conflict, are chiefly influenced by the standard of
hygiene maintained; and, as is stated elsewhere, it is
difficult to cite campaigns in which the death rate
from sickness has not been greater than that from
casual ty.
The diseases observed during continued warfare,
according to Laveran, are largely brought about by
four chief influences: atmospheric, exhalations from
the soil, evil condition of the latrines, and poor food.
The atmospheric exposure to which the soldier is often
subjected is one of the greatest hardships of a cam-
paign. Sleeping on the bare ground and often
drenched with rain, standing in trenches exposed to
snow and cold, or making long marches under a
tropical sun, are a few of the influences by which he
is debilitated and his constitution impaired. Service
in a malarious country is notoriously productive of
disease, while illy-policed sinks are potent factors in
the occurrence of typhoid and dysentery. The
influence of insufficient or improper food in lowering
the resisting powers of the soldier is well recognized.
Excessive fatigue and moral influences also play an
important part in determining the sick rate, it being
well established that victorious forces have less sick-
ness than armies which have been beaten and demoral-
ized. The endemic and epidemic diseases of an
occupied country, together with the influence of a
change of climate, aggravate also to a considerable
degree the sickness and mortality of an expeditionary
corps.
For our own service the influence of hostilities upon
607
Army Medical Statistics
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
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608
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Army Medical Statistics
mortality from disease is well illustrated in the accom-
panying chart (p. 608), showing, as it di>e>, the rates
[or certain affections in the United States army, dur-
M! r the Civil war, for periods before and subsequent
Othat war, and also as compared with the death rates
or the corresponding class in civil life. As compared
with the mortality from continued fevers — which
ins may he considered, in the light of present
aowledge, as of typhoid natun — war brought about
in increase of tenfold. Malarial diseases were
1 and diarrhea and dysentery tripled. Deaths
mm eruptive fevers became about twenty-two times
is frequent as they were before the war, while those
rotn diseases of the respiratory organs were more
[uadrupled. Camp life appeared to have little
nlluenco in affecting the mortality from nervous
ons. Deaths from diseases of the circulatory
nl digestive organs were practically doubled in fre-
quency, as was also the mortality from consumption.
Rheumatism, as regards a fatal termination, and con-
iaiy to expectation, was not increased; but scurvy —
be former bane of armies in the field — was doubled.
The average annual death rate from disease during
the entire war was 53.48 per thousand strength
imong white troops, while it was 18.98 for these
during the eighteen years before the war,
xcluding the two years of hostilities against Mexico,
and somewhat over six per thousand for the decade
[uent to the war.
The following table shows the influence of the war
with Spain upon the rates for sickness and death, as
regards the prevalence of certain classes of diseases:
UNITED STATES TROOPS
I YEAR 1881-2
\ FROM TYPHOID FEVER
MORTALITY -
1 FROM DISEASE
1 YEAR 1898-B
FROM TYPHOID FEVER
f4
<
MAY IJUNC JULY AUO.|»EPT, OCT. NOV. | OCO. JA* ffl>,|M»H '*>n
JJ.O.
5.5,
_5.0
I 5
0.0
0.5
5.CL
A
/
\
\
\
1.5
4.0-
3.5-
3 0-
\
\
1 '1
\
j
\
\
.3 5-
i
•
30L
_2.5_
i
:
':/
\
2.5.
-2.0-
1/
A
\
s
20
1.5
1.0-
!/
:< \ \
/
1.5
1
y
\
\
—
0.5-
1 ;
•
'"■■*"
~~-
05
-0.0-
•"""
.-/ '
Fig. 326. — Mortality from All Diseases and from Typhoid Fever
during the War with Spain and during the Corresponding Period
of the Civil War. (After Sternberg.)
Table Giving Figures for the Comparison or the Year of Peace, 1897, with the Year of War, 1S9S.
Group.
Admissions per
1,000 strength.
I lonstantly non-
effective per
1,000 strength.
Deaths for
1,000 strength.
Discharges for
disability per
1,000 strength.
1S97.
isi.s
IS',17
1S9S.
1898.
1897.
Total losses
per 1 ,000
strength.
1897. 1S98.
Infectious diseases, general and local
Diseases of nutrition
of the nervous system
Diseases of the digestive system
■ nf the circulatory system
Diseases of the respiratory system
- of the genitourinary system
Diseases of the lymphatic system and
ductless glands
Diseases of the muscles, bones, and joints,
of the integument and subcu-
ius connective tissues
i of the organs of special sense... .
[tied
total for diseases
Total for injuries
Total for all causes
326.10
2.05
56.94
244.05
4. OS
77.71
9.76
2.36
72 . .32
72 . 55
21. 17
2.41
1,034.97
3.49
52.81
505.71
6.73
114.511
11.77
3.22
77.34
60.57
17.39
19.17
S96.53
l.'i::7 71
290.08
209.23
1.1S6.61
2,146.94
12.59
.19
1.63
3.75
.41
1.61
.SO
.17
2.85
1.70
.92
.09
26.73
9.12
35.85
57.90
.21
1.33
7. CI
.60
2.04
.67
.17
2.70
1.06
.79
.59
69.09
1.35
.33
.55
.37
.04
.04
.04
3.14
1.97
5.11
15 '.19
.09
.92
3.11
.49
.96
.24
.30
24.94
8.41
33.35
1.28
.29
1.79
.55
.95
.40
.44
.31
7.60
2.01
9.61
2.14
.13
.86
58
.96
.26
.43
.02
1.33
.04
.62
.02
7.40
4.1.8
11.58
2.63
.29
2. 12
1.10
1 . 32
.62
.66
.01
1.31
.62
.04
10.74
18.13
.22
1.78
3.69
1 . 15
1.22
.67
.02
1.33
.34
.62
.02
32.34
44.93
All things being considered, it is safe to assume that
I outbreak of hostilities will be followed by a vast
increase in the death rate, probably from six to twelve
or more times that normally occurring in peace; the
proportion naturally varying with the character of the
campaign, the climatic conditions to be encountered,
the local diseases to be undergone, the efficiency of the
commissary and transportation departments, the
employment of seasoned or unseasoned troops, and
many other factors. The rate of admissions to sick
report from disease in time of war is not, however,
increased proportionately to the death rate — a fact
.sufficiently proving the more serious nature of dis-
Vol. I.— 39
eases when affecting troops in the field. As to the
rate for non-efficiency, this is largely dependent upon
the ratio for admissions, and naturally bears in its
fluctuations a close relationship to the prevalence and
character of disease. If the records of the Spanish-
American war be accepted as typical in this respect,
no great differences in the rates for discharge by
reason of disability, in peace or war, may be antici-
pated. (See chart, above.)
In comparing the results of the Spanish-American
war with the corresponding period of the civil war
the advantage is much in favor of the former, al-
though the progress of disease by months is quite
609
Army Medical Statistics
dissimilar. It is particularly noticeable that not
only was the death rate during the war with Spain
reduced by 43.9 per cent, as compared with the
struggle of the previous generation, but the amount
of epidemic typhoid, largely resulting from the
inexperience of the volunteer troops, rapidly decreased
as a result of scientific sanitary measures enforced
as soon as the magnitude of the typhoid outbreak was
fully understood. And in future wars, through pre-
ventive inoculation and better appreciation of the
protective value of good sanitation, the amount of
typhoid fever to be expected will be very greatly
reduced below past standards.
Comparison of Monthly Death Rates (per 1,000) from
Disease.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
1S61-1862.
189S-1S99.
Months.
5 M
l_ 50
o
ogaj
a »
a a
3
>-i S
iS s
3T3
*-8
K |^
«
i~°
16,161
r.6,'.i.-.i>
71,125
112,359
IS
55
106
242
1.11
.82
1.49
2.15
(i
1
5
.26
.44
.72
.21
42
90
451
1,400
163.726
_' 12,526
July
362,613
August
268,507
September. . . .
165,126
365
2.21
5
.89
1,541
261 ,824
October
256.SS4
725
2.S2
:;
.IV
809
_'.-,.-,, Ml III
November. . . .
.301,848
1,145
3.79
1
.51
365
242,000
December
343,184
1,471
4 . 29
.84
201
240,000
January
352,760
1,593
4 . 52
.85
ISO
211.
327,734
1,316
4.11
.87
156
iso.ooo
328,S7S
1,575
4.79
.90
123
l.;r. ni III
410,116
229,452
l.SSl
10,522
4.. 58
45.86
25
.71
.73
SO
5,438
113,000
Annual
211,350
As already intimated, so many factors combine to
determine mortality from sickness in campaign that
any attempt at the close comparison in this respect
of different wars — carried on under entirely different
conditions — can yield only misleading results. Gen-
eral deductions can of course be drawn, and hence the
following figures may be of advantage as well as
interest :
Deaths from Disease During Certain Wars of the Past
Century, i After Bradford.)
Name of War.
Nation.
Mortality from
disease per
or period, i , 00 strength.
Year
Walcheren expedition..
West Coast of Africa. .
Mexican
Crimean
Chinese
Civil War
Civil War
Franco-Prussian
Cape Coast . .
Afghanistan
Egypt
Soudan
Madagascar
Chino-Japam-.'
Spanish-American
Great Britain..
Great Britain..
United States.
Great Britain..
France
United States.
United States.
Germany
Great Britain..
Great Britain
Great Britain..
France
France
Japan
United States
1S09
1824
1S46-4S
1S54
1S62
1862
1863
1S70-71
1S73
187S-S0
1SS2
1SS3-86
1S95
1895
lS'.lS
346.9
690.0
100.0
230.0
118.0
40.0
60.0
IS. 6
173.0
93.7
72.1
2S0.0
i i il
14.8
25.0
shown in the following diagram from the report of the
Surgeon General for 1910. Since 1897, the chart
illustrates the influence on our medical statistics of
the Spanish War; the Philippine Insurrection; the
China Relief Expedition; various other outbreaks; the
second intervention in Cuba; the opening up of new
posts in Alaska, along the seaboard and in the interior
of the United States, and in Hawaii; the occupancy
of vast tropical territory and the shifting of troops
therein, and many other factors.
It will be noted that despite the far less favorable
environment that surrounded our army at the time of
the outbreak of the Spanish war, the death rate from
disease is now about what it was then. For this, an
improved sanitary administration is responsible.
The rates for discharge and constant inefficiency still
continue high, but these are largely the result of
exposure to tropical infections together with the
tremendous increase in venereal disease which has
been the special sanitary feature of the past decade.
The results of the Russo-Japanese war are not given
here, as the statistics winch have been published are
not regarded as reliable.
The results of war, supplemented by the maintenance
of troops under unaccustomed climatic conditions,
and frequently in an unhealthf ul environment, are well
G10
Pao.-ths
Chart Showing Ratios of Deaths, Discharges, and Non-efficiency
in the U. S. Arm} .
With regard to the results of campaigning undci
tropical conditions, the most satisfactory data are
naturally furnished by the two great colonizing
powers, Great Britain and France. The figures
given for these services are, however, so widely dis-
similar as to furnish no foundation for any general
conclusions based upon them both. For pur)
of comparison merely, they are certainly valuable;
the French having little reason to be proud of their
sanitary showing.
REFERENCE HANDBOOK OF TIIK MKDICAL SCIENCES
Army Medical Statistic!
ABU OF MORTALITY PROM DISEASE IN CAMPAIGNS IN TROPICAL
Coi .urn-, Showing Rati: op Death pbh 1,000
Strength. (After Bradford.)
Briiish Expeditions.
French Expeditions.
oudan
land
lukim
ludan
I ih, n-
ahanti
'.II orce
land, .
kshaoti
tiiuland
hitraJ ...
,'ile
loogola
Lfuhaaistan . .
1889
I s7ii
INS.",
lss:, 86
1860
189 i 96
1882
is.;,- nn
1877-78
I860
1896
1S7I
1S7'.>
ISM.",
0.6
2 n
1.1
5
5
5
12
14
14
16
17.4
24.8
25 . 1
1SS4-S.-. 26. I
1896 16.6
1878-8093.7
Tonkin
1884
Tunis
1881
I,. 83
Tim kin
1 ss:,
1 tahomey. . . .
[893
Tonkin
L886
Tonkin .
|ss7
( i>. Inn-China
1863
Soudan
i lochin-China
1862
1862
Tonkin
lsss
lss.-, -si;
Soudan
1SS6-87
Soudan
1887 ss
Soudan
18S8-89
Madagascar. .
1S95
I ',11 II
(il .11
71.0
79.0
S7.ll
99.0
I in; ii
107.0
116.0
117.0
118.0
133.0
200.0
220.0
225.0
280.0
HOO.O
i i unities of the French expedition in Madagascar
is given by Gayet:
Killed by the, enemy 7
Wounded 04
Deaths from sickness 5,600
Sick, more than 15,000, or S3 per cent, of the whole.
From the above table it will be observed that with
lie exception of the Afghanistan campaign, in which
he high mortality was largely the result of an out-
ireak of cholera, the most unhealthful of seventeen
English expeditions in warm climates had a lower
1 :ath rate than the healthiest of an equal number of
pi inn campaigns under presumably similar climatic
conditions. The British expedition against the
\diantis, in 1874, certainly demonstrated the effi-
•iency of military hygiene under notoriously unhealth-
ul conditions; and, in the excellent results obtained,
he second expedition against this same tribe, in
1896, even surpassed the first. In our own expedi-
ion against Manila, during the war with Spain, the
■esults were admirable, only eight per thousand
lying from disease. During the Cuban insurrection
lie Spanish are reported, for the year 1S07, to have
tad a death rate of thirty-six per thousand from all
auses. The admissions to hospital for the same
icriod were 1,900 per thousand, of which 420 per
housand were for malaria. During 1897 the Spanish
roops appeared to have suffered but little from yellow
ever; this being probably due to an immunity to this
iisease acquired through previous visitations.
That constant exposure to infectious disease of all
kinds, and not only yellow fever, does actually exert a
seasoning influence on the survivors and reduce their
mortality is well known. As illustrating this point, it
may be noted that the sick rate of colored troops during
the civil war fell from 4,092 per thousand during
the first year of their service to 2,797 in the last, while
their death rate dropped from 211 to 94 per thousand
strength. The total rates for sickness during the
civil war underwent considerable diminution, as
follows:
First year, admissions per 1,000 strength 2,983
~ ■ n,l year, admissions per 1,000 strength 2,696
Third year, admissions per 1,000 strength 2,210
In this connection the chart already given in the
section showing the influence of race as affecting the
prevalence of disease is of interest.
It is not, however, dining active wars or on ex-
peditions that the highest mortality is observed
a moiig troops in tin- field. When an army is condemn-
ed to inaction through a siege, for purposes of
mobilization, or even in cantonments after a faborious
expedition, sickness rages with the greatest violence.
The typhus i bat nied tin- Crimean army occurred in
the winter after the capture of Sebastopol and aftt c
conclusion of the armistice; and examples might be
indefinitely multiplied in our own service to show
that the stationary force, dining war, is an un-
healthy force. In January, lsi>2, the medical
director of the Army of the West, then in winter
quarters, reported 13.5 per cent, of the total strength
as bring excused from duty, and a little over twelve
per cent, in March of the same year. [n August,
1861, of some troops encamped on the Arlington flats
on the Potomac, thirty-three per cent, were reported
sick with diarrhea and malarial fever. During the
war with Spain the typhoid epidemics, as is veil
known, occurred in the large fixed camps. An ex-
cellent instance is found in the condition of the
French troops during the Crimean War, a struggle
from which so many sanitary lessons have been
drawn. According to Rawlinson, reliable estimates
as to the sickness among these troops, for the winter
■ if I 854—55, were as follows:
46,000
55,000
6.->,000
75,000
ss.000
3,200
.5,000
December
January
February. .
6,000
9,000
S.000
These figures do not include the sick treated in the
regimental infirmaries or in the hospitals at Constanti-
nople.
Comparison of Military Statistics. — It is a matter of
the greatest difficulty, if not indeed impossible,
accurately to compare the sanitary conditions of
various armies, since their statistical tables are often
differently constructed, the physical requirements for
recruits are not identical, and diverse regulations as to
discharges for disability prevail.
In attempting to institute such comparisons it is
well to appreciate at the outset that a sick rate can be
kept low by excluding the doubtful or milder cases
from the benefits of quarters or hospital, and so pre-
venting them from appearing on the official records;
that the sick rates, mortality, and constant non-
efficiency can be held down by a searching system of
discharge for disability, and that the total loss — as
shown by the sum of the rates for death and discharge
— is, in determining the sanitary states of an army,
of much more importance than either of its com-
plementary factors.
In comparing the rates of our service with those of
foreign armies the admission rate is the one which, by
its magnitude, attracts attention. This higher rate of
admission, however, does not in itself imply a greater
prevalence of disease among the troops of the United
States; since with us, in contradiction to the practice in
other armies, the soldier is officially taken on sick
report whenever he is excused by the medical officer
from any part of his duty, whatever be the cause.
When it is observed, as was the case in the year 188S,
that 796. .89 admissions per thousand strength from the
Italian army resulted in a death rate of 9.31, while
1,270.73 admissions for each thousand United States
troops for the same period — divided into 62J.61
611
Army Medical Statistics
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
cases admitted into hospital and 649.12 treated in
quarters — had a mortality of only 8.15 per thousand,
it is evident that the admissions in the two instances —
the rates for discharge for disability not varying
greatly — do not constitute facts of equal gravity and
are therefore not available for comparison.
The rate for constant non-efficiency is obviously
largely dependent upon the admission rate and that
of discharge for disability, and reflects, to a con-
siderable degree, their variations. Taken by itself
the rate is misleading, and it acquires a certain value
only when considered in connection with other rates,
particularly that for admissions. As between services,
for the reasons already given, it is evident that non-
efficiency rates are not susceptible of proper com-
parison.
The death rate alone, as a means of comparison be-
tween several armies, is wholly unreliable and merely
productive of error; since, as above stated, it can be
marked reduced by the removal from the service of
those subject to or predisposed to disease.
Of all the ratios which go to determine the health-
fulness of any army, as shown by statistics, that
giving the discharge for disability is of the greatest
importance. In its relation to military morbidity
it is at once evident that the admissions to hospital
will be largely furnished by the physically less sound,
and that a prompt and proportionate diminution in the
sick rate must follow the elimination of these weak-
lings by their discharge from the service. In addi-
tion, the number of men withdrawn from the ag-
gregate strength of the command, the rate of non-
effectiveness from disease or inujry, is not a factor
of equal importance in all armies and cannot be
justly used for purposes of comparison. It undoubt-
edly embodies the number of admissions and the
gravity of the cases so admitted; but it is obvious
tli at the constant non-efficiency as well as the ad-
mission rate varies inversely with the rigor of the
system of discharge. As to mortality, this too
depends upon the physical standard maintained, and,
as shown in the German army, a low death rate is
naturally consequent to the early elimination of those
soldiers who are predisposed to or actually affected
with disease. Hence the rate of discharge for
disability is the controlling factor in the determination
of the rates of admissions, deaths, and constant non-
efficiency; while it is itself largely dependent upon the
physical standards to which the recruit, before en-
listment, is required to conform. To institute ac-
curate comparisons, therefore, a constant, unvarying
standard for discharge for disability should obtain in
several military forces to be compared; and such a
constant standard does not — and practically cannot —
exist. Requirements as to discharge for disability
necessarily vary with the customs of each military
service, and, to a certain degree, with the personal
equation of each medical officer. As an instance of
the former, it may be noted that the Germans are
especially assiduous in promptly removing the
tuberculous from their armies; we, on the other hand,
maintaining a sanitarium for soldiers affected with
this disease; and this single source of error, to which
might be added many other less aggravated instances,
prevents a comparison of sick rate, mortality, and
non-efficiency upon anything like equal premises.
If it be admitted, however, that the physical re-
quirements for the recruits of various armies are
approximately the same, the total losses, irrespective
of either non-efficiency or admission rate, should
afford a somewhat inaccurate, but still the most
available and satisfactory method of determining
the comparative health and physical efficiency of
various services.
The following figures, taken from Marvaud, show the
annual sick rates, mortality, loss by discharge, and
total losses in various European armies for a period
about ten or twelve years ago:
X.'IMic
< o
E o
f ~ s
a S3
S 3S
Belgium
Austria
Great Britain (home
stations)
France (home stations)
Germany
Italy
Russia
Spain
1S87-S8
338*
3.9
17.0
1887
995t
6.9
15. Of
18S4-S5
877
5.2
20.0
1888
500
6.1
21.0
ink;: m
819
3.9
29.0
1887
760
8.7
28.0
1880-S4
845
8.9
31.3
1886
13.5
30.8
20.!
21.1
25.:
27.
32.!
36.;
40.:
44.:
During the year 1SS8 the total admissions p<
thousand strength in the United States army amounte
to 1,270.73, the deaths were 8.1.5 per thousand, tl.
constantly non-effectives were 41.91 per thousanc
the discharges for disability 27.75 per thousanc
These figures give a total annual loss of 35.90 — tin
making our sanitary showing for that time inferior t
that of the above-named nations except Italj
Russia, and Spain; all countries notoriously the lea>
advanced in matters pertaining to hygiene. It cai
however, scarcely be believed that our men, undi
equal conditions of selection, broke down nearl
twice as readily as the Belgian or Austrian soldiei
and half again as rapidly as the British soldiers, an
hence the conclusion would seem to be inevitabl
from the above figures that our troops were at th:i
time examined on enlistment with a laxity as to thei
physical condition which did not obtain in foreig
services. This idea is further strengthened by th
fact that during the same year (1SSS) out of 742 me
discharged on certificates of disability, in 129 instance
the disability was specifically declared to have e:i
isted prior to enlistment. About this time the larp
number of discharges for disability attracted th
attention of the authorities, and recruiting officer
were warned to be more strict in their examination
for enlistment; while a general order required tha
all men recommended for discharge on account o
disability be sent to the headquarters of each militar;
department for observation by the chief surgeoi
pending final action in their cases. As a result >
these requirements the rates for discharge weri
decreased by nearly one-half in a single year, sine
which even further diminution has taken place. Fo
the year 1897 the rate for discharge on account c
disability was only 9.61 per thousand as compare)
with 27.75 during 1SS8. On comparing the statistic
of the above armies for a more recent period — exclud
ing France and Spain, for which countries no late
figures are obtainable — the relative status of th<
United States service is found to be as follows:
Country.
Admissions
to hospital or
infirmary per
1,000 strength.
Death rate
per 1,000
strength.
I lischargeg for
disability per
1,000 strength.
r.
° b
a, C
- i
c
H o
1S95
1S97
1897
1897
1S97
1896
1897
819.0
129.3
1.1S6.61
640.6
694.0
31 1.6
332 . 7
2.6
2.0
5.11
3.42
1.2
5.40
4.0
9.0
12. 1
9.61
1 9 87
21.2
21.9
37.5
11 6
1 1 1
United States
Great Britain (home
11.7:
11 B
Italy
* General hospitals only, t Including detention in barracks.
% Not including temporary invalids.
612
REFERENCE EANDBOOK OF Till: MEDICAL Si T I
Army Medical Statistics
It is evident from the above that much had ba Q
LCCOmplished during the next decade toward improv-
es the sanitary condition and effectiveness of our
irmy and it is safe to assume that at the present time
he 'United States soldier is better card! for than is
he man-at-arms of nearly every other military service.
sanitary standing of our army, as com-
iarea with that of other armies of the world, and
rearing in mind that the climatic and other conditions
which these various forces are serving are
[tiite different, is quite well illustrated in the follow ins;
■hart from the report of the Surgeon General for 1910.
Although, as stated, attempts at the comparison of
tatistics of different armies are at best necessarily in-
T)'l ScKo>.RqeS I I
Scale io -to I iviek.
accurate and unsatisfactory, within the limit - of the
same service such action is both feasible and desirable;
the standard for the health of an army, as expressed
by Smart, being its own best annual record, i lutside
of unusual vicissitudes, exposure, and epidemics, and
of the unsanitary condition- which bri: [ and
death into the ranks of a military command during
campaign, the sanitary surroundings of the soldier t i i«mfcj '^ 'W'twm m nA ^^m
III
Fig. 328. — Series of Electrocardiagrams showing the Results
Obtained by the Three Leads from a Normal Heart. (From
Barker after Einthoven.)
Of these lead II is most used and gives the biggest
variations. A series of normal electrocardiagrams is
shown in Fig. 328 and a key diagram in Fig. 329.
P represents the auricular systole and Q, R, S.
and T. are all dependent upon the ventricular systole.
Any marked departure from the normal picture
represents either some abnormality in the place of
618
1. Sinus arrhythmia.
2. Extra-systoles.
3. Auricular fibrillation.
4. Tachycardia.
R
5. Heart block.
G. Bradycardia.
7. Pulsus alternans.
8. Pulsus paradoxus
319.
Q s
-Diagram of the Electrocardiagram. (Hoffman.)
Sinus arrhythmia includes those forms of irregu-
larity in which each individual heart beat originates
in the sinoaurieular node and spreads over the heart
by the usual paths, but in which the intervals between
the beats vary in duration. It is caused by variation
in the strength of the impulses passing by the extrin-
sic nerves to the heart and modifying its rate (chrono-
tropic impulses). These impulses may pass by
either the sympathetic (positive), or the vagus
(negative), but the latter are the most important.
Sinus arrhythmia is known by a number of different
names each of which refers to some characteristic of
one or other of the forms in which it is seen. Besides
sinus arrhythmia, the following terms are in common
use and are more or less synonymous: respiratory,
diastolic, youthful, and vagus.
Respiratory arrhythmia is applied to those cases in
which the variations in rate correspond with (he
phases of respiration. It would seem that where
the medullary centers are in a certain condition of
excitability, the rise and fall of activity in the re-
spiratory center is able to communicate itself to the
neighboring cardioinhibitory center, modifying peri-
odically the inhibitory influence of the vagus. This
is a normal phenomenon in the dog, in which animal
the pulse is often more frequent during inspiration
(Fig. 330). In man a similar condition may be
induced by forced breathing.
Diastolic arrhythmia is another synonym, and
indicates the fact that this form of irregularity is
due to variations in the length of the pause or diastole
between the different heart beats, and not to any
departure from the normal in the site of origin of the
contraction wave or in its course over the heart,
This is very well illustrated in Fig. 331, in which there
is marked irregularity. In the venous pulse we can
see the normal sequence of auricular, carotid, and
ventricular waves in each cardiac cycle, but there is
great variation in the length of the second onflow
wave which represents the pause or diastole.
The youthful type of arrhythmia is another term
which has been applied to this form by Mackenzie,
on account of the fact that it is more frequent in
childhood. In the young the "pace maker of the
heart" in the sinoaurieular node seems to be more
amenable to vagus influences. A similar condition is
present in convalescents when the heart is slowing
down after the frequent rate of fever. It is also
often seen in the neurasthenic and the debilitated.
In all such cases sinus arrhythmia is common.
REFEHKXCK HANDBOOK OF THE MEDICAL SCIENCES
Arrhythmia, Cardiac
Vagus arrhythmia is another name given to these
, es, because it is usually through the vagus thai
chronotropic influences responsible for the
irrhythmia roach the heart. While the vagal effects
ire "usually dependent on the alternating phases of
espiration, this is not always the case. The activity
if the vagus may be modified by a great, variety of
nfluences reflex, central, and peripheral. It must
ui he forgotten that even the endings of the vagus
ii the heart may 1"' directly all'ecteil by certain drugs.
\iiiung the conditions which have been thought to
a causal relation to vagus arrhythmia are
.lion, high intracranial pressure, brain tumor,
neningitis, injuries and diseases of the upper cer-
i spine, tumors pressing on the vagus, poisoning
drugs of the digitalis group, gastric and other
■ I reflexes.
found approximately equal in duration and loudm
in succe ive cycles. Simultan i tracings from
arteries and veins show waves of normal form and
sequence, except in those parts of the tracings which
correspond to diastole, which vary in length. The
electrocardiagram is similarly of normal form except
in the length of tin- pauses. Before expressing a final
opinion the possibility of extra-sy toles, heart-
block, and auricular fibrillation must be excluded.
Prognosis. — Sinus arrhythmia usually tends to
pontaneou ; reco\ erj , its I lie \ mil I, g] I1V , \ into I he
adult or as eon\ale renee becomes complete.
Treatment is unnecessary in most cases and where
called for should be directed to the general health.
Atropine often masks the symptom temporarily, but
it is not necessary to give it except in those extreme
cases of standstill of the heart.
Car
-J
See
I
~ J"9 J^
c
Flo. 3".0. — Tracing from the Carotid Artery (above) and Jugular Vein (below) in a Dog showing Respiratory Arrhythmia. /, Inspi-
ih.n; K, expiration. In the venous pulse the carotid (O and ventricular (V) waves are much the same in inspiration and expiration,
but there is a great difference in the length of the second onflow wave (On), which represents the pause. Time marked in seconds.
dstill of the heart may be mentioned in connec-
tion with vagus arrhythmia as it is brought about
by the same mechanism operating more powerfullj'.
! in- patient from whom Fig. 331. was taken was sub-
to attacks of syncope which raised the question
of heart block. No tracings were obtained during
these attacks, but, in view of the evident activity of
the vagus inhibitory mechanism in his case, they
may have been due to standstill effected through
this nerve. Cases have been recorded by Neubiirger
id Edinger, Mackenzie, Laslett, and others in which,
in a result of some vagus irritation, all the chambers
Extra-systoles or premature contractions are beats
starting from some cause other than the development
of the normal spontaneous contraction. They are
produced by the action of mechanical, chemical or
nervous stimuli acting on the primitive muscle, and
may occur in any part of the heart. They will be
more readily understood after a consideration of the
terms homogenetic and heterogenetic, which have been
recently applied (Lewis) to different types of heart
stimuli.
Homogenetic stimuli are those which result from the
normal development of unstable material in the
R.I.J
y a see
iiiiiiiii mi-iiA
jaj^jjijJijLjjajjuuAJLUJUUiJjja^
luum ujjojull
Flo. 331. — Right Internal Jugular Vein, above. Right Brachial Artery, below. .4, Auricular wave; C, carotid wave; V, ventricular
wave; Os, second onflow wave. Time in 1/5 second. Taken by the writer from a patient of Dr. G. Gordon Campbell.
el tjie heart have remained quiescent for two or more
ordinary pulse intervals. In some of these cases
unconsciousness may supervene.
Diagnosis of Sinus Arrhythmia. — The radial pulse
will be found irregular in rhythm, but more or less
constant in volume. On feeling the pulse and observ-
ing the respirations at the same time, a relation may
be observed between the phases of respiration and
those of the arrhythmia. The heart sounds will be
muscle cells with a resulting spontaneous or auto-
matic contraction. Under normal conditions they
materialize only in the "pace maker" or sinus, but,
where there is a defect of conduction so that the con-
traction impulse from the sinus cannot spread over
the heart, homogenetic stimuli may develop in other
parts.
Heterogenetic stimuli include all other kinds. We
are more or less ignorant of the nature of heterogenetic
C19
Arrhythmia, Cardiac
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
stimuli, but the following varieties may be suggested:
irritation from patches of degeneration, high intra-
cardiac pressure, distention of the heart by accumu-
lated blood, chemical stimuli resulting from faulty
metabolism or ingestion of drugs and poisons, and
nervous stimuli reaching the heart by the extrinsic
nerves. When a heterogenetic stimulus starts a
contraction in some part of the heart before the
impulse from the sinus has time to reach it the con-
traction is called an extra-systole. Such extra-
systoles may arise in either auricles or ventricles,
or in the junctional tissue between. They are
spoken of as auricular, ventricular, and auriculo-
ventricular respectively. The contraction wave
initiated by an extra-systole may be conducted in
any direction like the normal impulse, but more
readily downward. Ventricular extra-systoles are
usually limited to the ventricle. Auricular extra-
systoles are usually conducted down to the ventricle
and somewhat less frequently back to the sinus.
Auriculoventricular extra-systoles are conducted
down to the ventricles and up to the auricles, pro-
ducing more or less simultaneous contraction of the
two chambers.
Vi utricular extra-systoles are produced by some
unusual stimulus (heterogenetic) acting on the
muscle of the ventricle so as to produce a contraction
of that chamber before the impulse descending from
the sinus can reach it. In the radial pulse we find
the normal rhythm interrupted by a small beat
occurring before a regular one is due, and followed
by a long pause. The premature beat may be too
weak to be felt, in which case the pulse seems to
intermit. Tracings from the radial in two cases of
ventricular extra-systole are shown in Fig. 332. In
both these cases we see the normal rhythm inter-
rupted by small premature beats (A'), each of which
is followed by a pause longer than the usual pulse
interval and called the compensatory pause (4 to 5,
-\1
10
10
jV-vJ
7
13 10
10
/\~
B
Fig. 332, A and B. — Radial Tracings from Father (A) and Son
(/?), Both of Whom have had Ventricular Extra-systoles for Many
Years without any Obvious Disease of the Heart. The pulse beats
are numbered and the intervals marked in millimeters in B for
reference in the text. The extra-systoles are marked by an X.
Fig. 332, B). When the intervals immediately before
and after the extra-systole are together equal to two
normal pulse intervals, we say that the compensatory
pause is complete. Such is usually the case in ven-
tricular extra-systoles and is so in the two tracings
shown in Fig. 332. In B the intervals are marked in
millimeters.
Hirschfelder uses a different nomenclature to
describe the compensatory pause. He calls the
interval from the beginning of the last normal beat
lo the end of the pause following the extra-systole
(3 to 5, Fig. 332, B) a bigeminus; he would say that in
this tracing we have a full bigeminus, meaning that
the intervals before and after the extra-systole are
together equal to two normal pulse intervals. A
complete compensatory pause or a full bigeminus is
strongly suggestive of ventricular extra-systole,
but is not pathognomonic as it may occur with other
forms.
The pulse beat following the extra-systole (5, Fig.
332, B) is often larger than normal. This is because
the long conpensatory pause gives the heart time to
fill more completely so that there is a larger amount
of blood to be forced out and consequently a greater
pulse volume. The fact that the arteries have had
more time to empty themselves may also be a factor.
Fig. 333. — Ventricular Extra-systole in a Dog from Unknown
Cause. RA, Right auricle; RV, right ventricle; X, extra-systole
wave in ventricular curve; A, auricular systole; S, ventricular
systole; 1% ventricular wave (better first onflow wave); Oi t second
onflow wave; S', from fusion of wave due to premature contraction
of ventricle with second onflow wave; .4', high wave from contrac-
tion of auricle during ventricular systole. Time in 1/5 second.
On listening over the heart during a ventricular
extra-systole we may hear the normal rhythm in-
terrupted by a weak first and second sound occurring
before they are due and followed by a long pause.
Sometimes the second sound of the extra-systole is
not heard, because the ventricular contraction has
been too weak to open the aortic valves, "a frustrane
contraction" as the Germans call it. In the la
case as well as when the pulse is too small to feel,
we get A false intermission.
Fig. 333 shows an extra-systole which occurred in
a dog while tracings W'ere being taken from the right
auricle and ventricle with Hiirthle's apparatus. The
cause of the extra-systole was unknown.
The ventricular contraction marked A* occurred
before its time and its effect is seen in the auricular
tracing in the wave S' . Shortly afterward the auricle
contracted during the ventricular systole producing
the wave A'. This wave is high, showing increased
auricular pressure on account of the tricuspid valves
being closed while the auricle is contracting. A similar
high wave is seen in venous tracings in cases of ven-
tricular extra-systole and is always very suggestive
as it shows that the ventricle is still contracting and
keeping the tricuspid valves closed at the time of the
auricular systole. In Fig. 333. the compensatory
pause is complete as is usually the case with ven-
tricular extra-systoles. The intervals 3-4 and 4-6
together occupy the same time as the two preceding
normal intervals 1-2 and 2-3. Measurement by the
620
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Arrhythmia, Cardiac
time tracing below will show that this is the case, and
also thai the auricular wave A' occurs at the nor-
mal interval after the preceding auricular wave,
showing thai the auricular rhythm is unaffected.
334 .1 ami H shows tracings from a case in
which every third beat was a ventricular extra-
| i,;. 334, A and B. — Tracings from Radial (A) and from Carotid and Jugular (B) in a Case of
!'r. Blackader's in "the .Montreal General Hospital. Patient was a middle-aged -woman under
meat for indigestion. R. Car., Right carotid; L.T.J., left internal jugular; A", A", extra-
iles; A, auricular wave; C, carotid wave; I", ventricular wave; C", carotid wave of extra-
le; A\ large auricular wave occurring during ventricular extra-systole.
tole. Note the large auricular wave A' during
the extra-systole of the ventricle. In this case the
.1' waves occur a little prematurely, but as they fol-
low the carotid waves at an interval of one-fifth sec-
ond or more, it is probable that the extra-systole
has started in the ventricle and been conducted
backward to the auricle.
The reason for the compensatory pause has yet to be
explained. It is due to the fact that the systole of
the ventricles is still in progress when the auricles
contract. During systole the heart is refractory to
stimuli, both excitability and conductivity being in
abeyance, so that the stimulus from the auricle is
unable to descend or else finds the ventricle unable to
Apex
1 \ N s
1 '■> sec.
X
Fig. 335. — Apex Beat Tracing from a Patient of Dr. G. G. Camp-
bell showing Interpolated Extra-systole at A\ By measuring
between the vertical lines drawn it will be found that thebigeminus
including the extra-systole is just equal to the succeeding normal
interval
respond. The consequence is that the normal beat
of the ventricle immediately following the extra-
■ >le is missed, giving rise to the long compensatory
pause.
In rare cases, where the heart rate is infrequent,
the refractory period following an extra-systole has
time to pass off before the next regular contraction
becomes due. In such a case the extra-systole is
wedged in between two normal heart beats and there
is no compensatory pause at all. Such an event is
known as an interpolated extra-systole and an example
i hown in tin. 335, where it is very well -ecu in a
i racing from the apex beat.
Pulsus Bigeminus. — In some cases every regular
heart beat is followed by an extra-systole. This
produces a pairing of beats known a- pulsus bigemi-
ni] . It is probable that in some way the fir I I .cat of
the couple supplie the stim-
ulus for the second beat or
extra-systole. An example
occurring in a dog at the end
of a long experiment is shown
in I 'ig. 336.
Similar cases have been re-
ported in man, especially
after the prolonged adminis-
tration of digitalis. A pulsus
bigeminus may also be pro-
duced by a true or false in-
termission after every two
normal beats. These differ-
ent forms are very different
in their causation. They can-
not always be distinguished
from one another in the
arterial pulse, but from the
venous pulse or electrocardia-
gram a diagnosis can easily
be made. False intermission
has already been referred to
as due to a weak extra-systole
or frustrane contraction; true
intermission will be ex-
plained later on.
Sometimes two or three
extra-systoles occur after
each normal beat giving rise to pulsus trigeminus and
pulsus quadrigeminus respectively.
The electrocardiagram in ventricular extra-sys-
toles assumes various forms according to the part of
the ventricle in which they start. They all agree
Fig. 336. — Tracing from the Right Auricle and Right Ventricle
of a Dog showing Pulsus, or rather Cor, Bigeminus. This was
obtained with Hurthle's apparatus at the end of a long experiment,
but the cause of the irregularity was unknown. A, auricular
systole; S, ventricular systole; A', extra-systole.
however, in differing from the electrocardiagram of
the normal contraction which is caused by a stimulus
descending from the auricle. Two types produced
experimentally are represented in diagrammatic form
in Fig. 337. They may be compared with the nor-
621
Arrhythmia, Cardiac
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
mal shown in Fig. 329. The difference is due to the
fact that in an extra-systole the contraction wave
and the electric change accompanying it follow a
different path over the ventricle to those of a normal
beat.
Auricular Extra-systoles. — In the arterial pulse the
general picture is much the same as in ventricular
extra-systoles, but the compensatory pause is usually
incomplete. In venous tracings we see the carotid
wave preceded by an auricular wave, which may
show itself as a separate wave (Fig. 338) or as an
augmentation of the preceding ventricular wave
(Fig. 339). Although these tracings were taken
Fig. 337. — Diagram of the Electrocardiagrams Produced Experi-
mentally by Stimulating the Right {A) and Left (B) Ventricles.
(Kraus and Nicolai.)
from the same patient within a few minutes of one
another they present considerable differences suggest-
ing that the extra-systoles arose in different parts of the
auricle. In Fig. 338 the A wave of the extra-systole is
abnormally short showing abbreviated auriculoven-
trciular interval and suggesting that the extra-systole
originated in the lower part of the auricle or even in
the junctional tissues. In Fig. 339 the A wave is
fused with the ventricular but evidently makes itself
felt before the summit is reached giving us a length-
ened auriculoventricular interval and suggesting an
extra-systole starting higher up in the auricle. In
both cases the compensatory pause is incomplete, sug-
R 1
J
~^Y 1
1 sec.
X I
^_
Rl
3r
11 16
10 1 18
Fig. 338. — Auricular Extra-systoles. R.I.J., Right jugular vein ;
R. Br., right brachial artery; .4, auricular wave; C, carotid wave;
V, ventricular wave; Y, X, extra-systoles. Paper travelling 16
mm. per second indicated by horizontal line. Healthy young
man patient of Dr. A. H. Gordon.
gesting that the impulse traveled up to the sinus
causing it to contract prematurely and give the " pace
maker " of the heart a new starting-point. In Fie.
339 we have hardly any compensatory pause at all,
fifteen and one-half millimeters as compared with i he
normal interval of fifteen millimeters, which is also
strongly suggestive of an extra-systole arising near
the sinus. In Fig. 338 the compensatory pause is
longer though incomplete, measuring eighteen milli-
meters as compared with the normal interval of six-
teen millimeters, which supports the idea that we
have to do here with an extra-systole arising farther
away from the sinus.
622
In some cases of auricular extra-systole the com-
pensatory pause is shortened in accordance with the
law of conservation of the normal pulse periods. This
means that when an auricular contraction comes be-
fore its time the auriculoventricular interval is pro-
lunged and when the auricular contraction follows a
long pause the auriculoventricular interval is short-
ened, both of which facts tend to equalize the ven-
tricular intervals. In Fig 340, for instance, the
auriculoventricular interval of the extra-systole is
longer and that following the compensatory pause
is shorter than normal which minimizes the effect
on the ventricular rhythm.
RIJ
1 sec.
RBr
15
Fig. 339. — From Same Patient as Fig.* 338. Showing how
auricular wave of extra-systole may be fused with preceding
ventricular wave as shown at X in the venous tracing.
The effect of the long pause is also well seen in
Fig. 341 where the auriculoventricular interval (au-
ricular wave) succeeding the pause is much shortened
and helps to postpone some of the compensation to
the next pulse interval. Similar changes probably
occur in the sinoauricular interval in other forms of
arrhythmia.
In electrocardiagrams from cases of auricular extra-
systole the auricular complexes are of variable form
according to the part of the auricle in which they
originate and are often inverted. The ventricular
complexes are usually of normal form as they occur
Fig. 340. — Venous Pulse from Case of Auricular Extra-systoles.
A, Auricular wave; c, carotid wave; .4', auricular wave of extra-
systole superimposed on ventricular wave of preceding cyclo,
1, Normal A— V interval; 2. lengthened A-V interval of extru-
sysU>le; 3, shortened A-V interval following compensatory pause.
in response to stimuli reaching them by the usual
channels from the auricle. Where deviations from
the normal occur they may usually be ascribed to
some fault in the conducting path (Lewis).
A iirirulori utricular extra-systoles are those produced
by a stimulus acting on the junctional tissues con-
necting the auricles with the ventricles, usually per-
haps the auriculoventricular node. They have been
produced experimentally and are believed to occur
clinically. They form a link between auricular and
ventricular extra-systoles and resemble one or other
of these according to their exact place of origin.
As already stated it is open to question whether
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Arrhythmia, Cardiac
he extra-systoles shown in Fig. 338 should be re-
garded as originating low down in the auricle
ir in the junctional tissues. The extra-systole
town in Fig. 342 probably originated in the junc-
ional tissues, but is of the ventricular type with a
ugh combined wave A'. It differs from a ven-
ricular extra-systole in that the wave A' comes
the auricular contraction is due, which is not
■ til the vertical dot led line is readied, and also in
hat the compensatory pause is incomplete.
In a ventricular extra-systole the high .1' wave
either at the exact time the auricular wave is
1 to. 341. — Tracing Taken From Same < 'ase as Above. Receiver
I on neck in such a position as to get auricular wave of
r (.1) added to carotid arterial tracing. The auricular
belonging to the extra-systole is masked, but the shortened
following the long pause is well seen at A". The intervals
narked above are in 1/5 second, and show the compensatory
>ause to be incomplete.
Iue or else sufficiently long after the ventricular
beat to allow of conduction backward of the impulse.
Moreover the compensatory pause is usually almost
lite complete.
As to the electrocardiagram of auriculoventricular
i systoles, our knowledge is limited to cases in
which the auricle contracts a little before the ventricle.
In these eases the auricle or P wave is inverted on
mt of the stimulus first affecting the lower part
of the auricle, the P-R (.4-1') interval is reduced and
the ventricular complex is normal.
symptoms, while others complain thai their heart
gives a great thump or that il seems to flutter or
I top.
Etiology and Prognosis. — The writer has Been
extra-systoles in a great variety of conditions. They
are often found in people enjoying excellent health.
I ig. 332, .1 and />'. were taken i'l'oiu a father and son
aged about liity-iive and thirty, in good health and
free from any signs of heart disease. Fig. 340 waa
taken from a former laboratory boy who was e -
what anemic and had signs of old rickets, but was
otherwise well. Figs. 338 and 339 are from a healthy
youth of sixteen who had no symptoms and was
able to play football and run races up to 220 yards.
Fig. 342 was from a man of forty-one with shortness
of breath of six: months' duration following physical
overwork. At the time the tracing was taken he
had a dilated heart and pulmonary edema. 1 have
also seen extra-systoles in cases of indigestion,
diabetes, and chronic nephritis and in menstruating
women. Mackenzie has found them common in
old people with infrequent pulse and cardiosclerosis,
and in the rheumatic and the neurotic. Extra-
systoles may sometimes be attributed to excessive
irritability of the heart muscle which may be present
either in the healthy or the diseased, sometimes
it may indicate the action of a mechanical stimulus
like high blood pressure, or a chemical stimulus from
some drug or poison like digitalis, or a nervous stim-
ulus from some reflex cause. From the variety of
causes which may give rise to extra-systoles it can
be seen that in any given case their significance is
hard to determine. They should suggest a system-
atic examination of the patient, including an esti-
mation of the field of response. If there are no other
symptoms or signs of disease their presence may be
disregarded.
Treatment of extra-systoles is unnecessary. If
there is any concomitant disease, whether circulatory
or not, it should be attended to. The writer believes
he has seen temporary relief from atropine in doses
°f tItt grain three times a day in cases where the
thumping or fluttering of the heart has caused
annoyance.
Fig. 342. — Tracing of Extra-systole at X Believed to be Auricula-ventricular. Large wave A' can only be explained by simulta-
neous contraction of auricles and ventricles and it differs from that seen in ventricular extra-systoles in that it occurs before
the contraction of the auricle is due. The arterial pulse is poor and docs not show the extra beat, but this is hardly necessary.
From a patient of Dr. Ridley .Mackenzie with chronic bronchitis and dilated heart.
Sinus extra-systoles are also believed to occur and
experimental work has been done on them. We should
expect them to resemble auricular extra-systoles but
not to show any compensatory pause. Clinically it
would be impossible to distinguish them from sinus
arrhythmia although their pathology would be
different. Sinus extra-systoles would depend on a
heterogenetic stimulus acting before the homogenetic
had time to develop; sinus arrhythmia in its restricted
sense is due to the homogenetic stimuli developing at
irregular intervals under chronotropic nerve influence.
Symptoms. — Many patients are unconscious of any
Auricular fibrillation is the most important of
all forms of arrhythmia for two reasons. It is the
commonest variety, forming about fifty per cent, of
all permanent arrhythmias; and its presence offers
clear indications for treatment. Our knowledge of
auricular fibrillation has been a gradual growth,
and the development of this knowledge is marked
by the various terms which have been applied to it
at different times. Among these may be mentioned
the mitral pulse, the irregular pulse, pulsus irregu-
laris perpetuus, the inception of the rhythm of the
heart by the ventricle, nodal rhythm, and finally
623
Arrhythmia, Cardiac
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
auricular fibrillation. We are indebted to James
Mackenzie for most of our knowledge of the clinical
farts, one of the most important contributions in any
field of medicine during recent years. For the com-
pletion of our knowledge of the pathology we are
under obligation to Cushny and Edmunds and
especially to Thomas Lewis.
Auricular fibrillation is sometimes spoken of as
the absolutely or completely irregular pulse and these
terms very well describe the features found on exam-
Fig. 343. — Tracing from Case of Auricular Fibrillation. Points
marked in venous pulse correspond in time to systolic waves in
arterial pulse. Allowing for delay in conduction to the elbow the
large waves in the venous pulse are seen to be systolic in time.
There are no auricular waves and no negative waves in early
systole. These facts mark the venous pulse as of the ventricular
form and taken with the irregularity justify a diagnosis of
auricular fibrillation.
ination of the radials. The radial pulse in an un-
treated case is usually frequent, varying in rate from
100 to 200 per minute. In exceptional cases slower
rates are found. The pulse beats are felt at irregular
intervals and vary greatly in strength. On listening
over the heart we often find the heart rate greater
than the radial pulse gave us to expect, on account
of many beats being too weak to reach the peripheral
arteries or even to open the semilunar valves. The
sounds heard are irregular in rhythm and vary in
1 see
RBr
2
Fig. 344. — Tracing from Case of Auricular Fibrillation under
Influence of Digitalis. In the early part of tracing the beats show
a characteristic coupling and a frequency averaging 6S per minute.
In the latter part of the tracing the coupling has disappeared
and the rate has increased to about 106. (Patient referred by
Dr. Garrow.)
loudness from beat to beat. Many of them are
short and sharp like extra-systoles. They may or
may not be accompanied by murmurs.
Under appropriate treatment the rate of the
heart may become less frequent. The ventricular
rhythm may ultimately become very slow and fairly
regular, resembling that seen in complete heart
block, and we may notice the beats occurring in
couples. Simultaneous tracings from arteries and
veins show a venous pulse of the ventricular form
624
without any auricular wave and without any negative
wave X. Fig. 34.3 shows tracings from a man of
forty-eight with a dilated heart, but without any
murmurs or any history of rheumatism. This
tracing was taken before starting treatment. When
the patient came into the office his pulse was 132
but when the tracing was taken it had slowed down
to 120.
Fig. 344 shows tracings from a young man of
twenty-two with mitral stenosis and dilated heart,
following rheumatic fever. Two months before this
Fig. 345. — Tracing from Man of Seventy Recovering from an
Attack of Heart Failure with Dyspnea and Edema. At time of
tracing edema was gone: dyspnea was noticed only on exertion,
heart was moderately dilated, no murmurs, diagnosed as myo-
carditis. Pulse is irregular and venous pulse is of ventricular
form. Small waves of auricular fibrillation are noticed in some
parts of venous pulse (A') .
tracing was taken the patient had suffered with
severe dyspnea even during rest and was compelled
to stay in bed for several weeks. Under rest and
digitalis he improved remarkably so that he attended
college, was able to take long walks, and even attended
one or two dances. A few months later, however,
he had another attack of rheumatic fever which
failed to respond to salicylates and he died after a
month's illness. In some cases of auricular fibrilla-
tion the venous pulse may approach the arterial
form as seen in Fig. 345, from an old man with
myocarditis.
R.I.J.
c
^J^.PC
9 1
1 X *
c
JJUJL r
1
l.Br.
1
A^V
/>
Fig. 346. — Tracing from a Case of Arrhythmia. The arterial
pulse is like that seen in auricular fibrillation, but the venous
pulse is not of the typical ventricular form. The X negative
wave is sometimes well shown and the carotid wave is sometimes
preceded by a wave which may be auricular (?). Dunn- the
long pause, however, a number of small waves are seen which are
probably due to frequent contractions in the auricle, eitbtr
fibrillation or flutter.
This patient improved remarkably on digitalis
and enjoyed life and was able to take walks for somi
months. He passed from under observation for a
time and discontinued the digitalis. He died about
a year later from another attack of heart failure
following influenza.
Occasionally the venous tracing of auricular fibril-
lation shows a succession of small waves during the
diastolic pause. These are seen to a slight extent in
Fig. 345, but better in Fig. 346. They are usually
referred to fibrillary contractions occurring in the
REFERENCE HANDBOOK OF Till: MEDICAL S( 1 1 :X< 1 :s
Arrhythmia, Cardiac
uricle. In Fig. 346 a negative waveXmay be noticed
i early systole. This does not necessarily mean
!uit the auricles are contracting and relaxing in a
ormal manner as the negative wave .V has a double
ausation. It is partly due to the drawing in of
ilood from the veins by the auricular diastole, and
artly to the enlargemenl of the auricle by the f the auricles it disappears when these chambers
ass into fibrillation and cease to contract in any
ffective manner. We usually' find the presystolic
nurmur replaced by a diastolic murmur which is
troduced while the blood is being drawn through
■ constricted opening by the diastole of the ven-
ricle. Auricular fibrillation is still commoner in
niddle and advanced life as a result of degenerative
and is often seen without any indication of
.alvular disease being present. The postmortem
indings in auricular fibrillation have been mostly
if the nature of fibrous degeneration of the heart
nuscle, especially that of the auricles. In a number
< the changes have been well marked at the
junction of the superior vena cava and right auricle
[S-A node).
The symptoms complained of are chiefly various
of shortness of breath. Some patients
complain of feeling a fluttering or thumping of the
heart and can state the day and hour when the irregu-
larity suddenly began.
/' agnosia. — When the arterial pulse is absolutely
irregular in volume and rhythm and the heart Bounds
also show great irregularity, auricular fibrillation
should be strongly suspected. When at the same
time the venous pulse is found to be of the ventric-
ular form the diagnosis is almost certain. Whet,;
an electrocardiagram can be taken and the /' v..
are found to be replaced by a succession of smaller
waves the diagnosis is fully confirmed. Where
cardiac compensation is good the veins of the neck
may be too empty to give a good venous pulse (racing
ami we may have to base our diagnosis on the arterial
pulse and heart sounds alone. With a little experi-
ence i hese are sufficient for nil practical purposes.
Prognosis. — Sometimes this form of irregularity
occurs in attacks of shorter or longer duration and
there is a return to the normal rhythm. In the
majority of cases, however, when once established
it is permanent. The prognosis in any given -
must be based on the degree of heart failure present.
In some cases the fibrillation of the auricles repre-
sents one of the last s ;a! j,.^ ; n the downward path
of a case of heart failure. In other c:i-r- the patient
may live for many years in restricted activity, but
comfortable and able to earn a living. Of thirteen
unselected cases taken from my notes of the past
year or two, six died, two have been lost sight of, and
five are still under observation.
Of those who died one was under observation two
months and died from cardiac failure accompanied by
tricuspid regurgitation and signs of venous stasis.
One under observation for five months died of chronic
nephritis. One under observation for seven months
died of rheumatic fever after being temporarily re-
stored to activity. One a year after being first seen
died from multiple emboli following mitral stenosis.
One died a year after my first visit from heart failure
accompanying an influenzal pneumonia. One at the
end of two years, during which I had several times
helped to restore compensation, died under another
physician from heart failure which was proved post-
mortem to be due to a chronic fibroid myocarditis.
Of the five alive two men are earning their living,
one old man of seventy-one is enjoying fair health
at home, one woman is keeping a boarding house,
and one, a married woman, is able to do housework
and walk considerable distances at a leisurely pace.
One of the men has had the irregularity for twelve
years to my knowledge.
Treatment. — Auricular fibrillation is the condition
in which rest and digitalis give their most brilliant
results. If there are no symptoms of heart failure it
is necessary only to enjoin caution in the way of
physical and mental work, to bring the heart rate
down to seventy or less with digitalis and to keep
it there. In cases of noticeable heart failure, as shown
by shortness of breath on exertion, by marked dila-
tation, or venous engorgement, a rest in bed should
be insisted on. Three weeks' rest in bed is sufficient
for some cases but many need longer than this.
During the time the patient is in bed the opportunity
should be taken of getting the heart under the in-
fluence of digitalis. The form of digitalis is not so
important as the selection of the proper case and
most cases of auricular fibrillation will be found to
be proper cases for it. Mackenzie uses the tincture
in closes of twenty minims three times daily until
results are obtained. Less than this will often suffice,
especially if time is not important. He also uses
Nativelle's granules containing one-fourth milligram,
three times daily. I have used both these prepara-
tions as well as the infusion and several proprietary
preparations. In most cases any of them will give
results in proper doses.
Digitalis should be pushed until the heart is slowed
Vol. I.— 40
625
Arrhythmia, Cardiac
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
down to the point where the patient feels best,
which will be found somewhere between forty and
seventy per minute. The most desirable rate of
heart beat cannot be arbitrarily stated but differs with
individual peculiarities. In each case it must be
determined by the sensations of the patient and the
general experience of the physician. The inexperi-
enced physician should be cautious and watchful when
the rate gets below seventy. For the full effect of
digitalis to be obtained the patient must be under
close observation, as otherwise toxic symptoms may
develop and the patient may be afraid to persevere
with the drug. Among indications for discontinuing
digitalis are vomiting, diarrhea, dryness of the mouth,
aphasia, drowsiness, and partial heart-block. When
all goes well digitalis should be continued until the
desired rate of heart beat is attained and then the
dose should be reduced to the amount necessary to
keep the pulse rate under control. This is usually
one-third or one-quarter the daily amount which was
necessary to slow it down. Some patients may need
one Nativelle's granule daily or twenty minims of the
tincture, others only need a granule every two or
three days or five or ten minims of the tincture daily.
These smaller doses should be continued as long as
the patient lives and he should be taught to regulate
the dose by his symptoms. The action of digitalis
in these cases is believed by Lewis to be that of pro-
ducing partial heart-block and protecting the ven-
tricles from the multiplicity of stimuli. This allows
the ventricles to beat with a more leisurely rhythm
which conserves their energy and yet enables them to
maintain a better circulation. In cases in which
digitalis cannot be taken, which are fortunately rare
among those showing auricular fibrillation, the prog-
nosis is bad. They must be given a longer rest and
have their strength kept up by tonics such as a com-
bination of iron, arsenic, and strychnine. In some
cases adrenalin seems to be serviceable in doses of
twenty to thirty minims of the 1-1,000 solution
every two hours by the mouth, or half as much hy-
podermicaUy. In cases of very violent heart action
with frequent pulse and great distress a hypodermic
of morphine gr. J with atropine gr. T lj will often
give relief.
Auricular Flutter. — Jolly and Ritchie believe that
in some cases the auricles may beat regularly and in
their entirety but with a frequency of 200 or 300 per
minute. To this condition they give the name of
auricular flutter. In the cases they report heart
block was present but it is conceivable that such a
condition might exist without heart block and give
a clinical picture scarcely distinguishable from auric-
ular fibrillation. It is possible that we have such a
condition in Fig. 346, where the small waves f,f,f,
due to the auricles are so pronounced a feature.
Nodal rhythm was the term used for a year or two
by Mackenzie to describe cases of auricular fibril-
lation, in the belief that the auricles and ventricles
were contracting together under the influence of
a stimulus originating in the auriculoventricular
node. Since the real nature of these cases has
been demonstrated Lewis has come forward with the
statement that there are cases corresponding to the
condition Mackenzie had in mind when he invented
the term and which may properly be called cases
of nodal rhythm. Lewis refers to a case of Rihl's
and gives one of his own. He also describes an experi-
mental example. The main feaures are that auri-
cles and ventricles contract more or less together,
giving high combined waves in the venous pulse,
and the electrocardiagram shows a normal ventricular
and an inverted auricular complex with shortened
I'-R interval.
Tachycardia. — This term has been used by many
authors in the sense of frequent heart action under
whatever circumstances it may occur. Among the
examples which naturally suggest themselves are
fever, overexertion, anemia, organic disease of the
heart, exophthalmic goiter, and a variety of emo-
tional, reflex, and mechanical disturbances which
will be discussed in the article on functional dis-
orders of the heart. In all these cases the normal
origin (homogenetic) and sequence of the heart beat
are preserved, but beyond this they have little in
common and the advantage of grouping them to-
gether under one head is doubtful.
Paroxysmal Tachycardia is quite another matter.
It occurs in several varieties but they have much in
common both clinically and pathologically. It may
be spoken of as heterogenic tachycardia because the
heart rhythm is due to abnormal stimuli which, so
far as yet observed, seem to be of a different nature
from the normal stimulus and act upon other parts
than the usual "pace maker." Our knowledge of
this form of arrhythmia is still limited and the fol-
lowing account presents a somewhat dogmatic sum-
mary of current opinion, but is in no way to be taken
as final.
Paroxysmal tachycardia is characterized by sud-
den attacks of frequent heart action which last for
minutes, hours, or days and then cease almost
suddenly as they begin. During the attack the
pulse rate is usually very high, reaching 150 or evi D
200 per minute. It is frequently uncountable. ] i
some cases the increase of rate represents an exact
doubling or tripling of the preexistant rate but the
frequency of this occurrence has probably been
exaggerated. During the attack the patient may
or may not be conscious of fluttering of the hei
and sometimes complains of precordial distress or
pain. As a rule the sensory symptoms are slight
in comparison to the motor disturbance, while in
palpitation of the heart the reverse is the case. The
breath is short, especially on exertion. The short-
ened diastole does not give the heart time to fill -
that the circulation suffers. The arteries are com-
paratively empty, the face is pale and the vei
engorged. In the later stages the liver may be
enlarged and there may be edema of the legs and
lungs. The heart too may become dilated and
signs of tricuspid regurgitation are often found. In
attacks of short duration there may not be time for
many of these signs and symptoms to develop.
The arterial pulse may be regular or irregular. The
rate is frequently between 150 and 200 but may vary
considerably during an attack. It is wise to confirm
the rate by listening over the heart, as some of the
pulse waves may not reach the wrist with sufficient
force to be palpable. An examination of venous
pulse tracings throws considerable light on the nature j
of a case but does not always make it perfectly clear.
The electrocardiagram is a great help when available.
The cases of paroxysmal tachycardia so far re-
ported fall under the head of either extra-systoles or
auricular fibrillation. Most of them may be classed
as due to extra-systoles occurring in a long sei
and starting from a single focus in rapid succession.
The seat of origin may be in almost any part of the
auricles or junctional tissues and more rarely
in the ventricles. Some cases on analysis prove 1 1
examples of auricular fibrillation. All the varieties
have much in common. All are due to heterogenetic
or abnormal stimuli acting upon the heart muscle.
The difference between a succession of extra-systi
and auricular fibrillation is largely one of degree. In
the former the stimuli affect a single focus, in the
latter a number of different foci simultaneously.
The differentiation of the several varieties is to be
made by the examination of venous tracings and
electrocardiagram. The general characters ot
graphic records are similar to those already descrii
for extra-systoles and auricular fibrillation, but
tain difficulties arc introduced by the frequent rate.
The different waves of the venous pulse are crowded
together. The auricular wave may be superimposed
626
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Arrhythmia, Cardiac
ipon the ventricular wave, or even upon the carotid
vave of the preceding cardiac cycle. In the latter
,.,- ii may be hard to determine whether the blend-
M c of auricular and carotid waves is to be explained
iy the auricular wave falling upon the carotid wave
if the preceding cycle on account of the great fre-
of the heart rate, or by a simultaneous con-
i of the two chambers from a stimulus alfeet-
QB the junctional tissues. In cases due to auricular
ibrillation the proper auricular waves are ali.-ent and
lie venous pulse is of the ventricular form. Before
leciding that the auricular waves are absent one
■.elude the possibility of their being present
cured by combination with other waves as
•xplained above. Light is frequently thrown on a
ase by the occurrence of single extra-systoles before
ir after an attack. These single extra-systoles often
iriginate at the same focus as those of the paro
.,1 may help to localize the point from which the
utter start. Some cases are complicated by the
e of partial heart block. This fact may
xplain some instances of exact doubling or trebling
>f the rate which has been ascribed to a sudden
cturn to normal conductivity. In some cases of
achycardia we find an alternating pulse due to a
ailure of contractility.
The electrocardiagram like the venous pulse is
complicated by the fact that the auricular complex
lay be combined with some part of the ventricular
omplex. Where the paroxysmal beats originate
a the auricle the P wave may be seen in its normal
nisition but is liable to be combined with the T
eave of the preceding cycle. It is often inverted.
tYhcre the focus is in the A-Y node the P-R (.1-1)
nterval is shortened or absent. In the latter case
lie P and fl waves fall together and may- be difficult
o analyze. Where the focus is in the ventricle the
entricular complex will be found of abnormal form
ike those shown in Fig. 338 but, as similar pictures
ire occasionally seen where the auricles are the seat
if the disturbance, caution must be exercised in
(rawing conclusions. For further information about
he electrocardiagram in these cases the reader is
eferred to "The Mechanism of the Heart Beat" by
Lewis, as the subject is too difficult to treat in a short
summary like this.
In Fig. 348, A and B pulse tracings are shown
rom a case of paroxysmal tachycardia during and
ifter an attack. The patient, a man of forty-one,
same to my office October 24, 1910, complaining of
i heavy feeling in the epigastrium, shortness of
ireath and inability to lie on his back or left side.
Symptoms began suddenly six days before without
my known cause. He had had a similar attack four
nonths previously lasting two days. The pulse
ivas found to be irregular and to vary in rate, being
sometimes uncountable. The apex beat was outside
he nipple; the heart sounds were embryonic in
haracter. A murmur was heard from time to time
ivhich was found later to be systolic in time and best
Heard at the apex. The tracing shown in Fig. 348,
1. was taken. He was sent home to rest and given
incture of strophanthus (strophanthone) in ten-
minim doses every three hours.
The next day, October 2.5, he reported that he had
felt better a few hours after going home and was
able to lie on his left side. His pulse was S4 and
regular.
October 26, pulse 65, regular. Pulse tracings
shown in Fig. 34S, B, taken.
October 29, pulse 70. Apex beat in nipple line,
c murmur still heard at apex. Felt all right.
Passed from observation.
Comparing the tracings taken during and after the
attack. Fig. 348, A and B, we seem justified in
marking as partly auricular the pointed waves A'
seen in .4. These occur, however, at the time of
the ventricular systole and are superimposed upon
the carotid waves. As they preserve this relative
position with varying lengths of pulse intervals, they
must belong to tin- same cardiac cycle as the carotid
es on which they fall. These facts justify us
I think in classing this case as due to extra-systoles
originating in the junctional tissues in or near the
.1-1 node. (in account of 1 he difficulty of getting
good tracings of the -mull frequent waves in I
cases there ts often room for difference of opinion as
to the interpretation of the tr;n-itiL.'s. in th
of facilities for taking an electrocardiagram we have
often to depend a good deal on circumstantial
evidence.
Fig. 34S, A and B. — Tracings from a Case of Paroxysmal
Tachycardia During and After an Attack. R I J, Right internal
jugular; R. Br, right brachial artery. The upper figure is marked
with vertical lines marking what are believed to be the beginnings
of the brachial pulse beats and the points in the venous pulse
corresponding to these in time. Allowing for delay in trans-
mission the A' waves are seen to be systolic in time and by com-
parison with the tracing below seem to be partly auricular in
origin. The pulse rate in Fig. A is about 190 to 200 per minute.
Patient of Dr. Herbert Tatley.
Pathology. — A disordered action of the heart
resembling paroxysmal tachycardia may be induced
in animals by tying branches of the coronary arteries
or by applying the strong faradic current to the
auricles. It does not seem possible to produce the
same result by any procedure directed to the nerves
when the heart is in a normal condition. There is
some evidence however that an attack may be pre-
cipitated by- stimulation of the cardiac nerves when
the heart is already in an abnormal condition. The
postmortem changes are not constant. In different
cases valvular disease, coronary sclerosis, degenera-
tion of the heart muscle, and various nerve lesions
have been found and in still other cases the findings
have been negative. We have to admit that we are
ignorant of any constant underlying cause. The
principal seat of the disease is probably in the heart
627
Arrhythmia, Cardiac
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
muscle, but emotional and reflex causes have an
undoubted influence in precipitating attacks.
Diagnosis. — Paroxysmal tachycardia has to be
distinguished from simple acceleration of the heart
due to anemia, fever, exophthalmic goiter, etc., from
persistent frequency of the heart rate and from
palpitation.
The diagnosis rests on the occurrence of the attacks
in recurring paroxysms, the high rate suddenly
attained, the comparative absence of sensory phe-
nomena such as are common in palpitation, and the
evidence in the venous pulse and the cardiogram
that the pace maker of the heart has been changed.
Prognosis. — The prognosis depends to a great
extent on the duration, severity and frequency of the
attacks in individual cases. A number of cases have
been reported in which recovery occurred, others have
had repeated attacks for years without life being
endangered, and in others the attacks have exhausted
the heart and led after one or more seizures to a
fatal termination. Sometimes the tachycardia
becomes permanent for a while before death occurs.
The best guide to prognosis is the extent to which
indications of heart failure appear. Of these the most
important are dilatation of the heart, shortness of
breath, enlargement of the liver, and dropsy.
Treatment. — Many methods have seemed to succeed
in individual cases and none is of universal applica-
bility. Absolute rest seems indicated and is usually
to be recommended although Fairbrother found in
his own case that violent exercise cut short the
attacks better than anything else. The most ap-
proved measures have as their primary object the
stimulation of the vagus. This may often be accom-
plished by mechanical means. Success in varying de-
grees has been reported from swallowing movements,
from Valsalva's experiments of taking a deep breath
and exerting strong expiratory pressure against a
closed glottis, and from pressure against the verte-
bral column of one or other vagus nerve where it lies
beside the carotid artery outside the thyroid cartilage.
These mechanical methods succeed best at the begin-
ning of an attack. Where they fail strophanthus
may be tried either intravenously or by the mouth.
Digitalis acts well in some cases and is probably
safer than strophanthus, albeit a little slower. 'Where
all these measures fail a trial may be made of nerve
sedatives like morphine, bromides, or valerian. An
ice-bag applied to the precordium has been recom-
mended. Between the attacks any derangement of
the nervous, digestive, or sexual systems should' be
appropriately treated and the general health should
be looked after. Excesses in food and beverages
should be warned against and overstrain of all kinds
forbidden. The possibility of emotional and mental
strain should be considered. If any organic disease
of the heart is present it may require attention.
Heart failure may be combated by rest and digitalis.
The results of treatment should be published as more
light is needed.
Heart-block is a form of arrhythmia which
looms up too large in the perspective of most physi-
cians. It may be that the term is catchy and easily
understood, or it may be that it has borrowed im-
portance from the great names of the past which
have been associated with it. To many it is one of
the first things thought of when an irregular pulse is
encountered and yet it is comparatively rare. In
any large general practice sinus arrhythmia, extra-
systoles, and auricular fibrillation must be of al-
most daily occurrence but months and even years
may pass before a single case of heart-block is seen.
Definition ami Subdivisions. — Heart-block may be
defined as a solution of physiological continuity be-
tween different parts of the heart. Under heart-
block, however, it is convenient to consider all con-
ditions attended bv a depression of conductivity.
628
The following subdivisions may be made:
According to location.
1. Sinoauricular heart-block.
2. Auriculoventricular heart-block.
3. Intraventricular heart-block.
According to degree.
1. Lengthened conduction time.
2. Partial heart-block.
3. Complete heart-block.
Auriculoventricular heart block which is the com-
monest and most important form will be considered
first in the three degrees in which it occurs.
Lengthened A-Y Interval. — The A-V interval may
be measured by calculating the time from the begin-
ning of the A wave (auricular systole) to the beginning
of the C wave (ventricular systole) in the venous pulse,
see Figs. 327, 331, 340. It may also be estimated
by calculating the time from the beginning of the P
wave to the beginning of the R wave in the electro-
cardiagram {P-R interval). This is rendered pos-
sible by the fact that a time marking in one-fifth
second can be photographed on the same plate with
an electrocardiagram. The A-V conduction time
as estimated by either of these methods is found to l)e
from .1 to .2 second normally. It is claimed by
Lewis that it is commonly a little shorter when e
mated from the electrocardiagram than when the
venous pulse is used, but the difference is slight.
During the refractory period conductivity like other
properties of the heart is temporarily in abeyance
and recovers gradually. After a short pause the con-
duction time is long and after a long pause the con-
ductivity is at its best as has been pointed out in
writing about auricular extra-systoles. In view of
the above it seems like a paradox that we usually
find a shortened A-V interval with frequent heart
rate and a lengthened interval with an infrequent
rate. This is to be explained by the fact that con-
ductivity and rhythmicity are both under nerve
control and are usually influenced in the same
direction.
Where the A-V interval is more than 0.2 second
it is considered abnormal and it may be lengthened
to 0.3 or 0.4 second or even to 0.S second. Where
lengthening of the A-V interval is found we may
suspect some degeneration of or interference with
the junctional tissues between auricle and ventricle.
The part affected may be either the A-V node or
the bundle of His. Mackenzie has seen a case shofl
lengthened A-V interval for years without develop-
ing any arrhythmia, but these cases should be
watched for early signs of partial or complete heart-
block. It may also be said that lengthening of the
A-V interval is suggestive of widespread degeneration
of the heart muscle, such as is seen in many old
people with arteriosclerosis.
The most important practical point in connection
with lengthened A-V interval is the bearing of this
defect upon treatment. Digitalis has been shown
by Mackenzie to have a tendency to produce heart-
block in patients where the conductivity is already
depressed and in such cases it should be given with
discretion and its effects watched. It is going too
far to say that digitalis should not be given at all
in these cases as it is often useful in restoring i
to the heart, but it should be discontinued as soon as
any tendency is shown for the ventricle to drop
beats.
The following case will serve as an illustration of
lengthened A-V interval. An old lady of eighty
with a past history of rheumatism came under my
care with symptoms of heart failure following over-
exertion. There were signs of considerable dilata-
tion and a mitral systolic murmur. She was ordered
to bed and given tincture of digitalis in doses of
thirty minims per day for several weeks. During
this time her heart became smaller in size and the
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
\ i I li\ lliini ... < ardlac
murmur disappeared, bul she began to suffer from
dry mouth and somnolence. On listening over the
heart one day 1 heard it drop alternate heals three
limes ill succession anil then resume ils regular
rhythm. 1 suspected partial heart-block and
discontinued the digitalis. The next day the tracing
shown in Fig. 349 was taken in which it can l>e
seen that the .1-1' interval is ahout one-third second
or considerably longer than normal. She was given
a rest from digitalis and no more dropped beats
were observed.
Fie.. 349.- Lengthened .1-1' Conduction Time. Jugular vein
Brachial artery below, .4, Auricular wave; C, carotid
I , ventricular wave. Horizontal line shows distance
[led by kymograph in one second when well started. A-V
interval about 1/3 secoud.
Partial Am irulan utricular Heart-block. — In cases
where the conductivity is greatly depressed but not
entirely lost the junctional tissues may from time
to time fail to conduct the impulse from auricle to
ventricle so that the latter is not stimulated and
drops a beat. In Fig. 350 a tracing is shown from
:in old man of eighty-four by whom several different
kinds of irregularity were exhibited. To the right
of the tracing it may be seen that the ventricle
responds only to every second beat of the auricle. It
is somewhat surprising to find that when the ven-
tricle does respond the A-V interval is normal, one-
venous tracing fii i a normal A-V interval and then
a gradual lengthening of conduction time which
becomes longer with each cardiac cycle until ai la I
a ventricular heal is dropped anil then ue start all
over again.
Partial heart-block may occur in many different
degrees such as one ventricular beat dropped out
mi rare intervals or after every third or every second
auricular heat. In some eases there may be three
or four or more auricular beal to one ventricular.
lino can find described in the literature every deg
from Lengthened A-V interval through varying
degrees of partial heart-block up to complete heart-
block.
Complete Auriculoventricular HeartMoch. — In this
condition no relation whatever can be established
between the contraction of auricles and ventricle .
The auricles will be found heating from sixty to a
hundred or more times a minute, whili the ventricular
rule may he twenty or thirty or forty. Where an
occasional ventricular heat, seems to follow a heat
of the auricles it can lie seen to lie only a coincidence.
Attention is usuallyfirst attracted by the infrequent
pulse, but the real nature of the case is de QStrated
only by an examination of a venous pulse tracing.
In Fig. 35] a tracing is shown from a patient of Dr.
A. II. Gordon in the Montreal General Hospital. The
patient was a, man of thirty-six with a dilated heart
and an almost continuous murmur heard over a
large part of the precordium. He showed pronounced
arteriosclerosis, but there was no history of syphilis.
He was said by his friends to be subject to frequent
attacks of mental excitement, but did not have any
of these while under observation. Some time after
leaving hospital he became so maniacal in one of his
attacks that he was taken off to the police station,
where he died. During his stay in hospital his pulse
kept about thirty per minute and was not affected
by full doses of atropine. On exertion he readily
became dyspneic, but there was little or no change
in his pulse rate.
RBr
IU-11 II I I II LLL
I I I I I I I I I I I I I ' I I I II I I ' I I I I I I I I I I I I I I
Fig. 350. — Tracing from a Man Eighty-four Years Old, patient of Dr. A. D. Blackader in the Montreal General Hospital. Admitted
with complaints of weakness and shortness of breath. Heart dilated, systolic and diastolic murmurs present at first, but later
disappeared. Clinical diagnosis of myocarditis. Patient was in hospital for six weeks ami was discharged improved and able to walk
.ibout. R I J, Internal jugular vein; R Br, brachial artery; A, auricular wave; C, carotid wave; A\ premature auricular wave; S, wave
ascribed to systole of right ventricle. This tracing is believed to illustrate three different kinds of arrhythmia. 1. Hemisystole
(1). 2. Ventricular extra-systole (2). 3. Partial heart-block (3, 4, 5). Over the figure 1 in the tracing are seen two waves A' and S,
which occur before the carotid wave and therefore before the systole of the left ventricle. These waves resemble the A and C waves of
ither cardiac cycles and are believed to represent the contraction of the right auricle and right ventricle, constituting a hemisystole.
They are followed by an ordinary C wave due to the contraction of the left ventricle. In the absence of an esophageal tracing there
is no way of telling when the left auricle contracts. Note that the A' wave is premature, which may help to explain the imperfect
conduction. At 2 is seen a ventricular extra-systole with a high combined A and C wave. 3, 4 and 5 show auricular waves which
are not followed by any contraction of the ventricles constituting partial heart-block. It is noteworthy that where the ventricle follows
the auricle the A-V interval is less than 1/5 second and therefore normal.
fifth second. Other observers have also reported
normal conduction time alternating with partial or
complete heart-block. Some have assumed that
in these cases it is the excitability of the ventricle
that is depressed. Such an explanation will not
serve in this case, as a second or two before the ven-
tricle begins to drop beats in Fig. 3.50 we see a
ventricular extra-systole which is scarcely compatible
with loss of excitability, but rather the reverse.
In some cases of partial heart-block we see in the
In complete heart-block the contraction wave is
unable to descend to the ventricle so that the latter
either stops altogether or beats in response to its
own homogenetic stimulus {idioventricular rhythm).
Experiment seems to indicate that the more suddenly
the heart-block becomes established the more liable
the ventricle is to stop permanently. The most
dangerous time in a case of heart-block is at the
moment when a partial heart-block is changing to
the complete form and some unexplained cases of
629
Arrhythmia, Cardiac
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
sudden death are probably of this nature. When the
idioventricular rhythm is once well established it
may go on for months or years with little change.
The rate of the ventricles is usually about thirty, but
may for a time be as slow as eight or less, and it has
been observed as frequent as sixty per minute.
Pathology. — Heart-block may be induced in animals
in all its degrees by compression or severance of the
bundle of His. Similar effects have been seen to
follow the intravenous injection of poisonous doses
of digitalis. Temporary heart-block has been pro-
duced by stimulation of the vagus and by asphyxia.
In man nearly all cases so far observed have been
Stokes-Adams Disease or Syndrome. — Definition:
•' A condition of slow pulse with syncopal, apo-
plectiform or epileptiform attacks associated either
with (a) derangement of the junctional system of
the heart or (b) disease of the nerve centers of the
vagi or of the nerves themselves" (Osier).
"The cerebral symptoms are a direct result of a
circulatory disturbance following a momentary fail-
ure of the left ventricle. They vary in ditT.
cases. Attacks resembling petit mal are perhaps
the most common with twitching of the limbs and
face. The epileptic fit with its orderly sequence of
events is rare. A slight aura may precede an attack
Fig. ool. — Tracing from a Case of Complete Heart-block. Patient of Dr. A. H. Gordon in the Montreal General Hospital. Internal
jugular vein above. Apex beat below. The ventricular rate was very constant at 30 per minute so that each apex beat interval
corresponds to 2 seconds. .4, Auricular wave. Vertical lines show points of time in venous pulse corresponding to the beginning
of ventricular systole as shown in apex beat. Note the total absence of any constant time relation between the auricular waves and
the ventricular systole. The auricles contract nine times while the ventricles contract four times.
associated with some disease or anomaly of the A— V
bundle. The causes are various and include syphilitic
gummata and other tumors; fibrous, calcareous, and
atheromatous degeneration; infarction, necrosis, and
ulceration; atrophy from pressure or stretching or from
sclerosis of the coronary arteries; lymphocytic and
fatty deposits; rheumatic and diphtheritic infection.
Vagus stimulation from swallowing, pressure, or the
administration of digitalis may cause temporary
increase in a preexistent block. Fulton and Judson
have reported an instance of heart-block occurring in
a father and two children which they ascribe to con-
genital defect. Cases of partial or complete heart-
block alternating with periods of normal conduction
time and those rare cases in which no disease of the
A-V bundle has been found at autopsy cannot at
present be explained.
S imptoms. — The symptoms vary according to the
degree of cardiac failure present. The complaint
to be expected is above all shortness of breath on
exertion. To this may be added various degrees
of cardiac palpitation, oppression, and pain. In
some cases attacks of angina have been seen. Cya-
nosis, dropsy, and other signs of heart failure may
be present. The cerebral symptoms are interesting
and important. In some cases symptoms of neuras-
thenia may be present and the patient may be nervous
and apprehensive. In other cases transient vertigo
or fainting attacks may cause alarm. In still other
cases attacks occur in which cerebral symptoms are
still more prominent and which are known as the
Stokes-Adams disease or syndrome.
The Stokes-Adams syndrome and heart-block are
by no means synonymous and each may occur
without the other. All grades of heart-block may
occur without definite cerebral symptoms and attacks
which fully meet the definition of Stokes-Adams
di ea e are frequently seen from other causes than
heart-block. The two conditions are so frequently
I. however, that this seems the most con-
venient place to describe the Stokes-Adams disease.
and the patient may be able to ward it off. After
recurring for a year or more the attacks may cease;
in other cases they become extraordinarily frequent,
thirty, fifty, or even one hundred and fifty in a day.
and consist of brief periods of loss of consciou-
with twitchings of the muscles. During these
paroxysms the pulse rate may fall to six or eight and
there may be prolonged intervals between the ven-
tricular beats" (Osier).
The Stokes-Adams syndrome is most frequently
seen in association with heart-block (eardim- gro
under two conditions; first, when a partial heart-
block suddenly becomes complete, and second, when
in a complete heart-block the ventricular rate ■
denly becomes less frequent. When a patient is the
subject of partial heart-block some slight cause may
suffice to render the block complete and the ventricle
may be tardy in assuming its independent rhythm.
It may remain perfectly inactive for many seconds
(more than two minutes — Stengel), or it may I
u it li an extremely slow rhythm for a time. In either
case the cerebral circulation suffers and some form
of "attack" occurs. The causes which render the
block complete may be various such as over-exertion,
nerve influence, or drug action and in some cases they
escape detection. In complete heart-block the
ventricular rate may suddenl}" drop from thirty or
forty a minute to eight or ten, or the ventricles may
stop entirety for a time with a similar disturbance
of the cerebral circulation.
The other or neurogenous group of cases, not due
to heart-block, are caused by lesions of the medulla
or vagi and present similar symptoms of slow pulse
and cerebral disturbance. Among the principal
causes are the following:
1. Fracture or dislocation of the cervical spine.
2. Narrowing of the vertebral canal or occipital
foramen.
3. Tumors of the medulla or its neighborhood
(cerebellum).
630
REFERENCE HANDBOOK OK THE MEDICAL SCIENCES
Arrhythmia, Cardiac
I. Sclerosis of t ho medulla due to disease of the
, tebral and basilar arteries.
,. Vagal neuritis.
i. Pressure on the vagi in the neck.
'. Functional affections of the vagus as a cause of
i irt-block are regarded by Osier as of doubtful
, urrence.
\ case has been reported by James in which syn-
I ial attacks resembling those of Stokes- A. lam
■ase were caused by recurrent groups of ineffect ual
ra-systoles (frustrane contractions). Tt, may be
cd here that in some cases of complete heart -hi nek
radial pulse shows numerous tiny elevations
i ing the ions pause. These are believed to be
the beating of the auricle against the aorta
I I must be carefully differentiated from extra-
1 1 iles such as those described by James.
oris. — There is usually nothing; character-
i c about the symptoms of the slighter forms of
k. Lengthening of the A-V interval is
covered only when a venous pulse tracing or an
i 'trocardiagram is taken. In some cases of length-
i d conduction time a gallop rhythm is heard over
heart. This is due to the fact that the slight
ml produced by the auricular systole is heard
I arately from the first sound when the A-V interval
i I'tigthened, but is fused with it when the conduction
c is normal. Partial heart-block gives rise to an
gularity of the pulse which may be noticed in the
t lial, but it usually requires a venous tracing for
| differentiation from other forms of arrhythmia.
complete heart-block attention is arrested by the
i rcquency of the pulse or by the cerebral symptoms.
] the case of the latter, senile bradycardia accom-
lied by vertigo and true epilepsy must be excluded.
■ sounds heard over the heart in complete heart-
I ek vary according to the condition of the heart
i -cle and valves. In many cases weak sounds due
t the auricular systole are heard in the intervals
I ween the ventricular beats. Griffith has recently
Biwn attention to a striking alteration in the first
id which is sometimes heard in complete heart-
lick. It consists of a "singularly thumping and
: phatic sound" which is heard every few beats and
i iscribed by Griffith to a simultaneous contraction
i auricle and ventricle. In complete heart-block,
i in other forms, venous tracings and the electro-
i diagram are of great help in making the diagnosis
i tain. The electrocardiagram shows complete
i sociation in the time relations of the P wave and
I ! ventricular complex. The ventricular complex
i usually of normal form indicating that the idio-
■ itrieufar impulse originates above, presumably
i the main trunk of the bundle of His below the seat
disease. Atropine is often administered in full
to determine how much of the block can be
i noved by paralyzing the vagus endings. Any
lick removed by atropine may be considered of
i irogenic origin. The block that persists in spite
; atropine may be ascribed to local disease in the
I adle of His. It is important to determine the
iture of the disease present and especially its
ise. Slighter forms are more often due to rheu-
i it ism, the more severe forms to syphilis. Where the
••stion of syphilis is in doubt one should apply
■ therapeutic test of a thorough course of iodide.
Prognosis. — The prognosis depends largely on the
use. In eases associated with infectious fevers
presence of heart-block adds to the gravity of the
'■, bul where recovery from the fever takes place
c heart-block is likely to disappear in a short time.
philitic cases are the most favorable. Most eases
complete heart-block which have recovered have
'■n of syphilitic origin. In the senile and degenera-
c oases the course is often very chronic. The
nkes- Adams attacks often cease, however, when the
event ricular rhythm is fully established. Some
of thee patient-; Buffer with marked heart failure,
but other- are able to get about and even to earn a
living. Osier gives five to six years as the average
duration of life, but some have lived for t weilty J eai
or more. As in other myocardial affections sudden
death is apt to occur while the patient is up and
about. This happened in ten of Osier's cases out of
a total of twenty.
Treatment. — There is no specific treatment except
for the syphilitic cases in which iodide ef potassium
in full doses should be given and mercury or salvar-
an if necessary. There is s difference of opinion
as to whether iodide is likely to do good in the
arteriosclerotic cases. Strychnine is another drug in
which some have confidence. Heart failure is to be
met chiefly by rest and regulation of the diet and
mode of fife. Digitalis is regarded as contraindi-
ca,ted in partial block, but in complete heart-block
with indications of cardiac failure it should certainly
be tried and will sometimes do good.
Intraventricular heart-block occurs in two forms,
hemisystole and ataxia of the heart muscle.
Hemisystole. — In the dying hearts of animals one
Ventricle often stops while the other goes on beating.
The possibility of one sided ventricular contractions
in man has been disputed, but the evidence that it
sometimes occurs is now considerable. Von Leyden,
beginning in 1S68, reported a number of cases, but
his work has not been universally accepted. Riegel,
for instance, explained the cases as frustrane contrac-
tions (weak extra-systoles). Mackenzie in his book,
"The Study of the Pulse," presents one very convincing
case (page 294) of independent contraction of the
right ventricle in a boy dying of dilatation of the
heart from mitral stenosis. He gives another case
almost as convincing in which the right ventricle
seemed to contract more often than the left. Hewlett
reports a case following the administration of stro-
phanthin, in which the ventricular contractions some-
times caused waves in the venous pulse with little
or no effect on the apex beat. The presumption
was that the right ventricle was contracting alone.
In the same case it was shown that the right ventricle
sometimes began its contraction distinctly later than
the left as though the contraction impulse to the right
ventricle had been retarded. The parallelism to
lengthened A-V interval is obvious. Stengel and
Pepper report a case showing various forms of heart-
block in which the auricular wave was followed by
a beat in the radial pulse, but not by any C wave in
the venous pulse. They interpret this to mean that
the left ventricle had contracted without the right.
They agree with the writer that the C wave in the
venous pulse has little or nothing to do with the caro-
tid, but is a wave sent back through the tricuspid
valves by the contraction of the right ventricle. The
tracing shown in Fig. 350 shows what is believed
to be a hemisystole at the point marked with the
figure 1. There are indications here that the right
auricle and ventricle contract in proper sequence
and the left ventricle follows later.
Ataxia of the Heart Muscle. — Schmoll has reported
a case in which the right ventricle and perhaps part
of the left contracted independently of the principal
mass of the left ventricle. He compares such cases
to the incoordination seen in the body in such diseases
as locomotor ataxia and for partial contractions of
the heart he suggests the term ''ataxia of the heart
muscle."
Evidence of partial contractions of the heart
muscle is sometimes afforded by the occurrence of
weak ventricular contractions interrupted by stronger
ones without any pause between the two. It is
probable that some cases of pulsus bigeminus such as
that shown in Fig. 336 are of this nature. The most
extreme degree of ataxia of the heart is fibrillation.
This is common in the auricles, but fibrillation of
the ventricles is probably incompatible with life so
631
Arrhythmia, Cardiac
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
that our knowledge of it is limited to the hearts of
dying animals.
Diagnosis. — The recognition of intraventricular
heart-block is to be effected by the use of all the
methods at one's command. Besides tracings of
the arterial and venous pulse and apex beat, esopha-
geal tracings may be helpful, as in the case reported
by Schmoll. It is onty through the esophagus that
we can get a tracing from the left auricle. Kraus
and Nicolai claimed at one time that separate con-
tractions of the right or left ventricle gave charac-
teristic clectrocardiagrams by which they could be
recognized, but this is called in question by Lewis
who makes the statement that the authors have
themselves receded from this position.
Prognosis. — The presence of hemisystoles or ataxia
of the heart muscle must always indicate serious
changes in the heart and it seems only a step from
these conditions to fibrillation of the ventricles
and death. From the fact, however, that the case
figured in Fig. 350 and also those reported by
Hewlett and by Schmoll, left hospital improved, the
condition cannot be regarded as necessarily pre-
saging speedy dissolution.
Treatment. — This must be carried out on general
principles. Schmoll's patient was given digitalis for
his general heart failure with benefit. Stengel and
Pepper's patient improved under atropine and the
block disappeared. Dr. Blackader's patient, Fig.
(3.50), improved during his stay in hospital where
the principal drugs given him were strychnine and
digitalis. In Hewlett's case the block seemed to be
caused by the administration of strophanthin and
passed off when the drug was discontinued.
Sinoauricular block may be produced in animals
by ligating, crushing, or cooling the sinoauricular
border. Under these circumstances the sinus con-
tinues to beat as before and the auricles after a period
of standstill begin to beat with a slower rhythm of
their own. Lesser degrees of injury may produce a
partial sinoauricular block with one beat of the
auricle to two of the sinus. A parallel condition in
man would be a block between the sinoauricular
node and the auricles. In the absence of any cri-
terion of sinus activity it is difficult to demonstrate
it clinically, but its presence has been inferred on
circumstantial evidence by Hoffman, Hewlett, and
Gibson. To it have been ascribed sudden changes
in the rate in paroxysmal tachycardia, and also
certain cases where both auricles and ventricles have
dropped a beat without permanent dislocation of the
cardiac rhythm.
Bradycardia is the opposite of tachycardia and
means slow or, better, infrequent pulse. The con-
ditions embraced under this term do not form a
clinical entity, but the term is a convenient one to
use in any given case until we are able by careful
analysis to allot it to its proper class. We may
classify temporarily as bradycardia any pulse below
fifty per minute. On further study these cases may
turn out to be:
1. Complete heart-block.
2. Combinations of auricular fibrillation with
heart-block.
3. Extra-systoles replacing every second beat and
too weak to be felt at the wrist.
4. Pulsus alternans in which the weak beat is not
felt.
5. True bradycardia in which the whole heart
beats at a slow rate, but in normal sequence.
True bradycardia may result from any of the fol-
lowing causes:
1. Personal or family idiosyncrasy. These cases
are not usually pronounced in degree and may be
seen in individuals otherwise in perfect health.
2. Neurogenic, from lesions of the medulla, upper
spinal cord, or vagi nerves, from functional disorders
632
of the nervous system such as melancholia, hysteria
and neurasthenia, and from efforts of the will as has
been reported in oriental fanatics.
3. Reflex, from painful and other affections of the
thoracic, abdominal, and pelvic viscera. Notable
examples are hepatic and renal calculi.
4. Infective, as influenza, diphtheria, and typhoid.
5. Toxic, as seen in poisoning with lead or digitalis
and in autointoxication from constipation, jaundice
or nephritis.
6. Cardiac, as seen in the bradycardia of senile
degeneration of the heart.
These cases must be analyzed in accordance with
the principles already laid down and treated accord-
ing to the causes which seem to be at work.
Pulsus alternans is the name given to regular
alternation of strong and weak pulse beats at ap-
proximately equal intervals. An example borrowed
from Mackenzie is shown in Fig. 352. Where
there is any irregularity in the pulse intervals in
pulsus alternans it is usually the weak beat that is
delayed. This has been explained by a depression
of A-V conduction at the time of the weak beat
(Wenckebach). It has also been ascribed to a
longer presphygmic interval due to the weak beat
taking longer "to open the semilunar valves (Hering).
Fig. 352. — Pulsus Alternans. The numbers show a slight pro-
longation of the pause before the smaller beat, in contrast to what
occurs in pulsus bigeminus. (Mackenzie.)
In an individual case the venous pulse should show
which is the proper explanation. The venous pulse
is usually normal in form. Pulsus alternans must
be differentiated from pulsus bigeminus due to
extra-systoles. This may be done by noting the
length of the pulse intervals, and by examining the
venous pulse for signs of extra-systoles. In pulsus
bigeminus a longer interval precedes the large beat.
In pulsus alternans the intervals are equal, or if
there is a slight difference the longer interval precedes
the small beat as already explained.
Pulsus alternans is regarded by Wenckebach,
Mackenzie, and others as due to a depression of con-
tractility. It is seen in senile hearts where there is
considerable fibroid degeneration, and after exhaust- .
ing strain, such as after an attack of paroxysmal
tachycardia. It is frequently associated with at-
tacks of angina pectoris. Where predisposition
exists the onset of pulsus alternans is often deter-
mined by exertion or excitement. Sometimes it <•■
ushered in by an extra-systole. Where contractility
is impaired the large beat following an extra-systole
exhausts the heart muscle so that it has not time to
recover completely before the next impulse descends
and it responds with a weak beat. The weak beat
being small and of short duration, the heart has a
longer rest before the descent of the next impulse
and responds with a stronger beat and so the alterna-
tion goes on.
The diagnosis of pulsus alternans can be made
provisionally by feeling the radial pulse. The alter-
nating force combined with the regular rhythm of the
beats is often recognizable. Some have noticed
variations in the strength of the heart sounds esp< -
cially in cases where systolic murmurs are present.
The diagnosis is confirmed by taking tracings of the
arterial and venous pulse by which extra-systoles
may be excluded. The diagnosis is sometimes
rendered difficult by the fact that extra-systoles and
pulsus alternans may be present in the same tracing.
REFERENCE HANDBOOK OF THE MEDICAL SCIEXCES
Ari'h> thini;u Cardiac
In some of these cases the irregularity in rhythm and
volume is so great that the question of auricular
fibrillation may lie raised (W'imlle), but the latter
ma y be excluded if the venous pulse is found to be oi
the auricular form. Pulsus alternans may also be
plicated by the presence of intraventricular heart-
block. In apex beat tracings the alternation may or
may not show. Where the ventricular beats seem to
he iif equal force the alternation in the arterial pulse
be explained by variation in the tilling of the
ricles due to unequal activity of the auricles.
electrocardiagram does not give constant results.
the complexes are of normal form. There may be
-nation in the height of the waves, but there is
onstant relation between them and the size of the
arterial pulse.
The prognosis is, generally speaking, unfavorable.
As this form of irregularity indicates exhaustion of
heart muscle, the degree of recovery that may be
cted must depend to some extent on the causes
produced it. The prognosis is naturally better in
coming on after severe strain than in those due
to degeneration of the heart muscle in the absence of
al stress of work. According to Mackenzie the
ecta of this form of irregularity usually succumb
within a few years.
Treatment. — This form of arrhythmia more than
any other calls for absolute rest. Digitalis is con-
traindicated as drugs of this class have been seen to
ease the defect. Chloral may do good by pro-
ting sleep and lowering blood pressure. Sugar in
large quantities as a heart food, and tonics like iron
arsenic should be of benefit. A patient lately
under my care did not improve much after several
weeks in bed with treatment along the above men-
tioned lines, but began to improve as soon as he was
given adrenalin. This was first given hypodermic-
ally in doses of ten to fifteen minims every two hours,
and later by the mouth, six to eight suprarenal
tablets daily. The result was that attacks of pre-
cordial pain with pulsus alternans ceased and his
ability to stand moderate exertion returned.
Pulsus intermittens and Pulsus deficiens are
names without exact pathological significance. Pulsus
intermittens is used for dropping of beats in the radial
pulse. Pulsus deficiens is reserved for cases where
the ventricle itself drops a beat. A beat may be
dropped by the ventricle as a result of partial or
complete heart-block. A beat may be missed from
the arterial pulse as a result of heart-block, and also
from a beat of the ventricle being too weak to open
the semilunar valves or to reach the peripheral
arteries, as in early extra-systoles or in extreme
degrees of pulsus alternans.
Flo. 353. — Pulsus Paradoxus (Schrotter). Showing how the
puke volume approaches the vanishing point at the end of each
inspiration.
Pulsus paradoxus is the name given by Kussmaul
to a diminution in size or absence of the pulse during
inspiration. It is often spoken of as pathognomonic
of adherent pericardium, but this is not the case as
it is seen in cases of pericarditis with effusion (Roberts) ,
splanchnoptosis (Hirschfelder), and to a moderate
degree, it is said, in some normal individuals. A
converse condition known as Riegel's pulse is the
diminution in the size of the pulse during expiration
which is seen in some cases of adhesion between the
heart and the anterior wall of the chest. These
forms of arrhythmia can usually be recognized by
palpation of the pulse while listening to the heart
sounds and watching the re piration. Their diagno tic
significance is probably not very great, 'they usually
indicate some pulling upon the meal vessels which
narrows their lumen at certain stages of respiration.
The active agent is often a fibrous band resulting
from luediasl init is which compresses the aorta when
drawn down by the diaphragm in inspiration or by
the descent of the ribs in expiration. Sometimes the
great veins are also compressed, producing ta i and
-welling in the veins of the neck. Very few tracings
have been published. That shown in 1 i^r. 353 is
borrowed from ScbrStter's article in Nothnagel's
Encyclopedia.
The treatment is that of the underlying condition.
Some eases of adherent pericardium have been bem -
Sted by resecting parts of the third, fourth, and fifth
ribs over the heart (cardiolysit I.
William S. Morrow.
Bibliography.
I desire to express my indebtedness to the following Looks,
which have; been freely consulted:
Allbutt and Rolleston's System of Medicine. Articles by Arthur
Keith, Sir William Osier, and F. T. Roberts.
Hill's Further Advances in Physiology, The Heart, by Martin
Flack, and Pulse Records, by Thomas Lewis.
Diseases of the Heart and Aorta, by A. 3). Hirschfelder.
Functionelle Diagnostic und Therapie, by Aug. Hoffmann.
Text-book of Physiology, by W. H. Howell.
Mechanism of the Heart Beat, by Thomas Lewis.
The Study of the Pulse and Diseases of the Heart, by James
Mackenzie.
Nothnagel's Encyclopedia of Practical Medicine, article by
L. V. Schrotter.
Arrhythmia of the Heart, by K. F. Wenckebach.
The following have also been referred to in the text or laid under
contribution;
Barker, L. F. Electrocardiography and Phonocardiography.
The Johns Hopkins Hospital Bulletin, vol. xxi.,No. 237, December,
1910.
Cushny and Edmunds: Paroxysmal Irregularity of the Heart
and Auricular Fibrillation. Amer. Jour. Med. Sci., January, 1906.
Fairbrother, H. C: A Remedy for Paroxysmal Tachycardia.
Jour. Am. Med. Asso., 1909, kii., 300.
Fredericq, Leon: La Pulsation du Cceur du Chien. Archives
Internationales de Physiologie, July, 1906.
Fulton, Judson, and Norris: Congenital Heart-block Occurri-g
in a Father and Two Children. Am. Jour. Med. Sci., September,
1910.
Gibson, G. A.: Bradycardia. Edin. Med. Jour., July, 1905.
Griffith T. W.: Remarks on Two Cases of Heart-block. Heart,
February, 1912.
Hering, H. E.: TJeber den Pulsus pseudoalternans. Prager medic
Wochensch, 1902, Bd., xxvii.
Hewlett, A. W.: Heart-block in the Ventricular Walls. Archives
of Int. Med., September, 1908.
Jolly and Ritchie: Auricular Flutter and Fibrillation. Heart,
May, 1911.
James, W. B.: A Clinical Study of Some Arrhythmias of the
Heart. Am. Jour. Med. Sci., October, 190S.
Kraus and Nicolai: TJeber die funktionelle Solidaritat dor
beiden Herzhiilften. Deutsche med. Wochensch., 1908, xxxiv.,
1-5.
Kussmaul: TJeber schwielige Mediastino-pericarditis und den
paradoxen Puis. Berliner klin. Wochensch., 1873, No. 37.
Laslett, E. E.: Syncopal Attacks Associated with Prolonged
Arrest of the Whole Heart. Quar. Jour, of Med., July, 1909.
Minkowski, O.: Die Registrierung der Herzbewegungen am
linken Vorhof. Deutsche med. Wochensch., 1906, xxxii., 1248.
Neuburger and Edinger: Einseitiger fast totaler Mangel des
Cerebellums, Varix Oblongata?, Herztod durch Accessorius-
reizung. Berliner klin. Wochensch., 1S9S, xxxv., 69-72 and
100-103.
Riegel: TJeber extrapericardiale Verwachsungen. Berliner
klin. Wochensch., 1S77, Xo. 45.
Rihl, .:J TJeber atrioventrikulare Tachycardie beim Menschen.
Deutsche med. Wochensch., 1907, xxxiii., 632-634.
Schmoll, E. : Ataxia of the Heart Muscle. Am. Jour. Med.
Sci., November, 1908.
Stengel and Pepper: Heart-block with an Indication of Genuine
Hemisystole Am. Jour. Med. Sci., October, 1910.
Windle, J. D.: Observations on Pulsus Alternans. Heart,
November, 1910.
Young and Hewlett: The Normal Pulsations within the Esopha-
gus. Jour, of Med. Research, vol. xvi., No. 3, July, 1907.
633
Arrow-Head Hot Springs
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
-San Bernardino County,
Arrow-head Hot Springs. -
California.
Post-office. — Arrow-head Springs.
Access. — By electric car from San Bernardino, six
miles distant to the south. The trolley line is part
of the extensive system covering southern California
owned by the Southern Pacific System. San Bernar-
dino is reached by the Salt Lake, the Southern Pacific,
and the Atchison, Topeka, and Santa Fe Railroads.
The springs and lakes are situated on the side of
the Sierra Madre range.
Thcs,. springs burst from the mountain slope of the
Sierra Madre, 2,000 feet above the level of the sea. and
1,000 feet above the foot of the mountain. A bench-
like mesa, containing 100 acres, projects at this point
from the mountain, and is bounded on the east and on
the west by two enormous canons. Down the deep
ravine or canon on the east comes a mountain stream
of water as cold as ice, while in the canon on the west
flows a stream formed by the boiling spring so hot
that it fills the air with steam and sulphurous gas.
The springs here were known to the Indians long be-
fore the settlement of the country by whites. On
the face of the mountain back of the hotel is the figure
of an arrow-head 1,360 feet long and 4~>0 feet wide,
believed to have been executed by the aborigines.
The figure gives its name to the resort, and so perfect
is its contour and so elevated its situation that it can
be seen from almost every part of the valley, and
stands as a prominent landmark for miles around.
The tent cottages are an attractive feature. The
Arrowhead Hotel is located near the springs, on the
plateau of land between the two canons. The hotel
built in mission style is spacious, with broad verandas,
superb 200 foot foyer and lobby, with great fixed
stone fire places here and there. The bedrooms are
large and cool. The hotel is provided with elevators,
electric lights, shower baths, and every modern
comfort. The Arrow-head estate, hotel, bath house,
grounds and surroundings have been laid out and
designed for a "Kurort," a great natural sana-
torium. The grounds of the hotel cover 1,800 acres,
and include the great Cold Water Canyon up into
the heart of the mountains to the line of the Govern-
ment Timber Reserve and a long reach of the beautiful
Waterman Canyon up which an excellent carriage
road leads to the summit. Arrow-head is on a fine
highway system for automobiles. The meteorological
conditions are similar to those usually prevalent
in Southern California, the weather being, as a rule,
clear, balmy, and bright. The winter season is
most favorable for visiting the springs. These are
37 in number, the aggregate flow of water being equal
to 10 miner's inches. Following is an analysis:
The water shows a very high temperature, 202° F.
The analysis bears some resemblance to that of the
Carlsbad springs. The water is soft, clear, and
pleasant to drink. The springs owe their chief repu-
tation, however, to the beneficial effects of the water
when used for bathing purposes. It is employed in
the form of vapor, hot mineral water, and mud
baths.
Two of the most interesting features at Arrow-head
are these wonderful mud baths and the natural steam
room. The diseases and morbid conditions most
susceptible to the beneficial influences of the Arrow-
head waters are: Rheumatism, especially the chronic
form; gout and the uric acid and lithemic group;
dyspepsia and many chronic digestive disorders
both gastric and intestinal; congestions and cir-
rhoses of the liver, incipient gall-stone formation;
the early stages of heart disease; incipient Bright'.-,
disease and acute nephritis, and disturbances of the
bladder and urinary and prostatic disorders; dia-
betes; skin affections; neurasthenia, neuralgias and
many forms of neuritis, as well as asthma, "colds",
and bronchial affections are generally benefited;
relief from pain, stiffness and incoordination, is often
afforded in paralysis and paresis together with locomo-
tor ataxia and scleroses. The springs offer many
advantages for rest and enjoyment not only for in-
valids, but for those in good health
Emma E. Walker.
Arrow=poisons. — The use of poison to increase the
destructive effect of the arrow is probably as old as
the use of the arrow itself. In the Book of Job
(vi., 4) the poison is spoken of as inseparable from
the arrow: "For the arrows of the Almighty are
within me, the poison whereof drinketh up my spirit. 1 '
That the poisoning of arrows was a practice of the
ancients is shown by our word toxic, which is derived
from to&kos, relating to the bow, to&k6v cf>apfia.K6i>. meaning
arrow-poison. The manliness of the fighting men of
the middle ages led them to regard the use of poison
for their arrows and spears as unworthy of a knight,
much as the dumdum or soft-headed bullet is con-
demned by the moderns, but among savage races
it is still the accepted means of insuring victory in war
or the chase.
Poisons derived from the three kingdoms, animal,
vegetable, and mineral, are used, but for the most
part they are of vegetable origin. Of the mineral
poisons, arsenic and antimony are the most common.
The animal poisons are derived from the venom of
snakes, scorpions, and centipedes and from poisonous
fish. Among some of the tribes of American Indiana
it was the custom to stick the liver of a buffalo or
other large animal full of arrows and leave it to rot
ANALYSIS OF ARROW-HEAD WATERS
Grains Per Gallon
By PROF. GILBERT E. BAILEY.
Tem-
pera-
ture
Sod-
ium
chlo-
rid
Sod-
ium
car-
bon-
ate
Sod-
ium
sul-
phate
Sod-
ium
bor-
ate
Potas-
sium
sul-
phate
Potas-
sium
chlo-
ride
Cal-
cium
car-
bon-
ate
Mag-
nesium
car-
bonate
Mag-
nesium
sul-
phate
Silica
Lithia
Hy-
dro-
gen
sul-
phide
Iron
Total
Penyugal Hoi Spring.
Wa terman H o t
Springs.
Graniti! Hot Spring. .
202°
200°
100°
ISO"
7.070
6.104
6.607
5.269
2.733
1 244
1.045
3.224
2 . 243
2 903
42.650
33.215
34 . 6S7
90 Q03
0.887
4 007
1 594
2.395
i !.;7
4.246
3.521
4.211
3 nss
0.403
0.210
0.151
0.531
0.169
0.629
5.S06
4. 70S
5.301
4.240
0.911
1 . 758
Tr:ice
Trace
Trace
Trace
0.491
0.140
0.128
0.134
l',7 2D.5
.',2.675
55 78S
47.062
1 471 1 022
n n?n l sis
8 303
) 75J
O 367 1) 128 O 7v>4
Trace
* ''old Water Arrow-head Canyon.
t Cold Water Canyon.
g:u
niir.HKxci: handbook of the medical sciences
Arrow-poisons
i a damp place. The Apaches are said to have
| the beads of rattlesnakes with fragments <>f
i '- liver ami when the mass had become putrid the
beads were dipped in it and dried slowly. By
ome tribes the heads of veni us snakes were
I. a and the ashes moistened with water, the
mil so formed being smeared over the lame points
row heads. The toxic effect of such a prepara-
ion was probably more imaginary than real, unless
here was some other substance added, the nature
[ which was not revealed. In most cases, indeed,
iparation of the poison was a secret process
DOWH only to the medicine men and chiefs, the
lanipulations witnessed by the public being ex-
in nature and designed to impress the
lultitude while concealing the actual methods em-
Comparatively few of the vegetable arrow-poisons
Asia, Africa. .South America, and Australasia
ave been analyzed or indeed even identified with
ertituds. In most cases an extract is used, the
ource being kept among the secrets of the medicine
nen or chiefs, and revealed least of all to the strange
hite man. In many cases there is a mixture of
-itraets from several plants which still further
es the difficulty of identification. Xeverthe-
e number of natural orders of plants from
uembers of which arrow-poisons are known to have
ieen made is considerable and the number of genera
.irge. The natural orders best known in this con-
icction are Apocynaceae, and Loganiaceae, and
^preventatives of each are used in widely separated
egions of the world. The Apocynaceae are repre-
ented by three principal genera, Acocanthera, species
.mi varieties of which are used throughout Africa
.nd in the Fast Indies, Strophanthus and Adenium,
ihich are also used extensively in various parts of
\frica. The Loganiaceae, which comprise various
of Stryehnos including those which furnish
•urare, represent all the arrow-poisons of the Western
lemisphere and also are used extensively in the East
and Malay and are of considerable significance
:: Africa. Other natural orders represented in force
ire the Euphorbiaceae, which furnish a number of the
ninor poison plants of Africa, the Urticaceae. which
urnish species of the Antiaris much used in the East
indies and Mala}-, while the Ranunculaceae are
■epresented in the Himalayas by Aconitum, and the
Leguminosse by Erylhrophlaum in Africa and
Denis in Asia. It is not uncommon to find com-
ins of poisons from two natural orders or
genera. To go a little more thoroughly into the
and species, at least four species of Acocan-
hera are the main sources of special kinds of poison,
ivhile Strophanthus is represented by six, Adenium
>y two, and Euphorbia and Stryehnos each by a large
number. Antiaris and most of the other toxiferous
jenera are represented apparently b}' a single
It must of course be borne in mind that these plants
ire only the ultimate sources of the chief poisonous sub-
dances. The presence of other ingredients and the
technique of preparation enter extensively into the
individuality of the commercial (so to speak) articles.
The best known among the latter are waba or ouabaio
which is obtained from one species of Acocanthera
and used extensively in Eastern Africa. The poison
known as fra fra, used in the Gold Coast is also be-
lieved to be derived from a member of the same
g-'nus, while in the North East and in Southern Africa
other species are used for the same purpose. The
mode of preparation is inspissation of a decoction
of the wood, and the active toxic principle is a gluco-
side which is a cardiac poison. Other ingredients are
added to this extract. It is affirmed that waba used
utow poison will kill a man in a few minutes.
Kombi, a poison obtained from different species of
Strophanthus is much used in Central and Western
Africa and is far less toxic than i fra fra.
i. decoction is made of the strophai apo-
rated and mixed with various ingredients. The ti
action is that of strophanthus, arresting the heart in
systole in fifteen or more mi mite-. /•;. huja i- a poison
pn pared from the sap of species of Adenium which
exudes through the action of heat. This Bap is very
10US and is wound upon wooden bobbins. I'n-
like mosl of the arrow poisons it is a pure extract,
and is used just as prepared. It is an intense cardiac
poison like the Others enumerated and is used both
in German Wesl Africa and in Somaliland. The
Pygmy Arrow Poison so-called, is a mixture of extract
of Erythrophlanim judiciale and strychnine and is
powerful enough to kill elephants. The M
Arrow Po I by a single Central African people
is of unknown composition, a moderately virulent
cardiac poison. L used to some extent in
Herman I -last Africa, is also of unknown composition.
It is perhaps a mixture of species of Acocanthera and
Euphorbia.
The arrow-poisons used in Asia are limited very
largely to the Malay Peninsula and Fast Indies. They
are used to some extent, however, in Hindoostan and
the Philippines. A poison known by a variety of
native names, one of which is upas, and another poison
dajaksch, both consist of or contain the dried sap of
ri's toxiearia. These poisons are — sometimes at
least — mixed with a species of Stryehnos and other
ingredients. The active principle of the sap is a
glucoside which is a cardiac poison, the action of
which resembles that of digitalis. The word upas or
ipoh, with some qualification, is also used for arrow-
poison prepared from various species of Stryehnos
alone. Some of these poisons as they actually occur
should greatly resemble in composition and action the
South American woorara, or curare. They are used
in Malacia and Borneo, and to some extent in Hindoo-
stan. The principal arrow poison used in the latter
country contains aconite; but although it is used very
extensively throughout the northern part of the
Empire, and is even known in China and Japan,
authorities have little to say about it. It is no doubt
complex and secret in its composition. It has re-
cently been claimed that at least one arrow-poison in
India (that used by the Abors) contains no aconite
but some other substance which benumbs the tongue.
According to Windsor (British Medical Journal,
Jan. 6, 1912) the active principle Is from the croton
oilplant (not the seed). In the Philippines one arrow-
poison is in use by the Negritos. It is said to be pre-
pared from a species of Rabelaisia and to be a cardiac
poison.
The arrow-poison used in Australasia is a mixture
of animal, vegetable, and mineral matter and little
is known or said of it. While arrow-poisons have been
and are used extensively by the South American
aborigines they are almost all of one character.
Known as teoorara or curare they are obtained from
various species of Stryehnos (see Curare). A few less
virulent poisons are used to some extent in South and
Central America.
Authorities give sections on the treatment of arrow-
poisoning, but this appears to be largely founded on
a priori considerations. The rapidity with which
some of these poisons kill, and the mixture of animal
and vegetable poisons, the former comprising such
substances as snake venom, and cadaveric and sep-
tic poisons make antidoting difficult. Despite the
fact that some of these poisons already contain
strychnine it is advised to inject the alkaloid to
antagonize the cardiac failure. Aside from the gen-
eral management demanded by any poison wound it is
apparently the custom to apply permanganate of
potash in 3 per cent, solution locally. This oxidizes
and destroys some of the toxic material, including of
course all venoms.
Edward Preble.
G35
Arrow-poisons
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Literature.
The number of journal articles on individual arrow-poisons is
too great to be given here, and moreover many of the observations
have been made by untrained observers and add little to the knowl-
edge of the subject. The reader may consult with advantage
"Die Pfeilgifte " by L. Lewin, Berlin, 1894. The subject is also
very well treated in Geissler-Moeller's Real Enzyklopiidie der
gesamten Pharmazie, 1904-1912, and in Castellani and Chalmer's
Manual of Tropical Medicine, 1910, both of which have been con-
sulted in the preparation of this article.
Arrowroot. — Arroivroot Starch; Maranta Starch.
The starch obtained from Maranta arundinacea L.
(fain. Marantacece). The genus Maranta contains
some fifteen species, natives of tropical America.
They are perennial herbs, with tuberous or thickened,
starch-laden, scaly rhizomes, and leafy, often branched
stems.
The arrowroot plant is extensively cultivated in
nearly all tropical countries. A large amount of
arrowroot is now produced in Southern Asia. The
Indian plant differs somewhat from the American,
but is considered as only a variety of it.
The early medicinal application of arrowroot among
the aborigines appears to have been as a remedy for
the wounds of their arrows, to which it owes its name.
It was both given internally and applied as a poultice
on the injured part. It was also used as a food.
Accounts of its cultivation in the West Indies date
back about 150 years, since which time it has been
an article of general commerce.
Arrowroot is prepared in essentially the same way
as other starches, namely, by washing -it out of the
cellular tissue. The yield is about ten per cent, of
the fresh rhizome. That of the West Indies, generally
called Bermuda arrowroot, is regarded as the best.
It is a beautifully white, lumpy powder, without
odor or taste. Rubbed between the fingers it gives
a slight crackling sound, or rather, feeling, for the
sensation is conveyed more through the fingers than
the ears. Its other properties are simply those of
starch in general, to which the reader is referred.
When the antiphlogistic treatment of diseases was
more in vogue than at present, arrowroot took quite
an important place in the dietary of the sick. It was
also extensively used as an ingredient of foods for
infants. For neither of these purposes is it to be
much recommended. As a food, it has scarcely any
advantages over the cheaper indigenous starches now
so admirably prepared.
Florida arrowroot is a starch prepared from the
large fleshy stem of Zamia integrifolia Jacq.
H. H. Rusbt.
Arrowroot, Indian. See Curcuma.
Arsacetin. — Trade name of sodium acetyl-arsan-
ilate, C,H,O.NH.C„H 4 AsO(ONa)(OH)+5H_,0._ It is
derived from sodium arsanilate by the substitution
of a hydrogen atom in the amino group by an acetyl
radical, and may also be prepared by adding acetyl-
arsanilic acid to a warm concentrated soda solution.
It occurs in the form of fine light aeicular crystals,
without odor or taste, soluble in ten parts of cold
water and about three parts of boiling water. It is
employed in the treatment of trypanosomiasis, for
which purpose some prefer it to atoxyl, than which
it is said to be less toxic and more efficacious. Good
results are also claimed in the treatment of syphilis,
given hypodermically in doses of gr. i. (0.06) on two
successive days in each week for ten weeks. In try-
panosomiasis (sleeping sickness) it has been given in
doses of gr. i.-v. (0.06-0.3) hypodermically.
Arsanilates. — These are organic arsenic eom-
pounds, salts of arsanilic acid, the latter being derived
iron) arsenic acid by the substitution of one of the
hydroxyls (HO) by an aniline radical. The arsan-
ilates are employed in the treatment of various pro-
tozoal diseases, such as trypanosomiasis, syphilis
and yaws. The most commonly employed arsan-
ilates are arsacetin (sodium acetyl arsanilate) and
atoxyl or soamin (sodium arsanilate). T. L. S.
Arsenic. — Arsenic is a member of the group which
also contains nitrogen phosphorus, and antimony.
It occurs free, but is more often found in combination
as a sulphide. Its symbol is As, valence. III or V,
and its atomic weight is 75. It possesses a steel-grav
color and a pronounced metallic lustre.
General Medicinal Properties op the Com-
pounds of Arsenic. — The predominant feature of
the action of arsenical preparations is intense irri-
tation. Locally applied in fairly concentrated form
to a denuded surface the irritation is so severe as to
excite the extreme of reaction, namely, gangrenous
inflammation; the part sloughs, strangulated by con-
gestion and inflammation. Arsenic is thus indirectly,
and, because indirectly, is slowly, painfully, and
dangerously caustic. When arsenic is used to cau-
terize, there is also a risk of absorption of enough of
the mineral to produce constitutional poisoning, a
risk greater when the application is weak than v.
it is strong, since in the latter case congestion is
developed early, whereby absorption is impeded.
When arsenic is taken internally, gastrointestinal
irritation is easily produced, a result which, in acute
arsenical poisoning, constitutes the most prominent
feature of the derangement. Apart from a tendency
to irritate, arsenic is fairly antiseptic, and in the,
higher organisms, such as man, has an action upon the
nervous system. In arsenical poisoning nervous
symptoms are prominent, and, therapeutically, much
of the benefit of arsenicals hinges upon the allaying
of nervous derangements.
For the purposes for which arsenic is used in medi-
cine the remedy has to be administered continuously
for days, weeks, or months. In this medication the
rule is so to adjust the dosage as not to develop con-
stitutional disturbance. The initial symptoms of
overdosage with arsenic are, first, an irritation of the
conjunctiva, showing itself in suffusion and smarting
of the eye, and edema of the lower lid; and secondly,
an irritation of the stomach, shown by failure of
appetite and soreness and sensation of weight at the
epigastrium. In some persons the gastric symptoms
precede the conjunctival. The two sets of sympti
should be watched for in arsenical medication, and
the dosage diminished or temporarily discontinued
until their abatement, which speedily follows the
withdrawal of the poison.
Arsenic is valuable therapeutically on account of:
Improvement of Nutrition. — Even in the healthy
carefully graduated dosage with arsenic tends to im-
prove general nutrition, the individual fattening, the
skin being specially rosy and smooth, or, in animals
the fur sleek and glossy, and the bones thick and dense.
In the case of the so called arsenic eaters of Styria, the
women are said to indulge for the beautifying of their
complexion, and the men for an improvement of wind
and increased physical endurance which they claim
to derive from the use of arsenic. This habit of regu-
lar consumption of arsenic among certain of the work-
ing class in Styria seems now established as a fact by
competent and reliable testimony. Arsenous acid
is the preparation commonly used, and the daily
allowance has been known to reach five and even tea
grains. But attempts in other countries to acquire
the tolerance of the poison which the Styrian peas-
antry show commonly end in disaster. The prop-
erty of arsenic to modify nutrition is utilized prin-
cipally in the following diseases: Progressive per-
nicious anemia: In this affection, where iron is so
63G
-
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Arsenic
lotoriously futile, arsenic has in many cases proved
,i great benefit, patients even recovering fully under
tsuse. Scaly skin diseases: In skin diseases arsenic
more or less used, bu( experience shows that it is
•!, more likely to be of benefit in affections of the
pidermis than in those involving the corium. Psori-
, a typical disease of the runner kind, and in its
reatment arsenic is a standard remedy. At the
icginning of an arsenical course the symptoms often
utter an exacerbation, but this commonly subsides
B few davs. The medicine should not be pre-
oribed during the inflammatory stage <>f a skin dis-
nit when used should bo persisted in for weeks
en months after apparent cure. Under all
imstances, the remedial action is slow.
o\ of Veuroses. — The property of arsenic
o affect nerve functions, seen in the nervous phe-
omena that attend arsenical poisoning, shows itself
lerapeutically in a tendency to abate pain, spasm,
m.| undue reflex irritability. The property is util-
.1 most especially in the following conditions:
irritability: In idiopathic dyspeptic irri-
abUity of the stomach, or in the irritability at tend ins;
lie chronic gastritis of drunkards, or ulcer or cancer
if the stomach, arsenic is often of considerable benefit,
md is especially efficacious when the nervous dis-
urbance is disproportionately great. Neuroses of
he respiratory organs: Some asthmatics find a
■rtain amount of temporary relief from arsenic, a
vlief more likely to be obtained in the pure neurotic
orni of the disease than when the symptoms are
econdary to bronchitis, emphysema, or disease of
he hi': rt. Yet the nerve irritation in coryza may
ie relieved, and, according to Ringer, paroxysmal
rig is often promptly averted by the remedy,
tcept when caused by true hay fever the result of
lie inhalation of pollen. In chorea arsenic is prob-
ibly the most generally serviceable of medicines.
Simple uncomplicated cases recover under the use
if the remedy more frequently than not. Neuralgia
tlso sometimes yields to arsenic, more particularly
ivhen the attacks show a regular periodicity of onset;
D other words, when the affection is very likely of
nalarial origin. Other neuroses also, such as angina
lectoris, and even epilepsy, have occasionally been
rented by arsenic, and isolated cases have been
•eported in which benefit has been claimed from the
medication.
Besides the foregoing, arsenic has been used in a
_'reat variety of diseases on the general principle of
being an "alterative," with alleged success in many
uses.
The Preparations of Arsenic Used in Medi-
cine. — The arsenical compounds used in medicine
ire the trioxide (arsenous acid), triiodide, and the
dts, potassium arsenite and sodium arsenate.
Arsenic Trioxide, As.,03. This well known com-
pound is official in the U. S. P. as Arseni Trioxidum.
This is the preparation known also as white arsenic,
or, in common parlance, simply arsenic. Arsenic
trioxide occurs either as an opaque white pow'der,
or in irregular masses of two varieties: one amor-
phous, transparent and colorless, like glass; the other
crystalline, opaque or white, resembling porcelain.
Frequently the same piece has an opaque, white,
outer crust enclosing the glassy variety within. Con-
taot with moist air gradually changes the glassy
into the white, opaque variety. Both are odorless
and tasteless. In cold water both varieties dissolve
very slowly, the degree of solubility varying according
to conditions and time, the glassy variety requiring
about 30, the porcelain-like about 100 parts of water
at 25° C. (77° F.). Both are slowly but completely
soluble in fifteen parts of boiling water. In alcohol
arsenic trioxide is but sparingly soluble, but it is
soluble in about five parts of glycerin. Oil of turpen-
tine dissolves only the glassy variety. Both varieties
are freely soluble in hydrochloric acid, and in volu-
tions of alkali hydroxides and carbonates. (U. S. P.)
Arsenic trioxide is obtained by sublimation, by roast-
ing ores containing arsenic, and is subsequently
purified by resubumation. tor medical use the
mineral is pulverized, appearing then as a very
fine, white, smooth powder, In this condition it is
easily adulterated, but the fraud can readily be
detected by submitting the sample to sublimation,
when the arsenic trioxide will till disappear by
volatilization, and the impurities be declared by a
non-volat tie residue.
Arsenic trioxide possesses all the physiological
properties of arsenicals, a- set forth above. It does
nni act upon the sound skin, but upon a mucous
membrane or denuded surface produces violent irrita-
tion. Taken internally it is capable of sufficient
absorption to produce the constitutional effects of
arsenic, therapeutic or toxic, and so may be used as
a medicine, in doses of gr. ,,\ T (0.002) three limes
a day, generally given in pill. But it is not an
eligible preparation for internal use, because of the
local irritation it is apt to set up. Externally it has
been employed to destroy the tissues of cancer or
lupus, applied in ointment or paste. For such pur-
pose the arsenic trioxide is mixed with from four to
eight times its weight of inert matter, such as oint-
ment or a paste made of some indifferent powder
mixed with mucilage. Such arsenical ointment or
paste is then applied to the tissue to be destroyed,
the point being observed, if the part be covered by
skin, first to remove the epithelium by blistering.
The application is to continue for from twelve to
twenty-four hours. Weak arsenical mixtures are
more dangerous than strong, because of the greater
likelihood of constitutional poisoning. Even strong
applications, if at all extensive, are risky, and at
best the destruction of tissue by arsenic is a slow,
uncertain, and very painful process, not to be com-
mended. Most of the numberless caustic pastes of
quack "cancer doctors" are preparations of arsenic
trioxide. The only preparation of arsenic trioxide
official in the U. S. P. is what is entitled Liquor Acidi
Arsenosi, Solution of Arsenous Acid. This is a one-
per-cent. solution of the arsenical in water slightly
acidulated with hydrochloric acid. The preparation
is of the same strength as Fowler's solution (see
below), and is given in doses of njt iii. (0.2) three times
a day, largely diluted with water.
Arsenic Triiodide, Asl 3 . — This compound is official
in the U. S. P. as Arseni Iodidum, Arsenic Iodide.
It is "an orange-red, inodorous, crystalline powder,
stable when protected from direct sunlight and kept
in a cool place. Soluble, with partial decomposition,
in about twelve parts of water, and in about twenty-
eight parts of alcohol at 25° C. (77° F.); completely
soluble in chloroform, carbon disulphide, or ether.
No loss of iodine occurs when arsenous iodide is
heated upon a water bath, but at higher temperatures
it completely volatilizes. When warmed with a few
drops of nitric acid, brown vapors of nitrous oxide
are evolved, followed by violet vapors of iodine.
The aqueous solution has a yellow color, is neutral to
litmus paper, and upon standing gradually decom-
poses into arsenous and hydriodic acids." (U. S. P.)
This iodide has been given internally as an arseni-
cal in doses of gr. ^ (0.005), and used externally on
malignant growths in a one-per-cent. ointment; but
its principal purpose among medicines is to furnish
the pharmacist with the arsenical ingredient of the
official preparation, Liquor Arseni et Hydrargyri
lodidi, Solution of Arsenous and Mercuric Iodides,
commonly known as Donovan's Solution. This is an
aqueous solution of one per cent, each of arsenous
iodide and red mercuric iodide. It is a pale yellow
fluid, slightly astringent in flavor, and precipitating
with alkalies, silver solutions, and solutions of alka-
loidal salts. It is used as a composite "alterative"
637
Arsenic
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
internal medicine, its reputation being principally
in the line of .scaly skin disease, syphilitic or idio-
pathic, and in rheumatic affections. Dose, m> iss. (0.1).
Potassium Arsenite. — An arsenite of potassium is
official in the U. S. P. only in the solution entitled
Liquor Polassii Arsenitis, Solution of Potassium
Arsenite, better known by the common name of
Fowler's Solution. This solution is made by boiling
one part of arsenic trioxide and two of potassium
bicarbonate in water until chemical union is effected,
then bringing the solution to the standard strength
of one per cent, of arsenic trioxide, and adding three
parts of compound tincture of lavender. This latter
addition is to give the preparation sufficient taste and
color to prevent its being mistaken for simple water.
Fowler's solution is clear, and tastes only of lavender.
It responds to the usual tests for arsenic. Physio-
logically it acts the same as would a solution of
arsenic trioxide of like strength. It was originally
prepared in imitation of a famous remedy known as
"tasteless ague drop," and is the most convenient
and commonly used arsenical for internal administra-
tion. The average dose is gtt. iii.-v. (0.2-0.3), well
diluted with water, to be taken, like all arsenicals,
after eating, and repeated two or three times a day.
Sodium Arsenate, Na,HAs0 4 +7H,0. — The salt is
official under title Sodii Arsenas, Sodium Arsenate.
It occurs in "colorless, transparent, monoclinic
prisms, odorless, and having a mild, alkaline taste;
it should be tasted with great caution as the salt is
very poisonous. Efflorescent in dry air, and some-
what deliquescent in moist air. Soluble in 1.2 parts
of water at 25° C. (77° F.)., and very soluble in boiling
water; very sparingly soluble in cold, but nearly
insoluble in boiling alcohol. When gently heated,
the salt loses five molecules of water (28.8 per cent.),
and is converted into a white powder. At 148° C.
(298.4° F.)> the rest of the water of crystallization is
lost, the salt fuses, and at a red heat is converted into
pyroarsenate." (U. S. P.) Sodium arsenate has the
usual properties of the arsenicals, but is a little milder
than potassium arsenite. ' It is generally prescribed
in the official Liquor Sodii Arsenatis, Solution of
Sodium Arsenate, which is simply a one-per-cent.
aqueous solution of the salt. This solution may be
given in the same dose and manner as Fowler's
solution.
Exsiccated Sodium Arsenate, Na 2 HAsO„ containing
not less than ninety-eight per cent, of the pure anhy-
drous salt, is official under the name Sodii Arsenas
Exsiccatus. "An amorphous, white powder; odor-
less, and having a mildly alkaline taste; it should be
tasted with great caution, as the salt is very poisonous.
Permanent in dry air. Soluble in three parts of water
at 25° C. (77° F.), and very soluble in boiling water;
very sparingly soluble in cold, but nearly insoluble in
boiling alcohol. When heated to 150° C. (302° F.),
the salt should not lose weight; at red heat it is con-
verted into pyroarsenate. It imparts an intense
vellow color to a non-luminous flame." (U. S. P.)
Dose, gr. ^ (0.003).
R. J. E. Scott.
Arteries, Anatomy. — See articles on the various
regions — Abdomen, Arm and Forearm, Leg, Neck, etc.
Arteries, Anomalies of. — Arteries are subject to
frequent variations of size, origin, and distribution.
Some of these are so common that it is difficult to
decide what is the normal condition. Many anoma-
lous arteries are merely a persistence of an early fetal
condition, others are reversions to forms of distribu-
tion which are natural in the various species of the
lower animals, while some are due to an abnormal
enlargement or diminution of vessels which naturally
exist. I propose in the present article chiefly to
describe those anomalies which are important surgi-
cally — that is, those which exist in parts liable to dis-
ease which necessitate a surgical operation for theii
cure or relief. However interesting would be a con-
sideration of anomalies of arteries from a morpholog-
ical point of view to pure anatomists, I fear the sub-
ject is not of sufficient interest to the general profession
to justify me in devoting much space to it here.
Aorta. — This vessel is subject to many variations.
It may vary in length and position. The summit ot
the arch has been seen as high as the top of the sternum
and as low as the fifth dorsal vertebra. The distance
to which it reaches on the spine before dividing into
the two common iliacs also varies, the point of division
being occasionally as low as the fifth, and as high as
the third, or even the second lumbar vertebra. The
aorta has been seen consisting of two closely united
tubes, in part or the whole of its course, due to a per-
sistence of the original double aorta of early fetal life
(Fig. 354). The aorta is sometimes very tortuous, of
large size, and displaced to one side, especially in old
people, but this
condition is due a /^T\
more to patho-
logical changes
than to congen-
ital malforma-
tion.
The m a i n
trunks of the
aorta and pul-
monary artery
are (4, Fig. 354)
both derived
from the arte-
rial bulb of the
fetal heart,
"and are liable
to variations
which may be
traced to devia-
tions from the
natural mode of
their septal di-
vision and of
th eir union
with the left or
right ventricles
of the heart
respectively"
(Quain's "An-
atomy"). These variations are generally associated
with malformations of the heart, and often with pa-
tency of the ductus arteriosus. The aortic or pul-
monary trunk may be almost obliterated, or the two
trunks may communicate freely with each other, ow-
ing to the failure of complete septal division; again,
their origins may be transposed, the pulmonary an
arising from the left ventricle and the aorta from
the right. A very rare anomaly has been reported
where the pulmonary artery and aorta form one
stem which arises from a simple heart like that seen in
fishes. A few cases are reported in which the de-
scending aorta arose from the pulmonary artery and
gave off the left subclavian, the left ventricle giving
off only the innominate and left carotid. Most of
these varieties are incompatible with life, and are
fully described in works on pathological anatomy.
Varieties of the Aortic Arch. — The various anomalies
of the aortic arch depend on the mode of develop-
ment of the fourth and fifth fetal branchial arches.
In man and nearly all mammalia the arch is a left one,
produced l\\ i lie per- \ tence of i he fourl h left branchial
arch (Fig. 355). In birds the permanent aorta i
formed from the right fourth branchial arch; and in
reptiles both the right and left fourth branchial arches
are persistent. In cases in which there is transposition
of the heart, and also, of course, of the arch of the
aorta, the aorta is a right one, instead of the usual left,
5'
Fig. 354. — Diagrammatic Outlines of Heart
and First Arterial Vessels of the Embryo, as
Seen from the Abdominal Surface. 4. Aortic
bulb; 5, 5, the primitive aortic arches and their
continuation as the descending aorta. These
vessels are separate in their whole extent in .1
(36 to 38 mm. in thickness), but at a later
period, as shown more fully in C, have coal-
esced into one tube in a part of the dorsal
region. In B, below upper 5. the second
aortic arch is formed and farther down the
dotted lines indicate the position of thesuo-
ceeding arches, numbering five in all. (Quain's
"Anatomy.")
638
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Arteries, Anomalies Of
md this is owing to the persistence of the right fourth
branchial arch, as in birds. The pulmonary artery in
hese cases i> also transposed and is formed from the
ighl fifth arch in place of from the left. .Many of
these cases have
ct\l\ <^«, /I/ * been reported and
have been diag-
nosed during life,
the. direct ion of I he
apex; of the heart
being toward the
right, the apex beat
being felt on the
right side between
the fifth and sixth
ribs. A very good
specimen of this
anomaly is to be
seen in the museum
of the Pennsylva-
nia Hospital in
Philadelphia.
Occasionally the
aortic arch has
been observed coin-
Iil itely double dig.
356), as in reptiles,
due to the persis-
tence of both right
and left aortic roots
(a, a', Fig. 355) and
the fourth bran-
chial arches of both
sides. The double
aorta embraces the
trachea and esoph-
agus, and unites
below to form a
single trunk on the
left side of the
spinal column, as in
early fetal life (B,
Fig. 355. — Diagram of the Fetal Aortic
, Showing Their Transformation
the Permanent Vessels of the Mam-
mal. (After Rathke.) The permanent
are represented by the deep
tg, the pulmonary arteries lighter,
tporary primitive arehes in out-
iv. A, P, Primitive aortic stem,
[ into A, aortic arch, P, pul -
nary artery; a, right aortic root: a' left
i< root: A' , descending aorta; 1, 2, 3,
1, 5, primitive vascular arches; pn, pn' ,
ml left pneumogastric nerves; '',
,-'. right and left vertebrals; s, s', right
Etnd left subclavians; ce, external caro-
. ri', internal carotids. (From
Quoin's "Anatomy.")
Fig. 354).
The aorta may pass to the right of the trachea and
esophagus instead of to the left, and this without
the transposition of the heart mentioned above.
If we study the fetal conditions the explanation of
this anomaly is easy. It is a persistence of the right
fourth branchial arch and aortic root instead of the
left i Fig. 355). In
these cases the re-
current laryngeal
nerve of the left side
hooks around the
subclavian, and
that of the right
around the arch of
the aorta. In some
of the cases of right
arch that have been
observed the left
subclavian arose
from the back part
of the descending
aorta, passed be-
hind the trachea,
I reached its
usual position in the
neck between the
alene muscles. In
9 of this kind
tlie first part of the
subclavian being
absent, owing to
the non-develop-
ment, or rather obliteration, of the fourth left
ular arch, the inferior laryngeal nerve does
not hook around it, but goes directly, to the larynx,
Fig. 356. — Example of a Double
Ascending Aorta, from the Arch of
Which Arise Six Branches — Two
Subclavian and Four Carotid Arteries.
(After Malacarne.)
I'm,. 357. -
T h e
Right Subclavian Ar-
tery Displaced or
Proceeding from the
Right Aortic Root.
a, right aortic root
mg as thesub-
claviau artery; a',
left aortic root; P,
pulmonary artery.
(Q u a in 's "Anat-
omy.")
and the vertebral artery may arise directly from the
arch.
Variations in Number and I' f the Bran
of the Arch of the Aorta.- These variations are very
numerous; 1 shall mention only the most common
and important. The branches of the aortic arch
may be gi-, en off from a single I riink,
which forms what is called the an-
terior aorta. This arrangement is
seen in the horse. 'I he common-
e t abnormal arrangement of the
branches is thai where the left
carotid arises from the innom-
inate; 1 1 1 1 1 3 only two bfanchi are
given off from the arch, the left
subclavian and the innominate*
This is the usual distribution in
most of the carnivora. There may
lie two Denominates given oil' from
the arch, each dividing into a
carotid and subclavian, as in the
bat. Three branches is the normal
number arising from the arch in
man, apes, and a few other animals.
i Iccasionally we see three branches
A, A', ascending and ar i s j n g from the arch in a different
descending portion from the norma l. We may
; have the two subclavians arising
separately, and the two carotids
arising from a common stem be-
tween them. This is the normal
disposition in some cetacea. Some-
times all four vessels arise sepa-
rately from the arch. Again, the
left vertebral may arise from the
arch, while the other branches preserve the normal
arrangement, or there may be five branches given off
separately, viz., the two subclavians, two carotids, and
left vertebral. As many as six branches have been
seen to come off from the aortic arch. This occurs
when, in addition to the above-mentioned five
branches the right vertebral is also given off. A
curious anomaly, and one which is interesting from its
rarity and manner of development, is that form of
arch, where the right and left carotids and left sub-
clavian arises separately from the arch, and the right
subclavian arises from the back part of the descending
aorta, passes behind the trachea and esophagus and
ascending portion of the arch,
and reaches its normal place
between the scalene muscles
(Fig. 357). In this case the
right inferior laryngeal nerve,
instead of hooking round the
subclavian, passes directly to
the larynx. The subclavian
here represents the persistent
right aortic root, and the
right fourth branchial arch is
obliterated (see Fig. 355).
Some years ago I met with a
curious anomaly having some-
what this character. I looked
upon it as a double sub-
clavian. The right subcla-
vian was given off as usual
from the innominate, but was
joined in the second part of
its course, between the scalene
muscles, by a small branch
which arose from the back
part of the descending aorta. I considered this a case
of persistence of the fourth right vascular arch, and also
of the right aortic root (Fig. 358). (lor a complete de-
scription of the very many varieties of the arch of the
aorta, see Turner on " Varieties of the Arch of the
Aorta," in Brit, and For. M , d.-Chir. I\< r.,lS62; Henle's
" Anatomy, " vol. iii.; Hyrtl; and Professor Struthers.)
Fig. 358.— Right Aortic
Root Persisting as a Small
Branch Which Connects
theDescending Aort;, with
the Subclavian. May be
regarded as an example of
double subclavian.
039
Arteries, Anomalies of
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Innominate, or Brachiocephalic. — This artery
occasionally varies as to the point of its division. In
some cases it divides above the sternoclavicular artic-
ulation, and in others considerably below it. When
there is a high division, there is danger of its being
wounded in tracheotomy, especially in those cases in
which the artery inclines to the median line. In
cases of ligature, however, the operation would be
much facilitated by a high division, and rendered
much more difficult by a low one.
The thyroidea ima or middle thyroid (Fig. 359) is not
infrequently given off from the innominate, and as-
cends to its destination in front of the trachea. When
present it would complicate the operations of trache-
otomy and excision of the thyroid gland. In observa-
tions by myself on 250 subjects, I found that this artery
occurred twelve times or once in 20.83 cases. Richard
Quain, in his valuable work on the arteries, found it
nine times in 291 subjects, or once in 32.33. It is
sometimes of large size, dividing into two branches,
one of which goes to each lobe of the thyroid gland.
This artery sometimes arises from the right common
carotid, and rarely from the arch of the aorta between
the left carotid and innominate.
Common Carotid Arteries. — These vessels may
vary in their origin and place of division. The right
carotid occasionally arises directly from the arch of the
aorta either alone or with
the left carotid. In the
latter case the artery, to
reach its usual position on
the right side, crosses the
trachea above the upper
border of the sternum, a
fact worth remembering
in connection with the
operation of tracheotomy.
It may arise above or be-
low the sterno-clavicular
articulation, according as
the innominate is longer
or shorter than usual. The
left carotid varies more
frequently in origin than
the right, as it is derived
from the innominate in
about one case in nine.
It may also arise from the
arch in common with the
right carotid.
Place of Division. —
The common carotid often
varies as to its place of division. The normal divid-
ing point is opposite the upper border of the thyroid
cartilage, but it sometimes divides as high up as the
hyoid bone, and as low down as the cricoid cartilage.
Morgagni reports a case in which it divided at the root
of the neck. Cases are recorded in which it did not
divide at all, one or other of its main branches being
absent. I have occasionally seen this artery give
off the superior thyroid and ascending pharyngeal
before its division, and also a small laryngeal. I
also once saw the left carotid giving off the left
vertebral.
External Carotid and Its Branches. — As men-
tioned above, the origin of the external carotid varies
considerably. It has in rare cases been noticed
arising from the innominate, and even from the arch
of the aorta itself. Absence of this artery has been
met with, the branches arising at varying intervals
from a common trunk, representing both internal
and external carotids. The artery sometimes passes
between the digastric muscle, and stylohyoid. I
have in one case seen it pass up to the parotid gland
superficial to both the posterior belly of the digastric
and the stylohyoid, instead of behind them.
The origin of the branches varies considerably; they
640
T.I.—
Fig. 359. — Showing a Middle
Thyroid Artery (T.I.) Arising
from the Innominate and Run-
ning up the Front of the Trachea
to Supply the Thyroid Gland.
(From R. Quain, sligh tly
altered.)
may be crowded together at the commencement ol
the vessel, or at a point higher up. Sometimes they
arise from the main trunk at nearly regular intervals
and occasionally we find several branches arising
from a single stem. Accessory arteries may arise
from _ the external carotid, such as the accessory
superior thyroid and accessory ascending pharyngeal.
The sternomastoid, which usually arises from the
occipital, occasionally arises from the main trunk,
and when this occurs the hypoglossal nerve hook-
around this small branch instead of around the oci i
pital. In consequence of the lower origin of the
sternomastoid, the nerve in such eases passes lower
down the neck before crossing the vessels to reach the
hyoglossus muscle.
Superior Thyroid. — This vessel may be very small
or absent, its place being taken by the artery of the
opposite side and the inferior thyroid of the same
side. It sometimes arises from the common carotid.
The cricothyroid may be of considerable size, and its
superior laryngeal branch may arise from the main
trunk, or pierce the thyroid cartilage instead of the
thyrohyoid membrane, as is the case in many mam-
mals. Mr. Walsham ("St. Bartholomew's Hosp.
Rep.," 1880) has several times met with a large
branch from the superior thyroid crossing the
trachea between the cricoid cartilage and isthmus
of the thyroid. He once wounded it in performing
tracheotomy.
Lingual. — This artery often arises in common with
the facial, and occasionally with the superior thyroid.
Instead of passing beneath the hyoglossus muscle
it has been seen to pierce it.
In some rare cases it has been absent, and its place
has been taken by a branch from the internal maxil-
lary. Its place has been taken also by a branch
from the facial, the submental. Its sublingual
branch is occasionally derived from the facial. The
hyoid branch is often wanting, and in such cases the
hyoid branch of the superior thyroid takes its place.
The lingual sometimes gives off the submental
and ascending palatine artery. In one case of opera-
tion on the dead subject, the writer could not find
the artery in the usual place, but it was found coming
off from the superior thyroid passing up to the
median line of the neck on the thyrohyoid muscle.
It crossed the hyoid bone internal to the lesser cornu,
pierced the hyoglossus muscle, and thence onward
its course was normal (Annals of Surgery, vol. ix.
1889, p. 33).
Facial. — This artery is very variable in size and
also in extent. When the facial is deficient its place
is taken by the transverse facial, internal maxillary.
or ophthalmic, most frequently the first mentioned.
Occipital. — This artery usually arises opposite
the facial, but its place of origin may be above or
below this point. Sometimes it is derived from the
internal carotid or the ascending cervical branch of
the inferior thyroid. It occasionally passes to its
destination superficial to the trachelomastoid mus-
cle, or it may pierce the sternomastoid and splenius
capitis muscles. R. Quain mentions a case in which
it passed superficial to the sternomastoid muscle.
It not infrequently gives off the posterior auricular
and ascending pharyngeal.
Posterior Auricular. — Often a branch of the occip-
ital; sometimes of small size, ending in the sterno-
mastoid muscle.
Ascending Pharyngeal. — Varies greatly in its place
of origin; may arsie from the internal carotid, occipital,
or a linguo-facial branch. It is occasionally double.
Superficial. — This vessel is very often tortuous,
especially in the aged.
The transverse facial is occasionally of large size,
and takes the place of the facial. It is sometimes
double.
Internal Maxillary. — This artery frequently arises
in common with the temporal. R. Quain has observed
REFERENCE HANDBOOK 01 THE MEDICAL SCIENCES
Arteries. Anomalies of
i, two instances arising from the facial, "fr
vhich it coursed upward, to pass beneath the ramus
,f the maxillary bone in the usual situation."
It very frequently (in about 1.5 per cent.) is cov-
iv, I by the external pterygoid muscle, instead of
vine superficially to that muscle, it sometimes
orates the external pterygoid, and rarely the
niernal. It may replace the facial by a 1. ranch
i the posterior dental, buccal, or infraorbital
[nternal Carotid and Its Branches. — This
irlcry in the neck is occasionally very tortuous. It
I known to be absent, its place being taken
the artery of the opposite side or by a branch
the internal maxillary. It is sometimes very
I, smaller than the vertebral (Hyrtl). The
tiding pharyngeal, occipital, lingual, or trans-
facial may arise from the internal carotid.
c communicating branch has been seen going
this artery, while in the cavernous sinus, to the
ia-ilar artery; in such a case the posterior communi-
lating branch is wanting. The posterior cerebral
ifrequently comes off from one of its branches,
terior communicating.
halmic Branch. — This has been seen to come
>1T from the middle meningeal artery. Occasionally
the middle meningeal conies off from the ophthalmic.
I he ophthalmic may, by its nasal branch, supply a
iency in the facial. In fifteen per cent, of cases
rosses beneath instead of over the optic nerve.
I; has been seen to go through the sphenoidal fissure.
Cerebral Arteries. — The anterior cerebral of one side
is often much larger than that of the other. In some
es (lie two anterior cerebral arteries are
united into a common trunk, like the basilar. The
nor communicating artery is sometimes double;
I have once seen it treble. It is often very short.
The posterior cerebral may arise from the internal
carotid by a large posterior communicating. It has
seen by Hyrtl to give off the middle cerebral.
The posterior communicating artery occasionally
comes off from the middle cerebral instead of from
ternal carotid.
Subclavian. — The varieties of origin of this artery
have ahead}' been mentioned in the account of the
anomalies of the arch of the aorta and innominate
artery. It is generally given off from the innominate
on the right side, opposite the sternoclavicular articu-
lation, but occasionally the innominate reaches nearly
as high up as the cricoid cartilage before it divides,
and in these cases the artery would be at an unusually
high level. The highest part of the artery is the
second portion, and it is normally about 1.2 to 2.7
em. (one-half to three-quarters of an inch) above the
clavicle, with the shoulder depressed, but not infre-
itly it may be below, or on a level with, the
clavicle, and sometimes, especially on the right side,
it may be placed as high as 3.7 cm. (one inch and a
half) above the level of the clavicle. It may, in
those rare cases in which a cervical rib is attached
to the seventh cervical vertebra, pass over this rib
in place of the first dorsal, and be raised fully two
inches above the clavicle. I have seen this occur
once in two hundred and fifty subjects examined.
In the living, when this condition exists, it may be,
and has been, mistaken for aneurysm. Sir James
Paget has diagnosed this anomaly four times during
life. It is obvious that the height to which the ar-
tery reaches is important in cases in which ligature
is necessary. I have seen in one case in which there
was an incomplete left first rib the artery pass over
the second rib. On the right side there was also a
rudimentary first rib completed by fibrous tissue.
There was a deep groove in this rib, in which rested
the artery; before complete dissection this was taken
for a cervical rib. The cases for which ligature is
undertaken are chiefly those of aneurysm of the
Vol. I.— 41
axillary artery, in which, in con i qui nee of the con-
dition of the pan , the shoulder is elevated. If the
artery should be al an unusually low level, or even
just behind I he clavicle, tin- operation, a- may be
conceived, would be rendered extremel] difficult.
The third part of the artery in thin people with
small muscles is very superficial, bill in stout, muscu-
lar individuals it is verj deeplj placed. Dupuytren
says: "The third part of the subclavian lies near the
skin in those who are thin and have -hauler and Long
necks, with lean and pendent shoulders; it i-. on the
contrary, deeply hidden in persons who have short,
thick necks and muscular shoulders."
Occasionally the subclavian artery pierces the sca-
lenus anticua instead of going behind it, and more
rarely passes entirely in front of the muscle; of the
first variety I have seen five cases in I wo hundred
and fifty subjects (three on the left and two on the
right side); of the second, in the same number of
subjects examined, I have seen only one example.
The vein may pass with the artery behind the
anterior scalenus, and in very rare cases their normal
positions may be reversed. The trapezius may
cover the third part of the subclavian, or it may have
in front of it the omohyoid muscle. These condi-
tions, however, will be more fully described under
Muscles, A nomalii .-. of.
Variations of Branches.— It is important, surgically
speaking, that the position of the various branches
given off from the subclavian should be considered.
The branches given off from the first part do not,
as a rule, vary much in their arrangement, but
several may be transferred to the second or third
portions. The left vertebral may arise from the
arch of the aorta instead of from the first part of the
left subclavian, and the branches of the thyroid axis
may be given off separately.
The first part of the right subclavian, having been
occasionally ligated, it is necessary to known at what
distance from the innominate the branches arise.
In the majority of cases this is from 1.25 can. (half an
inch) to 2.4 cm. (one inch) (R. Quain); but it often
exceeds this, and is frequently 2.4 em. (one inch)
to 3.S em. (one inch and three-quarters). In a small
minority of cases the distance is under 1.2 cm. (half
an inch).
In the second portion of the artery, one branch, as a
rule, is given off, the superior intercostal; occasionally
no branches are seen here, and again, not infrequently,
there are two or three.
The third portion, in a little more than half the
cases, gives off no branch, in a little less than half,
one branch, occasionally two, and in very rare cases
three and four.
Vertebral Artery. — Origin: The right vertebral, in
those rare cases in which the right subclavian arises
from the arch of the aorta, is given off from the com-
mon carotid of the right side. The right vertebral
has been seen coming from the arch. Mr. A. M.
Paterson (Jour. Anat. and Phys., April, 1SS4) records
a case of right vertebral arising from the aortic arch
beyond the left subclavian, and reaching the vertebra-
arterial canal by passing behind the trachea and
esophagus; in fact, following exactly the course of
the subclavian when it arises from the back part of
the arch, as figured above. Mr. Paterson regards
this anomaly as a persistence of the right aortic root,
with obliteration of the connection between the
subclavian and vertebral arteries where they cross.
The left vertebral not infrequently is given off from
the arch of the aorta, generally between the left
carotid and left subclavian. I have seen this arrange-
ment twelve times in two hundred and fifty subjects.
I have once seen it come off from the left common
carotid. The vertebral has been seen with two,
and even three roots (R. Quain).
Course: This vessel may fail to enter the trans-
verse process of the sixth cervical vertebra, but
641
Arteries, Anomalies of
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
continue up the neck between the inferior thyroid
artery and vein to enter the transverse process of any
of the vertebrae from the fifth to the second. It is
not uncommon for it to enter the transverse process
of the fourth or fifth vertebra, but it is only very
occasionally that it passes up as high as the third and
second before entering the foramen. Again, it may
enter the transverse process of the seventh cervical
vertebra, instead of the sixth.
Size: The left vertebral is frequently much larger
than the right, especially in those cases in which it is
given off directly from the arch of the aorta. Some-
times the vertebral is nearly as large as the common
carotid, at other times as small as the ascending
cervical branch of the inferior thyroid.
Branches: The vertebral may, as a very rare occur-
rence, give off the inferior thyroid or superior inter-
costal artery. I have seen two examples of the first
variety occurring on both sides of same subject. Its
inferior cerebellar branch is frequently absent on
one side.
The thyroidea ima has been observed in rare cases
to come off from the right subclavian.
The upper end of the vertebral artery occasionally
divides into two branches, which unite a little higher
up, thus forming a loop through which pass filaments
of the hypoglossal nerve. I have seen this anomaly
in two instances.
Thyroid Axis. — This trunk occasionally arises
beyond the scalenus anticus muscle (according to
R. Quain twice in two hundred and seventy-three
cases). It not infrequently gives origin to the inter-
nal mammary. It is sometimes absent, its branches
being given off separately from the subclavian.
Inferior Thyroid. — This artery frequently arises
as an independent branch from the subclavian. It
has been seen to arise from the common carotid, and
6.S
Fig. 360. — Inferior Thyroid Artery Dividing into Two
Branches, one of which (a) passes in front of the carotid sheath,
the other (b) behind it. (Anderson: Jour. Anal, and Phys.,
vol. xiv.)
not infrequently from the vertebral. It varies con-
siderably in size, and when small its place is taken
by the superior thyroid. In cases of enlarged thyroid
gland (bronchocele) it is often nearly as large as the
carotid. Two inferior thyroids have been found on
the same side, one having the normal course beneath
642
the carotid artery, and the other reaching its destina-
tion by passing superficially to that vessel (Fig. 360).
Its branches of division are closely connected with
the recurrent laryngeal nerve, which may pass
beneath or above them, a point to be borne in mind
in extirpation of the thyroid gland. The inferior
thyroid may be wanting altogether, its place being
supplied by an enlarged superior thyroid of the same
side.
The ascending cervical branch of the inferior thyroid
may be derived directly from the subclavian or one
of its branches. It is occasionally of large size, and
may take the place of the occipital.
Suprascapular. — This artery is usually derived
from the thyroid axis, but not infrequently has a
different origin. It is often given off directly from
the subclavian. It may be given off from the internal
mammary. I have several times seen it derived from
the subscapular and also from the axillary. It is
often very small.
Transverse Cervical. — This artery when given off
from the thyroid axis divides into two terminal
branches, viz., the superficial cervical and posterior
scapular. Very often the superficial cervical only is
given off from the thyroid axis, the posterior scapular
coming off as a separate branch from the second or
third part of the subclavian, rarely from the first part.
It is well, when ligaturing the third part of the sub-
clavian, to remember that the posterior scapular
comes off from it about once in every three cases.
When the posterior scapular artery is given off from
the third part of the subclavian I have not infre-
quently seen it pierce the fibers of the scalenus
medius muscle, and occasionally go between the
cords of the brachial plexus. The posterior scapular
artery may be given off from the axillary, or it may
end near the scapula in a small branch, its place
being supplied by branches from the suprascapular.
The superficial cervical may come off from the sub-
clavian as a separate branch, the posterior scapular
alone being derived from the thyroid axis. When
the posterior scapular is a branch of the third part of
the subclavian it often gives off a large branch to
supply the trapezius, which represents the greater
part of the superficial cervical, the latter artery in
such cases being very small ^r absent.
The transverse cervical artery is occasionally
given off from the subclavian as a separate branch.
Internal Mammary. — This is a large and very regu-
lar branch of the subclavian, generally arising from
the lower part opposite the vertebral. It may arise
from the thyroid axis, axillary, or innominate, or
even from the arch of the aorta. It may also form
a common trunk with either of the scapular arteries,
and be given off from the second or third part of the
subclavian. Hyrtl describes a case in which the
trunk of this artery crossed in front of the fifth right
costal cartilage, coming out of the thorax through
the fourth interspace and re-entering it by the fifth.
In one case the author saw the phrenic nerve pierced
by this artery.
A branch is sometimes given off from the upper
part of the internal mammary, called by Henle the
A. mammaria interna, lateralis, which crosses the
inner surface of the upper four to six ribs and inter-
costal spaces at right angles, about midway between
the spine and sternum, anastomosing in its course
downward and outward with the intercostal arteries.
In penetrating wounds of the thorax, fractured ribs,
and other injuries, this lateral branch might be
wounded and give rise to dangerous hemorrhage.
It might also be wounded in the operation for evacu-
ating an empyema.
Superior Intercostal. — Sometimes arises from the
thyroid axis or vertebral. I have seen it arise from
the internal mammary. It may be of considerable
size, and may supply three or four intercostal spaces.
It in some cases passes between the neck of the first
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Arteries, Anomalies of
i second rib and the corresponding transverse process
f the dorsal vertebra, li is very rarely absent.
Deep Cervical. — This artery is generally a branch
i the preceding, but occasionally is derived directly
,,m the subclavian, in the proportion of 1 in 20
tbiects (R. Quain). In rare cases it arises from
po terior scapular and interna] mammary. It is
,,t infrequently of small size, its place being taken
, the deep cervical branch of the occipital, a branch
: the inferior thyroid, the ascending cervical or a
osterior cervical branch of the transverse cervical
Henle).
li may pass between the transverse processes of the
ith and sixth cervical, first and second dorsal, or
nil and third dorsal instead of between the
th cervical transverse process and first rib.
Ih, re is sometimes an accessory branch accom-
anyingit.
Axillary Artery. — The most important anomaly
f this vessel is its early division into two trunks, one
f which may give off all or most of the branches, or
lay be a high origin of the radial, ulnar, or even the
iterosseous artery (Fig. 361). When one of the
runks gives off all or most of the branches it is nearly
surrounded by the brachial plexus of nerves
id embraced by the two heads of the median. The
ranches given off from this common stem may vary.
I have seen it give
origin to the acromial
thoracic, long thoracic,
anterior and posterior
circumflex, subscapu-
lar, and one or both of
the profunda arteries of
the arm; the anterior
and posterior scapular
with the subscapular
arteries not infre-
quently come from a
common stem. This
arrangement of the
branches of the axillary
occurs normally in
many animals, e.g. the
lemur, tapir, peccary,
dolphin, etc., and much
resembles that which
takes place in the lower
extremity, viz., the
common femoral divid-
ing into a superficial
and a deep branch, the
deep giving off all the
branches, and the
superficial going down
the extremity branch-
less. According to
Richard Quain, this
variation occurred
twenty-eight times in
506 arms examined. I
have met with it only
fifteen times in 500
irma in which the arrangement of the axillary was
ibserved. Quain gives the proportion of cases in
vhich one of the arteries of the forearm is derived
rom the axillary as 23 in 506; Gruber, 21 in 1,200.
( have found this condition to exist twelve times in
500 arms examined.
The radial is the branch most frequently given
iff in these cases, next the ulnar, and very rarely the
nterosseous. I have only once seen the interos-
seous arise from the axillary.
An aberrant artery is occasionally found arising
;rom the axillary; it generally courses down the arm
alongside the brachial, which it joins near the elbow.
Sometimes this aberrant vessel joins the radial,
Fig. 361.— Origin of Radial (R)
rom the Axillary (B). (After
teeves.)
ulnar, or interosseous artery near the writ. Our
remarkable case Came Under my observation sonic;
years ago in which this aberrant artery passed down
the arm superficial to the la cia, in tic- forearm fol-
lowed the course of the 1 lian nerve, coininiinieated
with the radial by several transverse branches, and
finally ended by taking the place of the superficial volar,
completing the superficial palmar arch il ig. 362).
The most constant branch of the axillary is the
long thoracic or external mammary; this, or a repre-
sentative of it, is nearly always seen running along
tin' lower border of the iieetoralis minor muscle; it,
however, not infrequently arises from the thoracic
axis and occasionally from the subscapular. Then-
may also be an accessory external mammary. The
subscapular and circumflex branches frequently
arise together. The dorsalis scapula 1 , instead of
being derived from the subscapular, may arise directly
from the axillary.
The posterior circumflex occasionally fails to enter
the quadrilateral space (formed by the humerus,
subscapulars muscle, long
head of triceps, and teres
major), but reaches the
deltoid muscle by winding
round the lower border of
the tendons of the latissimus dorsi
and teres major muscles. It not in-
frequently arises from the superior
profunda, and is sometimes double.
In rare cases the internal mammary,
posterior scapular, or suprascapular
may arise from the axillary.
Brachial Artery. — The varia-
tions in the course, relations, and
distribution of this artery are very-
numerous and of special surgical
interest.
Course: The brachial artery some-
times, accompanied by the median
nerve, courses down the arm to the
internal condyle of the humerus, and
thence regains its normal position at
the bend of the elbow, by passing
forward under a fibrous or bony arch.
This arch is formed, usually, partly
by bone and partly by ligament; the
bony process is called the supracon-
dyloid and the fora-
men, which is com-
pleted by a ligair°nt
from the tip of the
process to the in-
ternal condyle, the
supracondyloid for-
amen. In these
cases it is usual to
have a high origin
of the pronator radii
teres muscle from
the supracondyloid
process. This ar-
rangement is said to
be more common in
dark races, and is
the normal one in
all the cat tribe and
in monkeys, lemurs,
and sloths. In
these animals the
foramen is nearly always completed by bone, and
affords protection to the median nerve and artery
during flexion of the fore-limb, and also affords them
a more direct course to the fore-limb. In man the
artery may occasionally take this course without there
being present a supracondyloid process; there may be
only a high origin of the teres muscle.
643
Fig. 362. — Example of an Aberrant
Artery from Axillary, Going to Com-
plete the Superficial Palmar Arch, Tak-
ing the Place in the Hand of the Super-
ficial Volar.
Arteries, Anomalies of
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Division: I have once soon the artery divide near
its commencement into two branches which unite
to form one trunk near the bend of the elbow, from
which the ulnar and radial arteries are given off at
the usual place (Fig. 363).
In 4S1 arms examined by R. Quain a high division
was found sixty-four times, a low division (that is,
below usual place) only once. Gruber, in 1,200
arms examined, found a high division in 82. In 500
arms examined by myself, I found a high division in
only 27, and in one case the brachial divided below
the pronator teres.
Adding to these the cases in which the division
takes place in the axilla, in 4S1 arms examined by
Quain two arteries existed in the arm in 9-4 cases, or
1 in about 5|. My statistics are quite different
from the above, and I cannot account for the great
diversity. The same class of people were examined,
and they were of the same race. In 500 arms I
found that two arteries existed in only 43 cases.
This is made
up as fol-
lows: divi-
sion of axil-
lary, 12; di-
vision of
brachial, 27; aberrant arteries, 4
— total, 43, or 1 in 11.6 cases.
W. Gruber, in 1,200 arms, found
a high division in 103, or 1 in
11. (3, the same proportion exactly
as in my own cases.
The point of division is in most
cases in the upper third of the
arm. It is also seen in the mid-
dle and lower thirds, but much
Fin. 363. — Brachial Dividing
High up, Reuniting at Elbow,
and then almost Immediately
Dividing into the Radial and
Ulnar. V. Vas aberrans. (After
Reeves.)
Fig. 364.— High Or-
igin of the Ulnar Ar-
tery(U). Ab, aberrant
artery; R, radial, giv-
ing »ff the interos-
seous arteries.
less frequently. The artery which is given off thus
prematurely is generally (three cases out of four) the
radial; this vessel is most frequently to the ulnar side,
and subsequently crosses to the radial. Next in fre-
quency comes the ulnar, which often, in these cases,
E asses superficially down the forearm and gives off no
ranches, the interosseous coining from the radial
644
(Fig. 364). In rare cases the interosseous is the
branch having the high origin (Fig. 365), and still
more rarely it is a vas aberrans.
Three branches have been seen in the arm, viz., the
radial, the ulnar, and a vas aberrans.
The position of the two
branches in the arm when a
high division occurs is of
surgical importance. They
are usually in the ordinary
position of the brachial
trunk and lie close together
Fig. 365. — Anterior Interos-
seous (I) Given off from
the Brachial High up. (After
Reeves.)
Fig. 366.— Aberrant Ar
tery (3), separating fron^
the brachial (1) at the mid-
dle of the arm, passing
with the median nerve (d)
through the internal intei-
muscular septum, and
joining the regular ulnar
(4) lower down. (Quain i
but the radial, as mentioned above, often arises from
the inner side, and, after accompanying the large
vessel for some distance, crosses over it at the bend of
the elbow.
The ulnar artery, when having a high origin, may
incline toward the internal condyle, this, however,
occurs only when it nears the elbow. When there
is a high division of the brachial the ulnar-interos-
seous branch may pass through the supracondyloid
foramen mentioned above, and under a high origin
of the pronator teres.
The aberrant arteries, which are given off occasion-
ally, are long, slender arteries, which are derived
from the brachial or axillary, and end by joining the
radial most frequently and sometimes the ulnar ami
interosseous. They are loop lines, so to speak, and
in cases of ligature of the brachial their occasional
occurrence must be borne in mind by the surgeon
(Fig. 366). The two arteries in the arm are in sonic
instances connected together by anastomosing trans-
verse branches. These branches may number two
or three, or even four.
A median artery has been described as arising from
the brachial and passing down over the muscles of the
forearm and supplying the finger to which is distrib-
uted the median nerve.
The brachial artery may in some part of its course
(more frequently near the elbow) be covered by a
muscular slip. The median nerve sometimes passes
behind instead of in front of the artery, especially
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Arteries. Anomalies of
,, those cases in which the two heads embrace a
ommoo trunk from which the axillary branches
,,. riven off.
Superior Profunda. — This is occasionally derived
i/.ni a trunk common to it and several of the axillary
tranches, as mentioned above. It nol uncommonly
arises with the circumflex,
ami occasionally gives off the
inferior profunda.
Inferior Profunda. — This is
often absent. It is frequently
united with the superior pro-
funda.
A nastomotica M nana. —
Frequently of small size; its
place is sometimes taken by
the inferior profunda.
Radial Artery. — Origin:
I have found that the radial
has a high origin (Fig. 367)
in one case in twenty-one,
but Quain reports the high
origin to occur as often as
one in eight. Gruber in 440
arms examined found the
radial had a high origin in
twenty-six, or about one in
seventeen cases.
Course: The radial only
very occasionally deviates
from its usual course in the
forearm. It has been found
lying superficial to the fa-' ia
of the forearm, and the semi-
lunar fascia of the biceps.
It in rare cases courses down
the forearm on the surface of
the supinator longus instead
Fig. 367.— Dissection of
Right Arm. Showing an ex-
ample of high separation of
the radial artery (3) from
the brachial V2); a large
median artery (10) is seen in
forearm. (From Quain's
"Anatomy," after Tiede-
mann.J
Fig. 368. — No Dis-
tinct Superficial Arch.
Large superficial volar
supplying thumb and
index finger with half
middle finger, arid
rest supplied by ulnar.
(Reeves.)
of along its inner border. It not infrequently is
erficial to the tendons of the extensor muscles of
the thumb. It is occasionally joined by a vas aber-
rans. It may leave the front of the forearm near its
middle, its place being taken by an enlarged superfi-
cial volar. This would cause a weak wrist pulse.
Size : It does not vary often in size. It is, however,
sometimes much smaller than usual, its place being,
to a considerable extent, taken by some other vessel,
as the ulnar and anterior interosseous.
The radial has been described as absent by some
anatomists. Quain never saw a case of absence of
this artery, but such a case is described by Professor
t »i to, and 1 have seen one case.
Branches. Radial recurrent: This ve ''I i ome
times of large size, or it may eon i I of several small
branches. Winn the radial has a high origin 1 1 >• -
recurrent branch is given off from the ulnar-intero
seous trunk.
Superficial volar: Very often of small size, so small
thai it terminates in the muscles of the thumb, and
does not complete the superficial palmar arch. It is
occasionally entirely absent. It may be of large size
and furnish several digital branches (Fig. 'MW), and
it nitty arise much higher than usual.
I once saw it arise as high as the middle of the fore-
arm, and it was quite as large as tint radial, from
which it was derived; this is the normal arrangement
in some monkeys. The first dorsal interosseous is,
in s e cases, of large size, and may supply several
digits and end by completing the superficial arch.
The carpal and dorsal
interosseous branches are
|f,\ w|MJ\ \ often of very small size,
j \ their place being taken by
s^i'i A \ the perforating arteries.
FlG. 369.- Abnormal Su-
perficial Ulnar Artery (:i, 3'),
Rising Higher than Usual
from the Brachial. (Quain's
"Anatomy," after R.
Quain.)
Fig. 370. — Dissection of
Left Arm. Showing an en-
larged median arterj (5)
which replaces the radial [2)
and ulnar (3) arteries in the
supply of the palmar digital
arteries to half the fingers.
(From Quain's "Anatomy,"
after Tiedemanu.)
Ulnar Artery. — Origin: Quain found that this
artery deviated from the usual origin in our case in
thirteen, Gruber one in twenty-nine, myself one in
thirty-seven.
Where the origin of the ulnar is unusual, it most ci im-
monly arises from the brachial in the arm, and less
commonly from the axillary. In one case out of five
645
Arteries, Anomalies of
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
hundred I found it coming off from the brachial
below the pronator radii teres. In this case there
was, of course, a low division of the brachial.
Course: In the forearm this artery is much more
subject to variation than the radial. When it has a
high origin it nearly always courses down the fore-
arm superficial to the muscles, but beneath the fascia;
but cases occasionally occur in which it is immedi-
ately beneath the skin and superficial to the fascia
(Fig. 369). When the ulnar is superficial, it, as a
rule, gives off no branches in the forearm, these
being given off from the radial — interosseous trunk —
or the interosseous itself, which is invariably given
off from the radial. The ulnar, in rare cases, has this
superficial course when it arises in its usual situation.
Interosseous Artery. — This artery, in rare cases,
arises from the axillary or brachial artery (Fig. 364),
and gives off the recurrent radial and ulnar arteries.
The anterior and posterior interosseous may arise
separately from the ulnar.
Median Artery (Fig. 370). — This branch, which
accompanies the median nerve, is ordinarily of small
size, but occasionally it is developed into quite an
important vessel. It is usually derived from the
anterior interosseous, but sometimes from the ulnar,
and, in rare cases, it has been found coming from the
axillary or the brachial. It accompanies the median
nerve and reaches the hand beneath the annular
ligament, but, according to Tiedemann, sometimes
passes over the ligament. It may complete the
palmar arch, or be distributed as digital branches to
certain of the fingers, generally those supplied by
the median nerve, which it accompanies. In the
cases which I have observed, the latter arrangement
was the more frequent. I have occasionally seen
this artery pierce the median nerve.
Arteries of the Hand. — The arteries of the hand
are subject to man}' variations.
The superficial palmar arch is sometimes entirely
wanting. It has been occasionally seen double. In
Fig. 371. — Superficial
Arch Formed Entirely by
the Ulnar and Joining the
Princeps Pollicis Artery.
(Reeves.)
Fig. 372.— Lars e
Median Artery (Af),
Taking the Place of the
Radial in the Forma-
tion of the Superfi-
cial Arch and Giv-
ing off Outer Digitals.
(Reeves.)
the majority of cases the superficial volar branch does
not complete the arch, but it is completed often by
a large branch from the radial, which emerges between
the thumb and forefinger, and I have sometimes seen
it completed by a large branch from the radial,
which, after coursing over the back of the hand,
emerges on the palm between the index and middle
fingers. The arch is also often completed by a
transverse branch, which comes from the muscles
of the thumb and is derived from the princeps pollicis
or radialis indicia branch of the radial (Fig. 371).
A median artery may complete the arch (Fig. 372),
or it may go to the digits on the radial side, and the
646
ulnar to the digits on the ulnar side, and no regular
arch be formed. The superficial volar sometimes has
this arrangement (Fig. 372).
The superficial arch may be very small and some
of the digital branches be wanting, or it may be very
large, suppljing all the digital branches, both super-
ficial and deep.
The deep arch is occasionally formed by the ulnar.
It is sometimes so deficient that the digital arteries
are derived from the superficial arch. A large meta-
carpal branch on the back of the hand may give off
the digital branches.
Abdominal Aorta. — According to R. Quain, in
ten out of every thirteen bodies the division of the
great artery took place within half an inch above or
below the level of the iliac crest. Eckhard, Boinet,
and Cruveilhier record cases of division as high up as
the second lumbar. Two cases are on record (Quain,
tenth ed.) of a large pulmonary branch which arose
below the diaphragm, passed through the esophageal
opening, and divided into two branches which sup-
plied the lungs near their bases.
Celiac Artery. — The branches of this artery may
arise separately from the aorta. The phrenic arteries
may be given off from it, and it may be connected
with the superior mesenteric.
Renal Arteries. — Now that the operation of
nephrectomy has become so common, the variations
of these arteries have been rendered important surgi-
cally. Professor Macalister has reported (Journ. Anal,
and Phys., vol. xvii.) most of the anomalies of the
renal artery.
The renal artery may be replaced by two, three,
four, and even six branches. The origin of these
arteries is very various; they are usually derived from
the aorta, and are separated, at their origin, by a
larger or smaller interval; the lowest may arise quite
near the bifurcation of the aorta, and the highest just
below the celiac axis. In some
rare instances the renal artery
has been described as arising
from the common iliac, internal
iliac, and middle sacral. The
right and left renal arteries
have been found coming from
a common trunk; they may
arise from the anterior or
lateral part of the aorta. The
suprarenal frequently gives off
an upper renal, and it less fre-
quently is derived from the
upper lumbar, hepatic, and
right colic. Frequently when
the renal arteries come off from
the aorta low down or the
iliacs, the kidney on that side
is misplaced; it is situated lower down than usual.
opposite the bifurcation of the aorta and even between
the two common iliacs. In such cases the hilum is
usually placed on the anterior surface.
The branches of the renal artery, instead of entering
the hilum, may penetrate the kidney at its upper or
lower end. It is not uncommon to see the normal
artery entering the hilum, and two or three super-
numerary branches piercing the upper and lower end
of the gland. In two subjects I found that the kidney
was supplied by two arteries arising from the aorta
at some distance apart, one going to the extreme
upper end, and the other to the extreme lower end of
the kidney; no artery entered the hilum (Fig. 373).
The vein and duct were normal. This variation I
once met with while performing nephrectomy on the
dead body. R. Quain met with a case of absence of
the renal artery on one side. Multiple renal arteries
occur normally in fishes, lizards, snakes, crocodiles,
Fig. 373. — Abnormf.,
Right Renal Arteries. An
Artery distributed to each
extremity of the kidney!
but none entering the
hilum.
REFERENCE HANDBOOK OF THE MKDK'AL S( II. N< i -
Arteries, Anomalies (if
I'm. 374- — Obturator Given off
Internal 1 pigastric, and
•sine to the Inside of the Crural
Reach the Obturator
..Mien. (After Gray.)
,1 birds, and in man are due to a persistent early
Dndition.
Inferior Mesenteric. — It may be absent, its
being given off from the superior mesenteric.
SpBBMATIC Artery. — Sometimes double, not infre-
iently derived from the renal. Three spermatic
teries have been seen.
Common Iliac Arteries. — The place of origin of
ese arteries depends on the place of division of the
dominal aorta. This may be as high as the upper
border of the third, or as
low as the loner border
of the fifth lumbar ver-
tebra. In three out of
four eases the aorta di-
vides opposite the lower
border of the fourth
lumbar.
The common iliac ar-
teries vary considerably
in length. I once saw
them only 1.8 cm. (three-
fourths inch) long in a
negress, and, in another
case, 2.5 cm. (one inch).
In the large majority of
cases, according to R.
Quain, the length varies
oin 3.7 cm. (one inch and a half) to 7.5 cm. (three
ches). The greatest length is about 10 cm. (four
1 a half inches).
The right and left common iliacs differ in length
■ry often, the right, owing to the aorta dividing to
ie" loft side of the spinal column, being often the
tiger; but the left may be the longer, and in about
rd of the cases they are of equal length | R.
mitt i.
When the left is longer than or equal to the right,
is owing to the left artery descending to a lower
vel than the right. The artery has been seen
viding into internal and external iliacs as low down
iliac fossa.
The common iliac on one side has been reported
by Cruveilhier and Walsham. In this case
to aorta divided into three branches, two on the
\ternal and internal iliac), as is seen in birds,
id one on the left (common iliac). Surgically, these
ariations are of great interest.
Internal Iliac. — The place of division of this
aries considerably; it may divide as low as
ie margin of the sacro-sciatic foramen and as high
- tlie upper margin of
e sacrum. The point
f division is of impor-
irgieally; when
ie trunk is short it is
tore deeply placed in
ie back part of the
elvis, but when it is of
itne length, then a part
f the artery is likely to
e above the pelvic cav-
y, and therefore would
e much more easily
■ached by the surgeon
H. Quain). It ha- been
Hind as short as 1.2 cm.
half an inch), and as long as 8.2 cm. (three and a
alf inches).
The branches are given off from this artery very
ariously. In many cases there is no division into
nterior and posterior trunks. The artery occasion-
lly gives off one, and sometimes two branches he-
re it divides. The variations of most of the
•ranches of this artery, being of no surgical impor-
ance, will not be discussed here.
Fig. 375.— TheObturatorGiven
off from the Internal Epigastric
and Passing to the Outside of the
Ring. (After Gray.)
Obturator. — According to li. Quain, the obtura-
tor artery arises from the epigastric in one ca e in
:;.;,, His conclusions are derived from observations
in 36] cases. I have observed 500 cases (250 sub-
ject i. and have found this abnormal arrangement
much less frequently than Quain. I have found the
obturator coming from the epigastric in only i
Ca e in ni .",."> in 5011). Quain found the obturator
derived from tlie external iliac in si\ ca i out of
361. I found it only three time- in 500 cases. Quain
found tin- epigastric giving off the obturator twenty-
three time, ,,n both sides. I found this arrangement
eleven times.
When the obturator arises from the epigastric or
external iliac, it reaches tlie thyroid foramen ly
arching either to tlie inner or to the outer side of
the femoral ring. If it arches to the inner side of the
femoral ring, along the edge of < limbernat 's ligament,
then, in case of strangulated hernia requiring opera-
tion, it would be in great danger of being wounded
dig. 374); in fact, this accident has happened more
than once.
In only nine out of the fifty-eight cases in which
the obturator proceeded from the epigastric and
external iliac did I see the artery going to the inner
side of the femoral ring. In the remaining forty-
nine cases it either crossed it, in a few cases, or held
a position well to the outer side in the majority
(Fig. 375), so that in only about one case in fifty
is there danger of wounding the obturator in the
operation for strangulated hernia. The explanation
of the origin of the obturator from the epigastric is
simple enough. Normally, we have the pubic branch
of the obturator anastomosing with the pubic branch
of the epigastric; these vessels become enlarged,
and the proper obturator branch of the internal iliac
either remains undeveloped or becomes obliterated.
In four cases I have seen the obturator, epigastric,
and internal circumflex arise together from the
external iliac, and once these same arteries were
seen to arise by a common trunk from the common
femoral 2 cm. below Poupart's ligament. In one
case the epigastric and obturator arose together
from the femoral, a little below Poupart's ligament.
In some cases, in which the
obturator arises from the
epigastric, there is a small
branch, representing the
obturator, derived from the
internal iliac.
Interna! Pvdic Artery. —
This vessel is occasionally
of small size, and fails to
supply all the usual
branches; in s-uch an event
these are given off from an
accessory pudic. The
branches furnished by the
accessory artery are usually
those branches which go to
the cavernous body and
dorsum of the penis, the
,. ., ... ,r ., course .uiaway oeiween in
pudic itself ending as the Ischial Tuberosity and th
artery of the bulb. In a Coccyx. (After Henle.)
few instances the pudic ends
as the superficial perineal, the other branches coming
from the accessory vessel.
The accessory pudic is, as a rule, given off from the
deep pudic within the pelvis; it then passes alongside
the bladder and prostate, and, after piercing the
triangular ligament, supplies the dorsum of the penis
and the cavernous body, and, perhaps, the bulb. It
may be given off from the obturator in the pelvis, or
from the epigastric.
The pudic artery has been seen passing up to the
perineum midway between the tuberosity of the
ischium and the coccyx, and ending as the superficial
perineal and artery of the bulb (Fig. 376).
647
Fig. 376. — Abnormal Inter-
nal Pudic Artery, Which Has a
(nurse Midway between the
Arteries, Anomalies of
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Artery of the Bulb. — Is sometimes of large size,
placed farther back than usual, and ascends obliquely
to the bulb; in such a case it would necessarily be
wounded in the operation of lithotomy. It may
arise from the accessory pudic; when this happens
it would be placed well in front of the usual incision
for lithotomy.
The dorsal artery of the penis has in some cases been
seen to arise from the obturator artery near the thy-
roid foramen, from the external pudic of the femoral,
Fig
-Abnormal Origin of the Internal Circumflex Artery (I):
K, epigastric artery; PF, profunda femoris.
and from the deep femoral. In the first case it would
be in danger of being wounded in lithotomy. The
two arteries of the penis sometimes unite to form a
single trunk, or are united by transverse branches.
Mr. Spence has described a large prostatic artery
which gained the perineal surface of the prostate
without dividing into minute branches. Wounds
of the prostatic arteries have led to fatal hemorrhage
in cases of lateral lithotomy.
The sciatic artery is sometimes replaced by a branch
from the gluteal. In a few cases this artery has been
seen of large size, taking the place of the femoral
(see under Variations of Femoral). There is some-
times a large comes nervi ischiatici artery. The
gluteal artery has been reported as absent (Roberts),
its place being taken by a large branch from the fem-
oral, passing outward and backward to the gluteal
region.
External Iliac Arteries. — The length of these
arteries varies according to the point at which the
common iliacs bifurcate; they usually measure 7.50
cm. (three inches) to 10 cm. (four inches) in length.
In those rare cases in which the main artery of the
limb is a continuation of the sciatic, it is much reduced
in size.
Epigastric Artery. — May arise at a higher point
than usual. R. Quain reports it in one case 6.4 cm.
(two and a half inches) above Poupart's ligament.
It arises from the femoral in about one case in twenty.
The usual place of origin is close to or opposite Pou-
part's ligament. It may, in rare cases, arise from
the deep femoral.
The origin of the obturator from the epigastric has
already been noticed. In a few cases the epigastric
has been seen coming from the obturator when that
vessel is a branch of the internal iliac.
I have, in four instances, seen the epigastric arise
in common with the internal circumflex artery of the
deep femoral. In three of the cases the common
stem arose from the femoral 2 cm. below Poupart's
ligament; in the fourth, 2 cm. above the ligament.
648
In the last-named case the internal circumflex passe,
beneath Poupart's ligament in the same compart-
ment of the femoral sheath as the artery, and con-
tinued down the thigh about 5 cm., lying betweei
the artery and vein; it ended, after giving off a largt
branch to the adductor muscles, as the internal cir
cumflex proper (Fig. 377). A similar anomaly ha:
been observed by Mr. A. Thompson (Journal Anai
and Phys., April, 1SS3), but in the cases describee
by him the artery passed internal to the femoral vein
and would, he thinks, have been wounded in tht
operation for relieving strangulated femoral hernia
A similar arrangement of vessels exists normally ii
the American black bear. I have met with foui
cases in which the obturator, epigastric, and interna
circumflex arose by a common stem, two below
Poupart's ligament and two above.
Circumflex Iliac Artery. — The origin of this artery b
sometimes from the femoral. It is occasionally double.
again a single vessel. Sir Charles Bell, when liga-
Femoral Artery. — The femoral artery has, in
some rare cases, been found of small size, and termi-
\i }''!
FlG. 37S. — Posterior View of the Right
Thigh. The ischiatie artery much en-
larged, accompanying the sciatic nerve,
and taking the place of the femoral ar-
tery. (After Dubreuil.)
Fig. 370. — Bell's
Case of Double
Femoral Artery,
.showing HgatuN
of one of the
trunks and the
aneurysmal
below. (After Bell
fr< itn London Medr
ical Gazette.)
nating near the knee joint. When such a condition
exists, the main artery of the limb is furnished by a
branch from the internal iliac, generally the sciatic
(Fig. 37S), which is much enlarged, and accompanies
the sciatic nerve to the popliteal space, whence the
course of the artery is the same as if the distribution
had been normal. This is the usual arrangement
in birds.
Cases have been reported in which the femoral
divided into two portions, which united below to form
kitfi:f.vt: haxdkook or tiik medical SCIENCES
Arteries, Anomalies of
urine tli' femoral for popliteal aneurysm, met with
hi-c anomaly. Though t li<- ligation of the femoral
lid not arrest the pulsation in the aneurysm, the
recognized till after the death of the
tatient, when it was found that the femoral was
louble. and only one of its divisions had been liga-
ured (London Sled, and Phys.Jour., vol. lvi., 1826
Fig. 379.) Tiedemann, Houston, Dubreuil,
1'vrroll. and Quain also report cases. Mr. 11. A.
Kelly (American Journal of the Medical Sciences,
lanuary, 1882) reports three cases (one of which i
loubtful), met with in the dissecting rooms in Phila-
Iclphia. In two of these cases the artery divided
.■low the profunda, ami reunited just above the
in the adductor magnus. The division has
above the origin of the profunda.
The two femorals, when this arrangement occurs,
run down the thigh, side by side, in separate fibrous
.lis. m> that in cutting down on one the other
would not be seen.
1 have occasionally seen, in cases of high origin of
the profunda, the latter artery quite as large as the
rficial femoral, and running down the thigh
parallel to it. beyond the apex of Scarpa's triangle.
wch a case it would be difficult, in the living.
listinguish between the vessels, should ligature
of the femoral be necessary. As a rule, the profunda
li - to the outer side. The appearance of the above-
l cot dition in Scarpa's triangle is very similar
OS cases figured as double femoral, and I im-
agine that the cases of double femoral reported as
seen in amputating the thigh are only cases of larg -
profunda arteries, especially as the disposition of
the vessels below- the amputated point is not described.
The pro/undo, or deep femoral artery, may be
given off from the inner side of the main trunk, or
in some cases from the back part of the vessi I
It may arise above Poupart's ligament, or as much
as 10 cm. (four inches) below it. It not uncommonly
- 1.2 cm. (half an inch) below the ligament.
When it is given off low down, one or both circumflex
arteries arise from the femoral. The deep femoral
has been occasionally altogether wanting, its branches
arising separately from the main artery.
The external circumflex artery not infrequently
arises directly from the common femoral. It may
be represented by two branches, and even three.
which arise from the femoral or profunda — I have
seen it arise in common with the internal circumflex.
The internal circumflex artery also frequently arises
directly from the femoral. It occasionally arises in
common with the deep epigastric, ami passes down
to the thigh in the same sh ath as the femoral vessel.
This variety I have described under the Epigastric.
It may arise with the epigastric from the femoral
artery before the profunda is given off, and in some
cases might be injured in the operation for strangu-
late. 1 femoral hernia. I have twice seen it arise with
the obturator and epigastric from a common stem.
Unusual branches are. in rare cases, given off from
the femoral. I once saw the dorsal artery of tie
penis given off from the common femoral, cross the
thigh at right angles, and reach the dorsum of the
penis by piercing the deeper scrotal tissue.
A large saphenous artery has been found which
accompanied the great saphenous vein. It may
arise above or below the profunda, course down the
thigh between the adductor magnus and internal
vastus, and pierce the deep fascia of the thigh on the
inner side of the knee joint, where it reaches the inter-
nal saphenous vein and accompanies it to the internal
malleolus. This arrangement is the normal one in
the rabbit and in some other mammals.
_ I once saw this branch, after reaching the inner
side of the knee, wind round to the front of the joint,
below the patella, and divide into a cutaneous branch
and a branch which pierced the ligamentum patella?
to supply the interior of the joint.
Popliteal Ak i i ry. This artery is not Bubjecl '.>
many variations. '1 he chief deviation from the
normal disposition consists in a high division of its
terminal branches. 1 saw this only twice in 2.~>0
subjects; in both, the artery divided immediately
above the upper edge of the posterior ligament of
the knee joint. In -'-'7 subjects Quain found a high
division in 10. Portal reports a case of low division
of the popliteal, the artery dividing about the middle
of the leg into anterior an. I posterior til ial. In
cases of high division, tic peroneal artery arises from
the anterior tibial; tin- was the arrangement in one
of my cases. The artery and vein, usually so con-
stant in their relation, may, in rare cases, eh:;
places. When there is a third head to the gastroc-
nemius muscle it usually passes between the artery
and the vein. Ward Collins has seen the popliteal
artery dividing in the upper part of the popliteal
branches which united again below
after a separate course of two inches.
Cases are reported (Otto) of branches from the
popliteal proceeding upward along the semin em-
branosus muscle, and ending in one of the perforating
arteries of the profunda. Also an aberrant artery
is described as being given off above the knee joint,
and joining tin- popliteal before its division (Hyrtl).
A small saphenous artery lias been seen which accom-
panies the short saphenous vein behind the external
malleolus and anastomoses with one of the tarsal
branches (Hyrtl). The azygos artery may be given
off from one of the articular arteries. I once saw a
common trunk give off the two superior articular
arteries and the azygos. One or other of the articular
branches may be absent, their place being supplied
by an enlargement of the remaining arteries.
Posterior Tibial. — In cases of high division of the
popliteal the tibial is larger than usual. It may be
increased or diminished in size. When increased, it
partly takes the place of the peroneal or anterior
tibial, and when diminished, it may be reinforced by
transverse branches from the peroneal near the ankle.
The posterior tibial may be of very small size and end
near the middle of the leg, its place being taken
by a large peroneal artery which furnishes the plantar
arteries. In a lesser degree of diminution of the
posterior tibial, the anterior tibial, or rather its dor-
salis pedis branch, furnishes the arteries which form
the plantar arch and its branches. In these cases the
external plantar artery ends near the accessorius
muscle. I have several times seen a muscular slip
(flexor accessorius), which arose from the lower end
of the fibula, or more commonly from the tibia, cross
the tibial vessels behind the internal malleolus. The
nerve is occasionally placed to the inner side of the
artery, at the lower part of the leg.
Peroneal Artery. — This artery, as described above,
may take the plaee of the posterior tibial, or it may
be of small size, and its place be supplied by a branch
of the posterior tibial. The anterior peroneal branch
may be of large size, and may take the place of the
lower part of the anterior tibial, furnishing the arter-
ies supplying the dorsum of the foot.
In cases of high division of the popliteal, the pero-
neal artery generally arises from the anterior til ial.
It also arises in the same way. occasionally, when no
high division takes place. I have seen it furnish a
large internal calcanean branch as well as an external.
An accessory peroneal sometimes exists.
The internal plantar artery is sometimes of very
small size, ending in the flexor brevis pollicis muscle,
or it may be of large size, and furnish digital branches
to the great and second toes.
The external plantar is occasionally very small,
ending in the accessorius muscle; when such a condi-
tion exists the dorsalis pedis artery furnishes the deep
plantar arch and digital branches. I have several
times seen this anomaly. The artery is occasionally
of large size, and partly takes the place of the dorsalis
649
Arteries, Anomalies of
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
pedis branch of the anterior tibial. The digital
arteries of two toes, generally the second and third,
not infrequently come from a common stem. The
deep arch is, in rare cases, double.
Anterior Tibial Artery. — In some cases this artery
is given off from the posterior tibial in the middle of
the leg. When there is a high division of the popliteal
it may give off the peroneal, and may pass beneath
the popliteus muscle. In the leg it may be subcu-
taneous, its pulsations being easily felt under the skin.
Velpeau reports a case in which this artery did not
pierce the interosseous membrane, but passed to the
front of the leg round the fibula with the musculo-
cutaneous nerve. It may be altogether wanting,
its place being supplied by perforating branches from
the posterior tibial, or it may end in the muscles about
the middle of the leg. When there is such a distribu-
tion the deficiency is made up by an enlarged anterior
peroneal or plantar artery. It not infrequently fails
to furnish digital branches, which, in this event, come
from the plantar arteries. The artery may be of
larger size than usual, and may take the place of the
Eeroneal artery in some eases, and of the plantar
ranches of the posterior tibial in others; the dorsalis
pedis branch being of very large size, as mentioned in
the description of the varieties of the posterior tibial.
The dorsalis pedis artery sometimes ends in the neigh-
borhood of the cuneiform bone. The anterior tibial, in
some rare cases, gives off an anterior tibial recurrent
to the knee joint. Francis J. Shepherd.
Arteries, Compression of. — Compression of arteries
for the arrest and prevention of hemorrhage and for
the cure of aneurysm is a very old procedure, and one
which, although in many instances superseded by
ligation, made safe by the introduction of antiseptic
surgery, is still employed to a considerable extent,
particularly in the prevention of hemorrhage. Com-
pression of the carotids, thereby lessening the blood
supply to the brain, has been recommended and prac-
tised at different periods in the treatment of epileptic
convulsions, maniacal excitement, congestive head-
ache, and for the purpose of producing sleep. Corning,
of New York, in 1882, strongly urged the advantages
of this procedure and devised a special instrument for
the compression of the carotids.
Compression is accomplished either by means of
the hand or by some mechanical device. Digital
compression may be either direct or indirect, that is,
in the wound or over the vessel of supply, and may be
employed for the immediate arrest of existing hemor-
rhage or for the prevention of hemorrhage during an
operation. This means is occasionally still used in the
treatment of aneurysm, but has largely been super-
seded by the ligature, by the combined use of gold or
silver wire and electricity, and more recently by
Matas's excellent endoaneurysmorrhaphy. For the
instant arrest of bleeding nothing is more readily and
satisfactorily employed than the fingers, placed either
directly in the wound or over the arterial trunk sup-
plying it. The greatest disadvantage of the method is
that it is impossible to keep it up for a great length of
time without the help of a number of intelligent assis-
tants. There are two ways of applying digital com-
pression, one by pressing the vessel between the fingers
and a bone, the other by compressing it between the
forefinger and the thumb. The former method is more
satisfactory, because it can be kept up for a much
longer period of time. When a change of hands is
made the fresh hand should always be placed above
the point of former compression before the first hand is
removed. Digital compression can much more readily
be employed when a wound has been made, thus ex-
posing the vessel, than when it is attempted with con-
siderable tissue intervening between the finger and
the vessel, as, for instance, in compression of the
abdominal aorta.
650
Innumerable forms of compression apparatus have
been invented for compressing blood-vessels, one of
the oldest and most universally used being the tourni-
quet of Petit (Fig. 120), which consists of two metal
plates, connected by a spiral screw, whereby they may
be separated, and a strap which buckles around the
limb. In the use of this tourniquet many surgeons
apply a roller bandage over the vessel to be com-
pressed and buckle the strap over this. The separa-
tion of the plates by the screw tightens the strap and
increases the pressure. In order to prevent the strap
from cutting the skin it is well to apply first a turn or
Flo. 380. — Esmarch's Elastic Compressor.
two of muslin bandage about the part. In an emer-
gency, when a tourniquet cannot be had, a fillet may
be employed by passing a handkerchief or piece of
cloth or cord about the limb and then tightening it by
twisting it with a piece of wooden stick. Only suf-
ficient pressure should be made to arrest the bleeding
or stop the pulse as too great pressure tends to pro-
duce gangrene. The most generally used means of
compression to-day is the Esmarch bandage and tube
(Fig. 3S0). The bandage is an ordinary rubber roller
applied from the tip of the extremity up to the p>
where it is desired to place the tube, and its object
is the saving of the blood in the extremity, in case of
amputation, and the freeing of the limb of blood
when any operation is to be done upon it. The tube
is of rubber, flat, and about one inch wide. This
is passed tightly about the limb and fastened by a
hook at one end of the tube and a chain at the other.
Certain precautions must be observed in the use of
this form of compression. One is to move the pari
as little as possible after the tube is applied, as tear-
ing of the tightly bound down muscles may occur,
and another is to see that each turn of the bandage
and tube overlaps the preced-
ing, else pinching of the skin
occurs. When a limb is dis-
eased, compression with the
bandage is not to be made
over the diseased area, but it
is to be applied above and
below it, or else it is not to be
used at all, but the limb is
simply to be elevated for a
time, after which the tube
alone is to be used. This
method of elastic constriction
has the great advantages of
simplicity and cleanliness
over other forms of mechan-
ical compression.
Other forms of compression
apparatus are so constructed that the pressure is
exerted over the main artery without constricting
the surrounding tissue. These forms are specially
advantageous in the treatment of aneurysm, for they
are much less likely to cause gangrene, which is so
apt to follow the prolonged use of the two forms of
compression above described. Esmarch's elastic com-
pressorium for the aorta and Skey's compressor (Fig.
381) illustrate this point.
Wyeth, of New York, introduced a method of
compressing the vessels of the thigh in hip-joir.t
3S1. — Skey's Arterial
Compressor.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Arteries, Compression of
amputation (see Figs. 191, 192), which is a combina-
h ,u of the older methods of Trendelenburg and
Dieffenbach. It consists in passing through the
muscular tissue and skin above the point of amputa-
tion two long steel mattress needles, and then apply-
ing above them the constricting band of Esmarch.
I u~ recent years I have used direct digital compres-
sion of the common iliac or the femoral in hip joint
md high thigh amputations and prefer it to the
Wyeth method. It must not be forgotten that all
'orms of compression, if kept up for a great length
if time or if the pressure is too great, may be pro-
ductive of destruction of tissue at the point of ap-
ilication or of gangrene in parts below. Also it
QUSt be remembered that after circular constriction
if an extremity reactionary hemorrhage may occur,
md hence it is necessary to tie all bleeding points
h fore closure of the wound.
Great improvement has been made in the tempo-
rary control of large arterial trunks by mechanical
compressors applied directly to the vessel. The rub-
ber-covered clamp of Crile is one of the best. The
compression to be put on the vessel is regulated by
i set screw. This method is most useful but care
should be taken to avoid too great pressure as injury
jf the intima, with the resulting thrombosis, will
-ccur. Matas and Halsted have done an enormous
imount of experimental work in the gradual com-
iression of the vessels by means of metal bands which
-an be tightened by degrees. In all likelihood some
method of this kind will ultimately prove sat-
sfactory in arresting the circulation in cases of
ineurysm involving vessels which cannot be ligated
ir dealt with according to the Matas method of
•ndoaneurysmorrhaphy.
Fiq. 382. — Compression of the Aorta. (Dr. W. W. Keen.)
Right hand closed, a little to the left ol the median line: knuckles
01 index finger just touching the upper border of the umbilicus;
left hand feels patient's pulse (femoral) at brim of pelvis.
Special Arteries. — The aorta cannot be com-
pressed until it has passed through the diaphragm
into the abdomen, and then only with difficulty, un-
less the abdomen be opened. Compression of the
abdominal aorta is resorted to as a means of pre-
venting severe hemorrhage from its distributing
branches or for the purpose of temporarily arresting
Fio. 383
Compression of the
Brachial.
the circulation in them: for example, in a hip-joint
amputation, or in an attempt to cure an aneurysm.
It can be satisfactorily accomplished without abdom-
inal section iii thin persons, but in those with thick
abdominal walls it is i erj difficult of accomplishment.
As to the precise mode of effecting the desired pressure,
one may employ an Esmarch 's elastic compressor or
that of Skey, the liitter which is shown in the illustra-
tion (Fig. 381), or the hand of an assistant may be em-
ployed (Fig. 382). All of
t he e mel hod are open to
objections: they may cause
an injury to the overlying
intestine — and this is more
likely to happen when an
apparatus is used — or the
compression ma} - prove to
be inefficient, as when the
instrument is not properly
applied, or when it slip-, or
when the, assistant's hand
moves to one side of the
artery. The usual position
for the compression pad or
the hand is just below the
umbilicus and a little to the
left; but the pulsation of
the vessel must be definitely
felt before compression is
applied, and after the ap-
plication of compression no
operation should be done until all pulsation has ceased
in the vessels below. There will be less danger of
injuring the intestinal canal if it be first emptied by
means of a cathartic and an enema; and before ap-
plying the pad, the bowels should be pushed to the
right side of the abdomen by rolling the patient on
that side. When the abdomen is opened compression
of the aorta is rendered easier and safer; it may be
accomplished with the fingers or with a specially de-
vised clamp consisting of two blades, one of which
fits into the other somewhat after the style of a
lithotrite. Great care should be exercised in the use
of such an instrument or an injury may be done to the
vessel itself or its neighbors.
Momburg in 1908 de-
scribed a method of produc-
ing ischemia of the lower
half of the body by con-
stricting the abdomen with
several turns of a heavy
elastic bandage; as a pre-
liminary procedure, the
blood in the lower extremi
ties is forced out by apply-
ing an Esmarch bandage.
Although this method of
compressing the abdominal
aorta has been used a num-
ber of times without detri-
ment to the intestine it
does not appear to be a per-
fectly safe procedure and
should not be lightly under-
taken.
The common iliac may be
compressed through the ab-
dominal wall, through the Fig. 384. — Compression of the
rectum, or through an in- Femoral,
cision in the abdominal wall.
The last method, which enables one to use the fingers,
is by far the most satisfactory of the three and the only
one that has been practised with anything like good re-
sults. It has become now one of the recognized means
of preventing hemorrhage in hip-joint amputation,
particularly in those cases in which, because of dis-
eased anterior flap, the Wyeth pins cannot be used.
Dr. Charles McBurney first employed this method of
651
Arteries, Compression of
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
preventing hemorrhage in 1S94. Experience has
shown that the common iliac can very readily be
compressed with the fingers in the abdominal cavity
without the exertion of much force and without
increasing the dangers of the operation. Compression
through the rectum by means of Davy's lever is not
so safe or so satisfactory as are the other methods.
External Iliac. — This vessel can be compressed with
tin- fingers or with an instrument placed just above
Poupart's ligament, midway between the symphysis
pubis and the anterior superior spine of the ilium.
Femoral. — The course of this vessel is covered by a
line drawn from the point midway between the
symphysis pubis and the anterior superior spine of
the ilium to the adductor tubercle on the inner
condyle of the femur, and can be compressed by the
fingers (Fig. 3S4) or by the tourniquet anywhere
throughout its course, the force being exerted tow aid
the bone.
The popliteal occupies the middle of the popliteal
space; it can best be compressed against the femur
in the upper part of its course.
The posterior tibial can readily be compressed by
the finger as it passes midway between the internal
malleolus and the point of the heel.
The anterior tibial lies between the tendons of the
tibialis anticus and the extensor longus hallueis, and
can best be compressed after it becomes the dorsalis
pedis and passes under the annular ligament.
The subclavian can be compressed, unless exposed
by incision, only in its last one-third, where ii
crosses the first rib. Pressure should be made with
the thumb in the angle formed by the posterior border
of the sternocleidomastoid and the clavicle, and
should be directed downward, backward, and inward
against the rib. The tip of the shoulder should be
depressed.
Axillary. — Compression of this vessel can be made
only in the last part of its course, and is accomplished
by making pressure from within outward against the
upper part of the humerus.
The brachial artery can very readily be compressed
against the shaft of the humerus, the inner edge of
the biceps being the guide to its situation.
The radial can be compressed against the anterior
surface of the lower end of the radius between the
tendons of the supinator longus and the flexor carpi
radialis.
The ulnar artery can be compressed against the
anterior surface of the ulna between the flexor carpi
ulnaris and the flexor sublimis digitorum.
The common carotid and the external carotid can be
compressed with the fingers or by means of one of the
instruments specially devised for the purpose. The
anterior border of the sternocleidomastoid is the
guide to the vessels, and the pressure should be
directed backward and inward.
The facial can be compressed with ease as it passes
over the lower jaw just in front of the masseter muscle.
The temporal may be controlled by making pressure
on the zygomatic process just in front of the tragus.
The labial artery may be controlled by compressing
the lips between the finger and thumb.
John H. Gibbon.
Arteries, Surgery of the. — Wounds of arteries may
be complete or incomplete, penetrating or nonpene-
trating, perforating, punctured, incised, contused,
or lacerated.
It is generally said that a non-penetrating wound
that does not injure the intima is not followed by
hemorrhage and it has been shown experimentally
many times that such wounds are not followed by
aneurysm, as was formerly thought to be the case,
1ml by a scar stronger than the original wall of the
artery.
Punctured wounds may be caused by various for-
eign bodies, the simplest form being a puncture by a
652
needle or pin. In these cases a small mural thrombus
forms at the site of puncture composed of blood
plates, fibrin, and leucocytes (white thrombus)
comparable in a general way to a tack with the stem
plugging the hole. Healing occurs without oblit-
eration of the lumen. Punctured wounds may also
be caused by many other foreign bodies such as scis-
sors, fish bones, spicules of bone following fractures
etc. Several cases have been reported of fatal
hemorrhage from punctured wounds of the carotid
and aorta by foreign bodies swallowed.
Penetrating wounds may be complete or incomplete
longitudinal, transverse, or oblique. When the wound
is longitudinal it remains as a slit and little
hemorrhage occurs, but when transverse,
the edges retract, making the wound oval
and the hemorrhage is greater. Oblique
wounds gape somewhat from retraction,
the amount depending on the obliquity of
the cut.
Gunshot wounds vary according to the
type of missile used. The lead bullet used
in former times, but now seen only in
wounds in civil life, inflicts a contused or
lacerated wound. The high velocity jack-
eted bullet of modern warfare often makes
a wound of the same type, but may make
a clean-cut complete or incomplete wound.
The missile may also wound both the
artery and vein, traumatic aneurysm and
arteriovenous aneurysm being common in
the late wars. Shell wounds are rarely
followed by immediate but are prone to
delayed hemorrhage. The chief symptom
of all these wounds is hemorrhage.
Spontaneous hemostasis depends on the
size and nature of the wound, the artery
injured and its condition, the tension in
the vessel, and on many other factors.
When a vessel is divided the ends both
contract and retract, narrowing the lumen,
and the intima also tends to roll up, thus
still further reducing the caliber. This
contraction is due to the muscles of the Ar'terie"
media and depends more or less on the (Schematic)
aim mnt of stimulation. Following the
injury there is an immediate hemorrhage
and the blood coining in contact with the
ad vent itia sheath into which the rest of the
vessel has contracted formsaelotwhichex-
tends around the wound for some distance 'j l h q e ua ^ ]
and up into the lumen. This is soft and c , division ol
is the red or temporary thrombus caused half the cir-
by chemical action, and has nothing to do c u m ferenee
with the white or true thrombus formed of the artety:
later as the forerunner of permanent /» l '" ll, i' 1 ' t,!
healing. The loss of blood also tends ^l 1 """]
to stop the hemorrhage as it slows the <££2t0
current, and the bleeding may cease
if the patient faints, only to recur when he regains
consciousness and the pressure rises. Blood in
exsanguinated subjects is said to clot more readily.
The permanent or white thrombus is formed on the
inside of the temporary or red clot and is composed
of blood plates, leucocytes, and fibrin. It is always
seen following any injury to the intima. The white
thrombus is laid down slowly, and plugs the vessel to
the nearest branch given off; in clean wounds it is
firm and of a grayish color but in septic ones is soft,
puriform, and loosely adherent to the vessel wall. It
was in this class of wounds that secondary hemorrhage
was so commonly seen in the days before aseptic
surgery. Spontaneous hemostasis is retarded by
increased tension following stimulation, unrest which
dislodges the clot, or partial division only of the
vessel, which prevents retraction and contraction.
It is also retarded by anything that inhibits clotting.
Contusion and Rupture. — These injuries may be
Fig. 384a,—
lougitudi-
n a I; 6, ob-
1 i q u e ; c,
tran SI 'i
f its growth. If the vein is destroyed as well as
the artery, gangrene is much more apt to occur and
to be of the moist rather than the dry variety. Out
if sixty-two cases of ruptured arteries collected by
Berzog in 1S90, thirty-two or fifty-three per cent.,
i -veloped gangrene, while of Monod and Vanvert's
fifty-eight cases of incomplete rupture, gangrene
followed in thirty-five, or sixty per cent. These
cases all occurred since the advent of aseptic surgery
and were as follows: Subclavian four cases, no gang-
rene; brachial seventeen cases, six gangrene; popli-
teal seventeen cases, fifteen gangrene (although in
another article the authors state that ligature of the
popliteal should never be followed by gangrene).
Jensen in an analysis of wounds of the popliteal
artery found gangrene in fifty-four per cent. Fol-
lowing ligature hi the femoral it is variously esti-
mated as from five to forty per cent. Accordii
the e statistic there ults are no better than before the
advent of asepsis. They probably give a fal e im-
pre ion, however, and it i-. to be supposed thai a
large number of cases of rupture are treated and
recover without being reported. Probably al o tl
would be many fewer cases of gangrene if the le ion
to the artery was recognized and treated promptly
and in a systematic manner. In general it may be
stated that simple rupture of the brachial artery
promptly treated u never followed by gangrene,
that of the axillary rarely. In the lower extremity
gangrene is more common but practically never
should OCCur after ligature of I he popliteal, although
it should bo feared after ligature of the femoral or
iliac.
The symptoms caused by a wound in an artery
may be divided into constitutional and local. The
constitutional symptoms are primarily those of
hemorrhage and shock and depend on the amount
of blood lost and the type of the wound. The local
symptoms are In— or diminution of the pulse in the
vessel below the point of injury, pallor, a cold ex-
tremity, and hemorrhage. The hemorrhage may be
active and visible, when the skin is wounded, or it
may be concealed, in which case a diffuse or circum-
scribed arterial hematoma forms. The hemorrhage
may also be delayed, if the wound is incomplete, or
it may be recurring.
Arterial hematoma occurs when there is a small
wound in the vessel and may be either circumscribed
or diffuse. In the diffuse variety the tissues are
everywhere infiltrated with blood and no definite
cavity is formed. The limb is swollen and cold, and
the skin is tense and of a livid or bluish color. This
causes great tension and pressure on the collaterals
and predisposes to gangrene. In the more common
or circumscribed form (false aneurysm) there is a
sac formed out of the adjacent structures lined with
fibrous tissue, clot, etc., and containing blood. This
sac communicates with the lumen of the artery by
a small opening and gives a distinct pulsating tumor
of varying shape over which a distinct thrill may be
felt and a bruit heard synchronous with the pulse.
Lejars, Haga, and Russian surgeons have had
occasion to treat a large number of these cases fol-
lowing gunshot wounds made by the high velocity
jacketed bullet in the late wars. The false aneu-
rysm may form rapidly or slowly in the course of
months, or may increase in size for a time and then
cease, only to grow again later. If small there may
be spontaneous cure, the cavity becoming filled with
clot and obliterated.
The treatment may be divided into constitutional
and local measures. The constitutional treatment
is the same as that for hemorrhage and shock and
consists of rest in bed, morphine, artificial heat,
stimulants, saline solution, transfusion, etc., as
indicated.
The object of the local treatment is first to control
the hemorrhage and secondly to repair the damage
done and prevent, if possible, gangrene. Imme-
diately following the injury a tourniquet is generally
applied as the quickest and easiest method of con-
trolling the hemorrhage. The patient should then
be removed to a suitable place and active local treat-
ment instituted. The skin should be very carefully
prepared and the vessel cut down upon and explored.
The surrounding tissues and vessels are also to be
carefully examined to determine the amount of dam-
age done not only to the artery itself but to the
satellite vein, the soft parts, and the collateral vessels.
If the artery is lacerated and the vein intact the two
ends may be ligated, the wound thoroughly cleansed of
blood clot, and the skin sutured. The wound should
be drained to relieve any pressure that might be
653
Arteries, Surgery of
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
caused by the collection of serum. A thick dressing
is then put on and the extremity kept warm, dry,
elevated, and aseptic — in fact, everything should be
done to promote the circulation. The above is the
treatment indicated in the majority of the cases.
If there is a small lateral wound in the artery it may
be closed by suture or if it extends over two-thirds of
the circumference the artery may be divided and end-
to-end suture done. When the artery has been
destroyed by the injury the bruised portion may be
excised, the clots and thrombi washed out of the
vessel with saline solution, and a piece of vein set in
to remedy the defect. This is particularly indicated
when the main vein is injured as well as the artery.
The actual treatment of a given case depends on
many factors and no definite rules can be laid down,
the proper procedure being a matter of judgment.
Treatment of Arterial Hematoma. — Diffuse hema-
toma and also circumscribed hematoma when large
and of rapid formation, should be treated on the lines
already laid down. When circumscribed and of
slow formation the majority of observers prefer to
wait until a more or less definite connective-tissue
sac is formed (false aneurysm) and the collateral
circulation has had time to develop. There has
been much discussion, however, as to the proper time
to operate. In these late-forming cases the Matas
operation is usually the procedure of choice. It is
always well before operating to determine if possible
the extent of the collateral circulation, which may be
done by compressing the main artery and noting if
this obliterates the pulse and noting also the ap-
pearance of the limb beyond the aneurysm. Inter-
mittent pressure applied in this manner also tends to
develop the collateral circulation. During the opera-
tion some form of temporary hemostasis should be
employed and the vessel treated according to the
condition found. In many cases the restorative
Matas operation can be performed. In others double
mediate ligation is necessary, while in some arterial
suture may be employed. Monod and Vanvert (1011)
have collected 215 operations done for this condition
on 20.5 patients since 1880. Suture was performed in
thirty-two of these with twenty-nine successes, one
death and one failure, while in one the result was not
noted.
Healing of Arteries. — This subject has been ex-
tensively studied by Zahn, Pitres, Warren, d'Eberth,
Schimmelbusch, and others and is essentially the
same when following a wound as when following ex-
perimental ligature.
When a large artery is tied in its continuity, the
intima and a variable portion of the media are usually
ruptured, and the adventitia is gathered into a dense
tendinous sheath around the constricted ends. The
first noticeable change is the formation of the thrombi.
The proximal thrombus is much larger than the
distal thrombus and owing to the more rapid coagu-
lation of the blood the vessel has an ampulla-like
distention. The vessel on the distal side of the ligature
is contracted and the thrombus is much smaller.
The ligature soon becomes embedded in a cell
growth which appears to proceed from the peri-
adventitial tissue, and varies according to the amount
of injury done by the ligature to the vessel walls,
or to the irritation which it produces. If the coats
of the vessel have been unnecessarily bruised and a
certain amount of extravasation has taken place in
consequence, or if the ligature itself, for some cause,
has created irritation, the surrounding inflammatory
tissue will form a well-marked callus. If an excessive
irritation has been produced, the growth of this
protective tissue may be retarded, or it may be
destroyed and the danger of hemorrhage correspond-
ingly increased. Following the development of
this external growth, we find that it extends some
distance up and down the sides of the vessel in the
periadventitial tissue, the round cells of which it is
composed invading only the superficial layers of the
adventitia; the breadth of the growth is, of course,
greatest at the point of ligature; in length it reaches
usually to a point on a level with the ends of the two
a _ 6 c
WM
Fig. 385. — Ligatured Vessel, a, Proximal thrombus in ampulla,
like dilatation of the vessel; 6, media; c, adventitia; I, site of
ligature. (Drawn from author's specimen.)
thrombi; when fully developed it is consequently
spindle-shaped (Fig. 3S5). At the point of ligature,
where the fibers of the outer wall are densely packed
(Fig. 385, I), the cell growth does not penetrate dur-
ing the first few days; but just above and below the
ligature they may be found already invading the
media as early as the second day; occasionally the
apex of a pyramidal-shaped mass of such cells will
have reached the thrombus.
These cells appear to exert a
solvent action on the bunch
of fibers projecting from the
ring of the ligature, which
thus becomes gradually liber-
ated from all connection with
the vessel, the two ends of
which now retract and leave
the knot embedded in the
center of the callus. The
fibers of the ligature itself
soon become infiltrated with
cells, and by the tenth day
they may have already dis-
appeared, or, if its resisting
powers are greater, may re-
main encysted for some
time. The period which the
ligature requires for this
separation varies greatly ac-
cording to the size of the
vessel and character of the
ligature, and is longer in man
than in animals. If the artery
has been properly dissected
out, this external growth
will be observed forming a
callus-like ring, in which the
two ends of the vessel are
embedded, in size about
twice the thickness of the
vessel, and it can still be seen
well developed at the end of
two months (Fig. 3S6). In the specimen from which
the accompanying drawing was taken the ligature
had caused suppuration about it, and had formed a
fistulous track at the fundus of which some fibers
were found still remaining. By the end of three
Fig. 3S6.— Carotid Artery
of Horse Two Months Alter
Ligature. I, Sinus at site of
ligature; the ends of the
artery have separated, but
are enclosed in a firm callus.
(Drawn from author's .speci-
men.)
G54
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Arteries, Surgery of
callus had disappeared, and
united the peripheral to the
onths the external
,ly a slender cord
roxiroal end.
\lrcady by the fourth day changes are noticed
it hin the vessel. Observing the proximal thrombus
, find an increase in the number of while corpuscles,
irticularly near the point of ligature, not in an
ulated mass, but mingled with red corpuscles.
asses of coagulated fibrin with young cells i while
irpuscles of clot, wandering cells from arterial
,:its and rarely also periarterial tissues) are at Inched
. I lie frayed ends of the media which have been
i by the ligature and are more or less inverted,
lie endothelial cells, when not firmly compressed
y the thrombus, as in the distal end, are in a stale
ity, undergoing proliferation to a moderate
stent. Occasionally, loop-like masses of cells may
■ seen projecting into the clot, or a delicate anas-
mosing network of stellate or spindle-shaped cells;
nt the total amount of this cell growth is small as
impared with the size of the thrombus. In the
.an time, in the second week, masses of granulation
lis ate seen infiltrating that part of the wall which
separating or has already separated from the
ature. Even at this period, with the external
rowth carefully dissected away, as is the custom in
iliseum specimens, the vessel appears to have united
\ first intention, that is, by a direct union of the
icdia and intima side to side. But the infiltration
rid softening continue until the walls are separated
ad expand, like the petals of a rose, yielding before
he advancing growth of granulation tissue. The
ceper portions of the clot are now infiltrated with
wo growths; the more superficial (that is, the por-
lon nearest the open lumen of the vessel) is com-
osed of tissue grown from the intima and media and
.andcring cells, and the deeper is composed of vas-
ular granulation tissue which has pushed its way in
roin without. Viewed at the thisd week, the ends
f the vessel will be found expanded and the space
etween them filled with well-formed granulations,
Mrh as are seen on the surface of a healthy wound.
\ portion of the thrombus, sometimes a large portion,
iss not been infiltrated, but is attached firmly to the
op. A longitudinal section of such a specimen gives a
triking illustration of what is understood as "healing
ly scabbing." As the clot shrinks the spaces left be-
ween the granulations, which have now rolled over
me another in cloud-like masses, become continuous
\ith the open lumen of the vessel, and the so-called
canalization" of the thrombus is thus effected. An
njection mass can be forced from the vessel for some
listance into these spaces, but as yet they do not
•ommunieate with the vessels of the granulation
issue. This communication usually does not occur
mtil the second month, that is, until the provisional
growth has reached its period of highest development.
The vessel walls have in the mean time been under-
ming certain changes. A proliferation of the cells
if the intima, as has been noticed by so many ob-
servers, unquestionably takes place; but the amount
li-velopcd is not sufficient to supply more than a
t cry small part of the provisional tissue. The cells,
however, have begun to grow before the other tissue
lias made its way into the vessel, and at this period
serve the purpose of attaching the thrombus to the
walls of the vessel, but even in this work they are
aided by other cells from the media. They also
furnish a new endothelial covering to the permanent
cicatrix, and a lining to the new vascular spaces that
have been formed. When the elastic lamina has
been ruptured (and this is frequently seen on the
-ides of the vessel near the ligature, and also here
and there higher up as far as the thrombus extends),
we find an intimate connection at such points of the
media with new growing tissue within the vessel.
In the second week, cells may be seen springing from
the media and growing into either the clot or a clump
Fio. 387. — Carotid Artery of Dog Four
Months After Ligature, showing shape
of cicatrix as modified by the presence
of a branch. (Drawn from author's
specimen.)
of cells attached to the inner wall. The cells are
round and spindle-shaped, frequently in bundle .
Evidences of cell activity in the media are abundant,
and in some specimens in animals a proliferation of
the muscular cells through the whole thickness of
the media is ob-
served, giving a
con iderable in-
ffillllA m»W elrne l.i Ihr width
Uk of this layer. The
clastic lamina is
frayed out at its
divided end, and
glistening elastic
lilier, are seen ex-
tending downward
into the external
growth as the two
ends of the vessel
gradually retract
from each other.
At the end of three
months the provi-
sional t issue has
been absorbed, and
we find the walls
united by a perma-
nent cicatrix which
joins the sides of
the vessel, still
somewhat separ-
ated from each
other. It consists,
in medium-sized
arteries, of a cres-
cent-shaped mass of
tissue, the concave
side of which faces
the lumen, while the
horns run up on either side of the vessel. One horn
may be long and the other short, the crescent being
placed somewhat excentrically. The longer horn
may be sometimes thickened (see Schultz and Thoma),
as in Fig. 3S7, if a branch lies opposite to it. In the
largest vessels the cicatricial tissue occupies a con-
siderable portion of the caliber of the vessel.
On the surface of the cicatrix is seen a thin layer
of endothelium; beneath this,
in medium-sized vessels,
there can be seen a layer of
delicate, tapering, spindle
cells with staff-shaped nuclei,
forming a continuous layer
from one horn to the other.
They run parallel to one
another and to the arc of the
circle made by the crescent,
and resemble in all respects
muscular cells; in short, a
genuine muscular layer is
found here (Fig. 3S8). Be-
neath this layer is a mass of
cicatricial connective tissue
which plugs the space lying
directly between the ends of
the retracted walls (Fig. 389).
The cicatrix is pierced by a
vessel of considerable size
which rapidly tapers to a
point and anastomoses with
a capillary network, ramify-
ing both in the cicatrix itself
and in the ligamentous band outside. This central
vessel, which in larger cicatrices becomes tortuous
and gives to the cicatricial tissue a "cavernous"
appearance, may be regarded as the unobliterated
residuum of the lumen.
We find in this anatomical peculiarity of the cica-
Fig. 388.— New Muscular
Cells in the Cicatrix; from
the femoral artery of a dog
three months after ligature.
(Drawn from author's speci-
men.)
G55
Arteries, Surgery of
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
fcrix an explanation of its immunity from aneurysmal
dilatation. The protective influence of the thrombus
enables the process of cicatrization to complete
itself before the cicatrix is called upon to withstand
blood pressure, and it is then armed with a muscular
coat (as is the normal vessel wall), which acts not unlike
a levator ani muscle in sustaining and modulating
the force of the blood column.
The ligament which unites the two ends of the
vessel represents, in part, the residue of the external
callus; it has become much elongated by the retraction
of the two ends. During the healing process, a small
pi lit ion of the vessel walls has become disintegrated
by the new growth, and a portion has atrophied and
ML
WW
I t.V
FlO. 389. — External iliac Artery of Man One Hundred and Thirty
Days After Ligature: formation of permanent cicatrix. (Drawn
from author's specimen.)
has been absorbed, the remaining walls have shrunk
greatly by retraction, and their caliber has been
filled to a greater or less extent by a cicatricial tissue;
so that the vessel has become practically obliterated
up to the first branches of the collateral circulation.
The thrombus is a mere passive structure, and
takes no part in the growth, but is protective and
affords an excellent medium for the germination of
the new tissue. Its upper portion is not penetrated
by the new growth, but rests upon it and forms a sort
of protecting scab. It is deposited gradually, and
has a stratified appearance. Its size appears to be
dependent upon the amount of injury done to the
vessel and the resulting inflammation. If the intima
or the elastic lamina has been ruptured in handling
the vessel, as can frequently be demonstrated by the
microscope, some distance from the point of ligature,
clots will form at these points, and the thrombus will
thus become elongated. Occasionally, the apex is
formed of white corpuscles only, and may be free or
lightly attached to the wall by a cell growth from the
intima.
Thrombosis and Embolism. — Arteriotomy for the
removal of a clot plugging a vessel, either a thrombus
or an embolus, and the restoration of the circulation
has been practiced a few times, but has not been
generally successful.
There are three types of embolism that have been
subjected to operative treatment or for which opera-
tion has been suggested, viz., embolism of the extremi-
ties, pulmonary embolism, and mesenteric embolism.
Emboli of the extremities, unless of traumatic origin,
are practically always seen only in disease of the left
side of the heart and are more common in the lower
than the upper extremity. Barie in an analysis of
fifty-four cases found the emboli situated as follows:
tioial artery fifteen, femoral twelve, iliac nine, popli-
teal seven, dorsalis pedis one, arteries of the fore-
arm four, subclavian three, axillary two. They may
lodge in the aorta even, in which case there is sudden
acute pain referred to the abdomen and paralysis of
the lower extremities in addition to the usual symptoms
of cold and loss of pulse below the obstruction.
Mniiod and Vanvert (1909) collected ten cases of
arteriotomy for the removal of a clot and Delbet and
Mocquot (1911) mention fifteen, none of which were
perfectly successful. The chief difficulty is in making
the diagnosis early enough to render the operation of
value, as secondary degenerative changes take place
very rapidly in the intima at the point of lodgment
of the clot so that even if the embolus is successfully
removed a second clot forms at the same site on the
damaged intima in a short time. In one of Stewart's
cases the clot formed twice after repeated arteriotomy,
and excision of the damaged portion of the artery
with end-to-end anastomosis was later performed.
This also became plugged and amputation was
resorted to some time later. Tixier has more recently
performed an excision of a portion of the brachial
artery for an embolus with end-to-end anastomosis
successfully. Another difficulty in these cases is in
exactly locating the point in the vessel at which the
embolus is impacted. At times this is comparatively
easy, but the symptoms are as a rule referred to a
portion of the limb considerably below the seat of
injury. There are certain points, however, at which
the embolus is apt to lodge such as the bifurcation of
the aorta, at the division of the popliteal, or in the
femoral artery where the profunda is given off. These
cases of arterial emboli also usually occur in the
a^ed and this fact makes operative interference
difficult as the walls of the vessels are stiff and
atheromatous. Thrombosis or embolism of the
main artery of a limb is usually followed by gangrene,
but this is not necessarily always the case.
The symptoms of emboli of the extremities are
usually acute pain, pallor, and loss of pulse and cold-
ness below the obstruction. Later there may be
both motor and sensory paralysis in a varying degree,
followed, if there is no collateral circulation, In
gangrene. In a few cases reported the symptoms
nave been of slow onset and have not been accom-
panied by great pain..
Operative treatment consists in arteriotomy with
removal of the clot, followed by rest, heat to the
limb, and measures to promote collateral circulation
and prevent the reformation of the clot. If gangrene
supervenes amputation should be performed. Hand-
ley has tried, unsuccessfully, to dislodge a clot situated
at the bifurcation of the aorta by passing a catheter up
the femoral artery, and it has been suggested that this
be done in emboli of the femoral artery in order that
amputation might be done at a lower level than
would otherwise be necessary. The operation of
arteriovenous anastomosis, or biterminal graft, may
also be performed when the diagnosis is made early
enough and the vessel walls are in good condition.
Pulmonary Embolism. — In 1907 Trendelenburg
devised an operation for the removal of an embolus
in the pulmonary artery which has been performed
four times, twice by him and twice by other surgeons.
One of the patients lived for five days.
Mesenteric Embolism. — Emboli "of the mesenteric
vessels usually lodge in the superior mesenteric
artery which is to all intents a terminal artery. No
656
REFERENCE IIANDHt >(>K OF Till', MEDICAL SCIENCES
Artcrtcs, Surgery of
ise has yet been treated by arteriotomy and the
imoval of the clot, although the operation has been
ted by several obsen ers.
i koi. of Hemorrhage. The methods of use
control of hemorrhage are heat, cold, elevation,
yptics, compression either direct or indirect, acupres-
forcipressure, torsion, ligature, and suture.
in mimic form, as cold compresses, ice, cold
etc., lias I ii used in the control of he ■-
from ili" earliest times and has a distinct \ alue
ain slight forms, but is not adequate to control
hemorrhage from a large artery.
ii the form of the actual cautery was the chief
leans of controlling bleeding during the Middle \v
i.l in fact was used by many surgeons during the
ighteenth century. Although discarded at the pre
it day for the ligature, it is used in a modified form
certain cases, as in the clamp and cautery opera! ton
i hemorrhoids, in certain operations on the bladder
id nose, and as the electrothermic angiotribe.
Vhen the tissues are charred an eschar forms, plug-
ing tlic vessel and later separating as a slough.
\tion of a part is of value in controlling slight
emorrhage, especially when it is venous in character.
Styptics are rarely employed at the present day.
it are of service in stopping ooze from small
Most of them act by causing the blood
.1 clot at once, and they make an extremely foul
,ound. Adrenalin is by far the best and most useful
and acts by causing a contraction of the
essels. It is used in strengths of from 1 to 10,000
n 1 to 1.000.
Compression may be either direct or indirect and is
he most valuable means at hand for the immediate
ontrol of hemorrhage from a large artery. Indirect
'impression is the method usually employed as a
rst aid measure; this may be either mechanical or
ligital. The best example of mechanical compression
3 the well-known tourniquet or Esmarch bandage,
tigital compression of the main artery of a limb is less
pi to injure the structures, but is very difficult to
uaintain for any length of time. Nearly all the large
essels can be compressed against some bony promi-
"iice with comparative ease and the circulation con-
rolled for some time if relays of assistants are at
land. While indirect compression is invaluable as a
uethod of expediency, it cannot be employed to con-
rol the hemorrhage permanently. In direct or im-
mediate compression the pressure is made directly on
he bleeding point. It may be either digital or by
nuking a wound with gauze sponges, and is of especial
alue in stopping a general ooze from a large raw
Torsion was not unknown to the ancients, and was
employed by certain surgeons in the Middle Ages; but
a more modern times, practitioners were not familiar
•vith it until it was brought to the notice of French
trgeons by certain statements of a visitor from
iennany. Both Velpeau and Amussat apparently
laimed the credit of introducing it, the former in
onsequence of his experience, when a student with a
veterinary surgeon, in the twisting of the pedicle in
paying and castration, and both as the result of their
it ions on the immunity from hemorrhage in
edarteries. The method employed by Velpeau
is thus described: "After having seized the vessel by
its extremity. I separate it from the surrounding
and grasp it. at its deepest point in the wound,
mother forceps, to hold it firmly while it is
I lined on its axis, three to eight times", by the first
forceps." He appears to have employed the
method in several amputations. Its supposed advan-
- the avoidance of a foreign body in the wound.
' ■ iignized the fact that animal ligatures would be
equally good for this purpose, and also the disadvan-
tage of torsion in diseased vessels, and that small
were not easily isolated. The effect of torsion,
Vol. I.— 42
according to Bryant, is a twisting of the ela tii B
of the adventitia bi yond the end of the vessel, and a
retraction and incurvation of the middle and inner
coats; the twist in the outer coal is permanent and
cannot lie unfolded by any legitimate force; the
middle and inner coats are una' ted in the direction
oppo ed to tin' lil I stream, approximated and over-
lapped. The safety from hemorrhage rest upon the
twist of the external, the retraction of the internal
coats, and the coagulation down to the firsl branch;
while, in acupre ure, the permanent safety depends
upon the lasl alone, temporary protection being
afforded by the needle.
Kocher found numerous and irregular In
of the inner coats over a considerable distance of the
wall, and independent of one aunt her, while in liga
the ruptures were circular and only close to the point
of liga! inn. I n unlimited torsion there is considerable
nan-owing of the lumen. ( Iwing to these peculiarities,
it has the advantage of favoring a rapid coagulation.
Acupn ture. — The introduction of this method
of hemostasis, which at present is chiefly of historic
interest, is to be accredited to Sir .lames Simp on
unless an obscure passage in John de Vigo's writings
be interpreted otherwise than as a description of the
ordinary ligature). He saw in the ligature a foreign
body in the wound which cut through the two coats
at the time of its application, and ate through the
outer coat. It was for this reason principally that
amputation stumps healed with so much greater
difficulty than wounds in the operation for vesico-
vaginal fistula, although the latter were constantly
bathed in leucorrheal discharges and urine. The
application of the ligature isolated a portion of the end
of the vessel, which remained in the wound as a piece
of dead flesh until it came away with the ligature.
The needle, on the other hand, did no injury to the
vessel and caused no irritation, its use being based
upon "the great pathological law of the tolerance of
living tissues for the contact of metallic bodies em-
bedded in their substance." Bryant showed, how-
ever, that the ligatured portion did not slough, but
became adherent and vascularized.
Although English surgeons supposed that no injury
was done to the vessel by the needle, Kocher and
other German writers demonstrated longitudinal slits
in the intima, but not so extensive as those occurring
in torsion. The vessel is thrown into longitudinal
folds, which become sufficiently firmly glued together
to retain this shape long enough, after the removal of
the needle, for the thrombus to form and become
firmly attached to the walls. A specimen examined
by Kocher at the end of twenty-two hours showed no
thrombus, the walls being compressed and somewhat
thickened, but a fine probe could be introduced
between them. At thirty-six hours a well-formed,
egg-shaped thrombus is represented by Shakespeare.
A drawing by Kocher shows a specimen fourteen days
old, in which the walls have already separated from
each other, and the thrombus is short and wide,
having a concave surface on the side toward the
lumen, and a convex surface at the other end. The
relation which the thrombus bears to the vessel is
that of a cork to a bottle, beyond the neck of which
it does not project. It is probable that the apex had
been detached.
In acupressure in the continuity, the proximal and
peripheral ends of the thrombus are continuous, as
are also the walls of the vessel, which at first are
thickened by a connective-tissue growth; the sub-
sequent changes differ in no way from those already
described.
Ogston tested mechanically the comparative
strength of arteries secured by ligature, acupressure,
and torsion, by subjecting them to the pressure of a
column of mercury. It was found that a column one
hundred and fourteen inches in height was insufficient
to rupture the ligatured artery. Twisted vessels
657
Arteries, Surgery of
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
unfolded at an average height of thirteen inches
(or a pressure of 6.5 pounds to the square inch). In
acupressure, the column of mercury showed an
average height of 23.5 inches. It would, therefore,
seem a more reliable method, he says, than torsion,
and less reliable than ligature.
Forcipressure. — This is a very convenient method
of stopping bleeding from both arteries and veins and
is employed universally, but chiefly as a temporary
expedient preliminary to ligature. It was used by
Desault in 1786 only to fall into disuse and was
reintroduced about 1865. The clamp, or hemostatic
forceps, now in use is a modification of that invented
by Pean in 1808. When a vessel is clamped the two
inner coats are ruptured and the ends curl back
plugging the lumen and favoring clotting while the
adventitia is transformed by the pressure into a homo-
geneous band. Although in the larger vessels it is
customary to follow this with ligature, in the smaller
it is unnecessary. Certain operators using the
angiotribe, a special broad-bladed crushing forceps,
do not ligate even the larger arteries. In certain
other cases such as in vaginal hysterectomy, where
ligature is difficult forceps may be left in place for
several hours and then removed with but little danger
of hemorrhage. The length of time necessary to
leave a clamp in place in order to insure permanent
hemostasis has been estimated by Bothezat at sixteen
hours for a vessel the size of the radial artery, and
eighteen for one as large as the femoral, but cases of
secondary hemorrhage have been reported after
vaginal hysterectomy when the clamps have been
left in place for twenty-four hours. Hopfner,
Payr, and Crile clamps exert forms of forcipressure,
but they are used only for temporary hemostasis and
should be carefully applied in order not to injure the
intima. Their use is sometimes followed by thrombus
formation.
Ligature. — Although the introduction of the liga-
ture is commonly ascribed to Par6, there is suffi-
cient evidence to show that it was employed by
surgeons in the earliest historic times. No mention
is made of the ligature by Hippocrates, but the
ancients used not only styptics and the actual cautery,
but also ligature and torsion. It is highly probable
that the Alexandrians were familiar with the use of
the ligature three centuries before the Christian era,
for Celsus (born 30 B.C.) speaks of it as a well-known
fact and recommends its use. Archigenes and Galen
both mention tying vessels for the purpose of stopping
hemorrhage; the name of Antyllus also bears testi-
mony to the skill of Roman surgeons, and in the
Museum at Naples there may be seen a forceps, with
sliding attachment, evidently intended to use with the
ligature. We find the ligature of arteries mentioned
again in the seventh century by Paulus of yEgina,
whose teachings were still preserved by the Italians
in the sixteenth century.
It is uncertain, however, whether ligatures were em-
ployed on large vessels before Pare's time. To this
great surgeon is due the credit not only of fully appre-
ciating the value of this mode of hemostasis, but of
making it a universally applicable method. At this
period, the middle of the sixteenth century, the imper-
fect knowledge of the anatomy and physiology of the
circulation prevented a due appreciation of the ad-
vantages of the ligature, and even Guillemeau, who
was the champion of his friend and teacher, confined
the use of the ligature to primary amputations.
Although Wiseman in England, Fabricius Hildanus in
Germany, Fallopius, and others favored the ligature,
they were but isolated examples, and at the opening
of the eighteenth century the actual cautery was still
the customary method of arresting hemorrhage at the
Hotel-Dieu.
The contrast between the two methods at that time
was not indeed as great as it would seem to-day. A
glance at Parti's plates shows the forceps as an instru-
ment of rude pattern and clumsy make; no attempt
was made to isolate the vessel; veins, nerves, and
arteries being included in one knot. No wonder that
surgeons had a " horrid apprehension of compressing
the nerves," and that Petit, with whom modern
investigation on the healing of arteries may be said
to have begun, actually proposed compression as a
substitute for the ligature. It was he who first called
attention to the agency of the thrombus in checking
bleeding, the blood around the end of the vessel being
termed the couvercle, and that found within the
lumen the bouchon. The retraction and contraction
of the vessel w-ere soon recognized by Morand, who also
called attention to the rupture of the inner walls by the
ligature. To Jones has been pretty generally accorded
the credit of producing the classical work upon this
subject. By a large and varied series of experiments
on animals he was able to give a complete account of
the macroscopical appearances showing injuries to
arteries, which account, in the main, holds good to-
day. He found that when a large artery was divided
it retracted into its sheath, and contracted slightly
at its extremity (a coagulum forming within the
sheath and external to the vessel, and appearing like
a continuation of the artery); and that later a slender
and conical coagulum formed within the vessel, being
only partially adherent to its walls. •
It was chiefly due to Jones' investigations that the
modern single thread was adopted. Cutting short
both ends of the knot was adopted in 1798 by an
Ameriican naval surgeon. The disadvantage of a
silk or hempen ligature was supposed to be due to its
non-absorption. The introduction of the absorbable
ligature is generally ascribed to Physick whose liga-
tures were made of chamois leather rubbed on a slab
to render them hard and round. Sir Astley Cooper
tried them and they were used in this country by
Jamieson of Washington. Absorbable ligatures did
not come into general use till Lister published his
method of preparation with carbolic and chromic
acid. At the present day absorbable ligatures,
represented by plain and chromicized catgut, are more
commonly used than the non-absorbable. The
chromic gut was introduced as plain catgut is absorbed
at times very rapidly, while the chromic gut resists the
action of the tissues for a varying period, depending
on the length of time it is treated with the acid, and
in fact occasionally it is never absorbed. Of the
other forms of animal ligature kangaroo and ox
tendon are the two in most common use. Of the
non-absorbable at the present day, Pagenstecher and
linen are used as freely as silk.
There was formerly a great deal of discussion as
to the tightness with which the first knot of a liga-
ture should be tied and Ballance and Edmunds tried
to introduce a soft ligature with the first knot tied
so as to approximate the intima without rupturing it.
It is accepted now, however, that the first knot should
be tied with enough force to rupture the intima and
part of the media.
Metallic ligatures are rarely used to-day except to
diminish the caliber of a large artery leading into an
aneurysm, dishing has recently suggested the use of
small pieces of silver wire as ligatures applied with a
special clamp for the control of bleeding from ve-
in an inaccessible position. These are comparable
to the "skin clips" and have proved of value in
cerebral surgery. Temporary ligatures are occasion-'
ally used to control hemorrhage and for this purpose
tape or floss silk is the best material.
Suture. — The first suture of an artery was done by
Hallowell at the suggestion of Lambert in 1759. He
successfully closed a wound in a brachial artery made
during a venesection, by pinning the edges of the
wound together with a needle held in place by B
figure-of-eight suture. Asman in 1773 did a series of
experiments on dogs using this technique, and found
658
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Arteries* Surgery of
ii although hemorrhage was perfectly controlled a
rombus always resulted and these views have held
iil comparatively recent times. The first success-
blood-vessel anastomosis was performed in 1879
a Russian surgeon, who made a lateral
istomosis between the vena cava and the portal
in — the .so-called Eck fistula.
reporting in a classical article the first successful < i i
of circular suture in man. Be ha In© described a
modification of this method using a removable cylinder
in two pieces as a support which brings intima more
nearly in conjunction with intima. The original
method consisted in passing a suture through the wall
of the distal end of the vessel which is brought out
W'
.1 B
Fig. 390. — Murphy's Invagination Mcih.nl. A, Two
the threads designed to invaginate the proximal into
e distal end of the artery have been passed; B t the
agination completed, showing also the superficial
laptation suture. (Delbet ana Moequot.)
A B C
Fig. 392. — Payr's Method. .4, The tube is placed in the proximal end
of the divided artery; B t the proximal end of the divided artery is turned
back over the tube and tied to it; C, the invagination is complete, the
distal end of the artery being passed over the proximal end and tied there.
(Delbet and Moequot.)
Gliick in 1883 showed that the repair of lateral
"iiids of arteries was possible, although most of his
vperiinents were failures. In 1SS9 Jassinowski
tade a series of experiments and showed that it was
ossible to get healing in lateral wounds of arteries
ithout thrombosis. He used fine silk as a suture
taterial and was able to close wounds that did not
through the lumen and caught the proximal end
through the outer coats only. Three such sutures
are placed about three-fourths of an inch from the end
of the artery. By traction on these the proximal end
is then invaginated into the distal, and the anastomo-
sis is completed with interrupted or a continuous
stitch to make a tight joint. (Fig. 390.) Nitze in
I
SB
1
[
fl
-«t
A
LyX
m
V* -
If
5?. *
3 .'
«•
' fa
1
■i
\ i. : .,'
io. 391. — The Jaboulay-Brian Method of Vertical
U-shaped Sutures. (Delbet and Moequot.)
Fig. 393. — Showing Repair of an Artery after Suture.
and Obstetrics.)
(iSwgery, G'i//' :
•xceed two-thirds of the circumference of the artery,
twenty-four of his twenty-six experiments being
successful. His sutures did not penetrate the intima.
In the next few years many articles were written, but
Few successful cases were reported. In 1894 Abbe sug-
gested doing end-to-end suture over a glass bobbin.
In 1S97 Murphy introduced his invagination method
the same year performed a circular suture by turning
back one end of the vessel over an ivory ring making
a cuff over which the other end of the artery was
drawn. Soon after this Jaboulay and Brian suggested,
in circular suture, splitting the vessel up for a short
distance and suturing the ends together with U-
shaped sutures bringing intima to intimr, — the broad
659
Arteries, Sui'scry of
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
marginal confrontation method. (Fig. 391.) Dorfler
in 1.S99 described a method of arterial suture in which
he used small round needles and silk, the suture being
continuous and penetrating all the coats. His method,
modified and perfected, is the one commonly em-
ployed to-day.
In 1900, Payr published a method which was popu-
lar for a time and which is satisfactory. He used
magnesium cylinders similar to Nitze's ring, but
absorbable, on which were one or two circular grooves.
One end of the severed artery was passed through the
cylinder, turned back as a cuff and tied into the upper
groove. The other end of the vessel was then drawn
over it and tied into the lower groove. (Fig. 392.)
Crile's transfusion cannula? are very similar to (his
ring. Later Payr advocated another method, using
two cylinders with a broad flange. In 190., Berard
and Carrel published a method similar to the Dorfler
method only the stitches did not penetrate the intima.
Later as the result of experiments with Morel and in
1905 with Guthrie, Carrel developed the technique
which is used practically without modification at the
present day.
Many other methods of arterial suture have been
published. Salomoni independently published a
suture similar to that of Jaboulay. De Gatano
suggested using an intravasal apparatus, while Lepi-
nasse used broad metal flanges. Dorrance has a
special stitch for use in lateral wounds, and Brewer
in these cases has wrapped the vessel with adhesive
plaster.
Repair after Suture. — Healing after suture occurs
with a varying amount of scar depending on the degree
of trauma and the accuracy with which the parts are
brought into apposition. In a well-performed opera-
tion the resulting scar is very slight. The intima
unites completely forming a smooth lining to the ves-
sel. There is some difference of opinion as to the fate
of the elastic tissue and while in some cases it regen-
erates, in others the defect is filled in with scar tissue.
The media often completely regenerates and shows
no visible scar. (Fig. 393.)
The success of arterial suture depends on absolute
asepsis and good technique and now experimentally in
the hands of men accustomed to the work is rarely
unsuccessful. The history of the repair of arteries is
thus comparable to that of intestinal repair, where
complicated mechanical devices have been replaced
by the simple needle and thread with good technique.
In 1900, Dorfler stated that there were reports of
but nine successful cases of arterial suture in literature,
while in 1909 Monod and Vanverts collected sixty-
five and Stich in 1910 stated there were over one
hundred.
Operations for circular suture of arteries may be
divided roughly into three classes: (1) The invagina-
tion method of Murphy; (2) Suture with the aid of
some mechanical apparatus (Payr); (3) Direct suture
(Jaboulay, Carrel). In the invagination method the
blood comes in direct contact with quite a large raw
surface and is very liable to clot. In many of the
me; hods the lumen is narrowed by the use of a cuff
or ring and a large amount of slack vessel is necessary,
or a mechanical device difficult to handle must be
used.
Suture for incised longitudinal or transverse wounds,
lateral suture, is almost always successful at the pres-
ent day in the hands of men trained in blood-vessel
surgery in the laboratory. Of the sixty-six cases
collected by Monod and Vanverts there was only one
failure, but it was impossible in many of these to
prove the permeability of the vessel. The absence of
■ ragrene after the suture of a wound in the main
artery of a limb ami the presence of a pulse do not in
any way prove the patency of the artery, as gangrene
does not necessarily follow ligature, the collaterals
taking care of the circulation very rapidly. In
certain cases, however, small emboli may break off
from the mural thrombus at the site of the suture and
give rise to small areas of gangrene. The scar follow-
ing suture is as strong as the vessel wall and never
gives rise to an aneurysm.
Comparative Value of Suture aud Ligature. — The
value of circular suture in human surgery is not
yet on as firm a basis although several successful
rases have been reported. Braun has reported a ci
of circular suture of the aorta which was torn in
removing a large adherent pelvic tumor from a young
girl; convalescence was uneventful. It has also been
done several times in reversal of the circulation.
Besides end-to-end and lateral suture, end-to-side
and side-to-side may also be clone.
Much has been written on the respective value of
suture or ligature in wounds of special arteries, and
the question is not yet settled. Suture should be
preferred in all longitudinal wounds of the large
arteries of the limbs where it can be done with some
hope of success. It should also be done when liga-
ture of the artery in question is apt to be followed by
gangrene, although the frequency with which gan-
grene occurs as the result of ligature of a given artery
varies greatly in the statistics compiled by the differ-
ent observers. If the ends of the vessel cannot be
brought together without undue tension bj' flexicn
of the limb, loss of substance can be repaired by
grafting in a piece of vein to take the place of the
artery destroyed or resected — the biterminal graft of
Carrel. When the blood is allowed to pass through
the vessel again the grafted portion of vein becomes
at first greatly distended but in course of time it
contracts, the walls become thickened, and it takes
on the general characteristics of an artery. Grafts
for loss of substance may be either autoplastic, where
a vein of the patient is utilized, or heteroplastic, where
a vessel from another person or animal is used. Ex-
perimentally this has been done with success, portions
of dog's vessels having been grafted in the fresh state
and also after having been kept on ice or preserved in
formalin for weeks.
Suture of arterial wounds is a recognized surgical
procedure and to be done when necessary but never
when the collateral circulation is sufficient to nourish
the part, in crushed and septic wounds, or when tension
is necessary to bring the ends of the vessel in apposi-
tion. It should be done only on large arteries and it
is difficult and unnecessary to perform suture on
anything smaller than the popliteal. Ligature
should be preferred to suture unless the surgeon has
the facilities at hand to perform a satisfactory opera-
tion and has had laboratory training in the repair of
arteries.
Besides its value in the repair of wounds, suture
may be done for the reversal of the circulation, in the
treatment of arteriovenous aneurysm, and in a modi-
fied form in the repair of common aneurysm (Matas
operation).
Technique of Arteriorrhaphu. — In arterial suture
special light instruments are necessary such as are
used in the physiological laboratory in experiments
on small animals. The special kit consists of three or
four pairs of fine straight or curved dissecting forceps
without teeth, or jewelers forceps with the cuds
rounded and smoothed; two or three pairs of fine very
sharp scissors, one curved on the straight; six M
eight mosquito forceps, and a sharp fine-pointed
knife.
Temporary hemostasis is absolutely necessary and
may be obtained by several methods. When the
artery to be repaired is in the extremity, a tourniquet
maybe applied to the limb, but this is rarely possil le
ami it is also usually better to control the hemorrhage
from the artery by some form of hemostasis in the
wound itself. Many forms of clamps have been in-
vented but probably the best form is the old-fashioned
serrefine. These should be small and light with a
spring strong enough to control the hemorrhage but
6G0
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Arteries, surgery of
,i to injure I In- intima. The corrugated blades are
i protected by being wound with thread or covered
ith thin rubber. Hopfner, Payr, or Crile clamps may
■ used instead, the pressure in these being regulated
v a thumb screw. In large arteries it is probably
ii,,- to place one of these on the artery above the
e to prevent accident in case the latter should
ip, Another method of temporary hemostasis is by
grounding the artery with a piece of tape which is
rawn taut, occluding the vessel, the ends being then
Ivy a pair of hemostatic forceps (Fig. 394).
irculation may also be slopped by kinking the vessel
ith a piece of tape passed under it. by digital pres-
u. 394. — Showing Two Efficient Methods of Temporarily Occlud-
ing Vessels for Suturing. (Guthrie.)
ire made by an assistant, or by temporary liga-
tre. Floss silk or tape is the best for temporary liga-
on but none of these methods is as universally
pplicable or satisfactory as the small serrefine or
lamp.
The needles commonly employed are Kirby No.
2, 14, or 16, depending on the size of the artery.
luthrie recommends No. 12 for arteries four milli-
leters in diameter or more, No. 14 if the vessel is
mailer. The needles should be highly polished,
■ee from rust, and have a small eye. Silk is probably
he best suture material although human hair is
ivored by some surgeons. The silk used is the
ntwisted floss silk. Guthrie uses "bead silk" com-
osed, as are all silk threads, of three strands each of
Inch is made up of two others. The silk is divided
ito its three strands and these are used for sutures or,
finer ones are wanted, each of these may be again
ivided. Horsley uses No. 1 black Chinese silk un-
wisteil into its three component strands. Many
f the surgical supply houses now have special silk
ir this work or it may be obtained already threaded
ml sterilized in oil in tubes, similar to the catgut
gatures. The silk should be of good quality,
mooth, and with a tensile strength of from three
unces to five ounces. Sutures are prepared before-
land, tied in the needle, with one end cut off short,
ml should be about eighteen inches long. Two are
nough for most operations although it is well to have
i'ic at hand. After being threaded the needles are
hrust through a card and the silk wrapped around
he latter. They are then put in a small bottle or
iox filled with liquid vaseline and sterilized by
•oiling cither with the instruments at the time of
iperation or beforehand. Instruments are sterilized
iy boiling as for any operation.
End-to-end Anastomosis. — The incision is made in
he usual manner and the vessel exposed. The
lamps for temporary hemostasis are then applied to
the artery, I he tourniquet . il one i i , i removed,
and all small bleeding points arc tied. It IS well to
put a strip of lint-free waterprool material undei the
artery at the point where the anastomosis is to be
made, of a dark color if white silk is being used and
white if the silk is black. Tin- vessel is then washed
out with saline soluti in to remove any clot and tl e
edges are trimmed smooth and even. A knife
bruises the tissues less but scissors make a mole . i ii
cut and should lie preferred if t hey are --harp. If the
artery has contracted into its sheath the ad ventitia is
pulled down and cut off. Three slay or guide sul urcs
arc then applied at points equidistant about the
artery, one being placed directly posterior. They
pass from without inward about one millimeter
from (he edge t h rough all the coat oi the distal end
of the artery and from within outward at the proxi-
mal end. The suture is then snapped and the other
two are placed in a similar manner, after which all are
tied and theends left long. If there is no tension the
sutures may be tied as placed. While doing this
work the fingers and the ends of the vessel are kept
smeared with a thin coating of sterile vaseline which
prevents the tissues from drying and also fends to
retard coagulation. Great care should also be taken
not to scratch or otherwise injure the intima in any
way as even the slightest scratch means a small
clot. The stay sutures being placed and tied, the
assistant takes one in either hand atid by gentle trac-
tion makes the segment of artery between them a
straight line (Fig. 395). The operator starts his con-
tinuous suture at one of the stay sutures and con-
tinues it with a simple over-and-over stitch to the
Fie. 305. — Apposition of the Ends of Divided Arteries by Means
of Stay Sutures, Preliminary to Continuous Stitching Together.
other, taking care to include all the coats of the vessel
in each stitch. It is tied to the second stay suture
with a double knot. From sixteen to twenty stitches
to the inch should be taken (Fig. 396).
The assistant then drops the first stay suture and
makes traction on the second and third, bringing
this portion of the artery uppermost. The continuous
suture is then carried to the third stay where it is
again made fast, care being taken not to pucker the
vessel. The same procedure is carried out between
the third and first stay sutures, thus finishing the
anastomosis. The distal serrefine is next taken off
and the stitch holes and line of suture are inspected
for leakage. There is practically always a slight
oozing of blood from the stitch holes which, if the
anastomosis has been well done, will stop in a short
661
Arteries, Surgery of
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
time if gentle pressure is made; but if there is too
much, one or two stitches can be taken through the
outer coats of the vessel. The proximal serrefine
is taken off last and, after inspection to see that the
anastomosis is working properly, the wound is closed.
When the ends of the vessel cannot be brought
together without tension and it is necessary to graft
in a portion of a neighboring vein, the same technique
is applied but the grafted portion of vein should be.
inserted with the valves pointing in the direction of
the blood-current in order that they may not hinder
the circulation. The saphenous and the external
jugular are the veins commonly available. In
Fig. 396. — Stitching Between Stay Sutures shown in Fig. 395.
human surgery the autoplastic graft is to be preferred
to the heteroplastic graft from animals (Carrel,
Guthrie).
In performing end-to-end anastomosis between
two adjacent vessels, as in reversal of the circulation,
they should be divided at different levels to allow for
the retraction that inevitably occurs and makes it
difficult to approximate the ends if divided at the
same level.
End-to-side Anastomosis. — The same principles
are to be applied in end-to-side anastomosis as in
end-to-end. The wound in the side of the vessel being
made triangular by the use of three stay sutures, or
by the use of light side clamps similar to gastro-
enterostomy clamps, the suture may be done as in
intestinal anastomosis. If the stay sutures are used
they transform the lateral slit into a triangle.
In lateral or longitudinal wounds stay sutures may
be employed or the suture may be made with the
finger passed under the vessel as one would repair a
cut in a piece of cloth. When the lateral wound is
transverse and embraces more than two-thirds of
the circumference of the artery, it is best to complete
the division and treat it as an end-to-end anasto-
mosis, as the retraction of the edges of the cut makes
any other procedure difficult.
Lateral Anastomosis. — Bernheim and Stone have
described a method of doing this operation, the
essential feature of which is to make the wounds in
the vessels opposite each other, transverse, and about
one-third the circumference of the artery. Retrac-
tion of the walls of the vessels transforms these slits
into ovals the edges of which are then sutured.
Arteriovenous anastomosis, or the reversal of
the circulation in an organ or limb, has been proposed
for Mime time for conditions in which the artery
beyond the point of anastomosis, because of injury
or disease, is incapable of transmitting the blood to
the part. Frank in 1881 did a series of experiment
on reversal of the circulation in animals, none o
which were successful; he did not publish them til
1896.
The first operation in man was performed by Sai
Martin y Satrustegui, a Spaniard, in 1901'* i'l,
reported two cases done in the hope of relievini
gangrene, neither of which was successful, and late
in the same year Jaboulay reported a case also i
failure. The operation was first successfully in-
formed by Carrel in 1902, and since then has beei
done experimentally many times. In 1906 Carre
and Guthrie reported thirteen cases with only oni
failure, and later reported the result of an autops;
at the end of seven months in which the anastomosi
was still in good working order.
In human beings reversal of the circulation ha
been performed fifty-eight times on fifty-six patient
(Halsted and Vaughn, 1912). These observers bavi
analyzed carefully forty-two of the cases. In thirty
one the anastomosis was done for actual gangrene
and in eleven for threatened gangrene. Three of th<
operations were for presenile gangrene, two in case:
of embolism, three for traumatic obliteration, am
one in a case of sepsis.
Reversal of the circulation in the extremities ha
been advocated for presenile gangrene, Raynaud'
disease or Judaische krankheit, common senili
gangrene, and for the obliteration of the artery by i
thrombus or an embolus or an injury.
Although there are many cases reported there i.
much difference of opinion as to the value of thi
operation. Weitung, whose name is intimate!
associated with the operation, strongly advocate- it
while Coenen and Wirwiorowski after careful experi-
mental work consider it unjustifiable and against
anatomical and physiological principles. In thi;
country Halsted and Vaughn conclude that it b
indicated only in traumatic surgery when the arten
is destroyed and then should be done simply wit]
the object of supplying more blood to the part unti
the circulation can be taken up by the collaterals
On the other hand, Bernheim (1912) who has hac
several cases and has analyzed fifty-two of those
reported, considers it a well-recognized operatic-]
justified by the clinical results.
The experimental and clinical observations are at
variance. Carrel showed that in animals the blood
pressure in the artery overcame the resistance of the
valves in the veins, while Coenen and Wirwiorowski,
experimenting on the cadaver, were unable to force
the injecting fluid past them. Bernheim ami
Weitung take exception to this and say that in life!
it is different and the constant pounding of the
arterial blood soon breaks down the resistance of the
valves as is proved by the clinical results. Halsted
and Vaughn conclude that there is enough clinical
and experimental evidence to show that the opening
is not permanent and that in the few cases in which a
thrombus does not immediately form the endothe-
lium gradually obliterates the opening, although
they admit the operation may be successfully done
on animals. They also say that even in the I I
where the stoma remains open and the resistance ol
the valves is overcome, the blood never reaches the
capillaries but is returned to the heart by the anasto-
mosing veins. They consider that in only two of the
forty-two cases was the circulation enough restore
to prevent the progressing gangrene, although local
changes showing improvement in the circulation
were noted in twenty-three cases. Lejars, in com-
menting on Weitung's paper, says that Weitung
advocates the operation only in the case of vigorous
people with no infection, in whom the gangrene is nol
advancing, and he thinks that in this class of cases
expectant treatment is usually indicated and is much
less dangerous.
Bernheim in his analysis of fifty-two cases con-
662
llEKEKEXCE handbook OF THE MEDICAL sciences
Arteries, Burger; of
iIits fifteen successful and remarks that in the last
teen cases reported there were nine sueeesses an. I
.,■ failures while the result in one was questionable.
1,11 hen of the patients died immediately after the
[,,11 while the course of tin- ili :ea e was uninflu-
| in i he remaining twenty-two.
i >ne of the chief causes of failure is the poor surgical
-k which the average patient who is submitted i" the
i. ration presents. Nearly all are old witli existing
e which is advancing, and there is often more
less infection. The arteries are usually throml >o ed
. distance around the gangrenous ana, and in
cases the operation is done as a last resort.
cases in which the best results have been ob-
oe those of " threatened gangrene." Raynaud's
ease, Judaische krankheit, and allied conditions,
it li pain, cold extremities, and loss of pulse but with-
uil gangrene. The other chief cause of failure
thrombosis from faulty technic or sepsis, and of the
ported cases infection has occurred in an unusually
rge number. As to technique, it is impossible for a
an who has not done considerable blood-vessel
irgery in the laboratory to do a satisfactory anasto-
losis on the human with any hope of success.
The success of the operation is to be judged by the
■lief of symptoms, i.e. increased warmth, improved
lor, relief from pain, pulsation in the vein, and the
■turn of the part threatened to normal.
The last word on the reversal of the circulation has
nt been said and it is unfortunate that the opinions
f good observers are so diametrically opposed. It
ould seem to be a justifiable operation in the hands
t competent surgeons in certain selected cases and to
e of especial value in cases of traumatic destruction
f an artery, or where the vessel is plugged by an
inhiilus. The operation may also be resorted to with
Hue hope of success in certain cases of gangrene,
articularly the presenile type, such as Raynaud's
isease, be/ore infection or marked actual gangrene
as occurred.
The technique of the operation is the same as that
~cd in the suture of any blood-vessel. There are
nur chief methods: (1) Proximal end of artery to
listal end of vein (Carrel); (2) End of artery to side
t vein (Weitung); (3) Side to side with ligature of
he vein proximal to the anastomosis (Bernheim and
'tone); (4) Anastomosis with a biterminal graft
■.hen there is loss of substance. It has been shown
hat a complete reversal of the circulation is unneces-
ir\ , it being sufficient to anastomose the proximal end
if the artery to the distal end of the vein and ligate the
ihcr ends, as the collateral anastomosing veins are
ufneient to take care of the return flow of blood.
klarked edema of the extremity is usually noted,
lowever, after the operation when it is done in this
iianner.
The Matas Operation fob Aneurysm. — The
Uatas operation for the cure of aneurysm was first
icrformed by Rudolph Matas in March, 188S, and
eported in October of the same year. At the present
lay it has replaced in nearly all cases the older opera-
ionsof Vntyllus, Hunter, and Basedow. The opera-
ion consists in opening the sae under temporary
lemqstasis, closing the orifices of all vessels leading
it" it by direct suture, and obliterating the sac by
Occasionally, in very favorable cases, the
trtery may be reconstructed. The object of the oper-
itioa is to cure the aneurysm and relieve the pressure
on the surrounding parts with as little interference to
the circulation as possible. It is simpler and easier
o perform than many of the other operations, such
as dissecting out the sac after ligature, and has a great
advantage in that the artery is controlled in all cases
at the point of hemorrhage and not in continuity, thus
interfering very little with the collateral circulation
and reducing the possibility of gangrene to a minimum.
The principle of the operation is as follows: The
Fig. 397. — Restorative Operation.
The Lembert sutures are closing the
single stoma of a sacculated aneu-
rysm.
sac is regarded as a serous lined cavity the endothe-
lium being continuous with that of the artery; this
endothelium acts when drawn together and irritated
in the same manner as does the peritoneum, and the
surfaces unite by the formation anil organization of a
plastic exudate. The
• list urbance of circula-
tion is reduced to a
minimum by I he intra-
saccular suture of the
bleeding points. If
the aneurysm is saccu-
lar the sac may be ob-
literated and the con-
tinuity of the vessel
restored or, if it is
necessary to obliterate
the artery, the small-
est amount of vessel is
destroyed. The col-
lapse of the sac, by
emptying its contents
and its further obliter-
ation by suture, re-
lieves all pressure on
neighboring parts and
the satellite vein is not
destroyed as is often
the case when an at-
tempt is made to dis-
sect out the sac.
The operation is ap-
plicable, in one form
or another, to all aneurysms except the intrathoracic
and abdominal varieties. It should be used in trau-
matic aneurysm only after the formation of a true
sac and not in the early stages when the tumor is
in reality a pulsating hematoma. Arteriorrhaphy,
which is an entirely different procedure, should be
clone in these cases.
There are three types of the operation, called by
Matas obliterative, restorative, and reconstructive
endoaneurysmorrhaphy.
Obliterative Endoaneurysmorrhaphy. — This is the
operation applicable in the largest number of cases
and is used where the vessel is dilated into a fusiform
aneurysm involving all
the coats for a varying
distance. The opera-
tion consists in open-
ing the sac and closirg
all the openings into tl
with continuous su-
tures. There are
always two openings,
representing the main
artery, besides a vary-
ing number of smaller
ones. After closing all
the openings the sac is
obliterated.
Restorative Endo-
aneu rysmorrhaphy. —
This is the ideal oper-
ation but is applicable
only in a compara-
tively small number of
cases. It is used in
sacciform aneurysm
where there is a dis-
tinct sac on one side of
the artery communi-
cating with the lumen
of the vessel by a comparatively small opening. In
these cases the opening into the artery is closed with
a continuous stitch and the sac obliterated by several
rows of sutures. These also reinforce the first suture
and strengthen the arterial wall.
663
Fig. 398. — Restorative Operation.
The stoma closed.
Arteries, Surgery of
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
K( c « nst ruct i ve Endoaneurysmorrhaphy. — This
method is applicable to aneurysms of the fusiform
type where the openings of the parent artery are on
the same level, on one side of the sae, and not far
apart. The utility of the operation is somewhat
Fig. 399. — Reconstructive Operation. Sacculated aneurysm
opened and seen from within. Note the opening of a collateral
to one side of the main stomata.
questioned and it should be used only in very favor-
able eases where the walls of the sac are elastic and in
good condition, and the danger of gangrene of the
part supplied by the artery is great. Since thrombosis
is very likely to occur it is of value in these cases as a
Fm. 400. — Reconstructive Operation. Aneurysmal sac shown in
Fig. 399. Stomata partly closed by Lembert sutures.
temporary expedient to supply blood to the part until
the development of the collateral circulation. The
operation consists in passing a catheter into the two
openings of the main artery over which the sac is
drawn together and sutured, making a new artery.
664
Technique. — Temporary hemostasis is a necessity
and is best obtained by a tourniquet. When this is
impossible, as in aneurysm of the iliac or axillary
artery, clamps of some form may be applied to the
main vessel or it may be tied temporarily with a tape
but severe hemorrhage from collaterals entering the
Fig. 401. — Reconstructive Operation. Catheter in situ.
sac should be expected. The incision should lie made
longitudinally directly into the tumor without prelim-
inary dissection, the clot turned out, and the walls
examined for the openings of the vessels. All of
these are closed by an intrasaccular suture. The
sutures used are either fine silk, No. 1, or chromic
Fig. 402.-
-Detail of Reconstructive Operation,
being withdrawn.
The catheter is
catgut, No. 00, on fine straight or curved needles,
both sutures and needles being coarser than those used
in arteriorrhaphy. The sutures are sterilized in oil
and in general the rules applying in arterial surgery
are observed, but the operation is less difficult. In
the closure of the orifice of the vessel, the suture is
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
\rterloflderoslfl
arted one-half inch to one side of the opening and
deep into the tissues. A continuous over-
Id-over stitch is used and in the restorative opera-
,. lumen of the artery is made someM hat smaller
ia n that of the original vessel. After the closure "I
[ openings the sac is obliterated. This may be
, ne in several ways. When opened and the con-
iracuated, the sac collapses and forms longi-
1G . 403. Obliterative Operation, Showing Insertion of Second
Row of Sutures.
udinal folds which are sutured together with a con-
inuous stitch. When the sac is small this may be
one and the soft tissues and skin closed over it.
V lien the sac is large several superimposed layers of
uture are used and the skin edges are freed and slid
ver (lie unobliterated portion to which they are
utured. In certain cases of stiff walled sac which
annot be sutured, a skin flap can be slid in and fast-
ned in the same manner that skin flaps are used to
ate stiff walled cavities in bone. When the sac
1(14.
-Detail of Imbricating Stitches for Obliteration of Dead
Spaces.
is trabeculated and it is impossible to close it at all by
suture a part may be excised and the rest packed and
allowed to heal by granulation. In post-peritoneal
aneurysm, aneurysm of the iliac, the same principle is
applied, the peritoneum being used in the same
manner as the skin.
The results of the intrasaccular operation are very
much better as regards cure and freedom from gan-
e, than those of the older operation Monod
and Vanverts (December, 1911) have collected from
the literature L05 cases with the following results:
Cures eighty-five (82 per cent i; mortality 11.6 per
cent.; gangrene I 9 per cent.; failures 14.5 per cent.
The remote results are given in only thirty-seven <>f
1 1,, e cm e and in many I he patienl had been ob-
served but a few weei . 01 the twi Ive death . two
occurred in eases of aneurysm of the aorta which
should not be included in this series. The others
1 i... 403. — Cross-section ol the I issues, Showing Imbrication in
the Reconstructive Operation.
were caused by shock, hemorrhage, gangrene, sepsis,
and pulmonary embolism. The failures consisted
in postoperative hemorrhage, of which six cases were
fatal, or recurrence of the aneurysm. Presence of a
pulse was noted in thirty-five case immediately after
the operation, while in others it did not appear for
several hours.
The results were very much better in long-standing
traumatic aneurysm in young people where the
vessels were elastic and in good condition, than in the
common aneurysm in old subjects. In the former
class were seveiitv cases with sixty-one cures, 88.4 per
cent, while in the latter class numbering twenty-
five, there were fifteen cures, sixty per cent, and twenty
eight per cent, mortality. These authors were struck
by the large number of postoperative hemorrhages,
Fig. 406.-
Cross-section of the Tissues in the Obliterative
Operation.
twelve cases, six of which were fatal. In the recon-
structive cases there were twenty-nine per cent, of
recurrences. .
Matas in 190S reported the results of eighty-five
cases and later said he had knowledge of 110 cases
operated upon bv his method. Of the eighty-five
operations fifty-nine were of the obliterative type,
thirteen restorative, and thirteen reconstructive.
Of the reconstructive cases, four or 2S.9 per cent.
recurred. _ _
Channing C. Simmons.
J. Collins Warren.
Arteriosclerosis.— See Blood-vessi Is, Pathological
Anatomy of, and BloocLpressure.
665
Arthritis, Acute
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Arthritis, Acute. — Anatomy. All diarthrodial joints,
that is, all joints possessing motion, are bounded by
two tissues, the cartilage and the synovia. Under-
neath the synovia is the ligament (or fascia), under-
neath the cartilage is lymphoid marrow. If the
synovia is inflamed, this inflammation constitutes an
arthritis. The cartilage itself is probably not capable
of inflammation (see Artliritis, Chronic), but an in-
flammatory process in the subjacent bone marrow
readily finds access to the joint at the circumference
of the .cartilage, or even through the cartilage itself
by depriving it of its nutrition and so perforating it.
Thus a myelitis may easily become an arthritis, and
usually does, when the lymphoid marrow is involved.
On the other hand, an arthritis starting in the
synovia, may involve the marrow by making its way
into the bone at the circumference of the cartilage.
These two tissues, the synovia and the lymphoid
Fig. 407. — Low Power Photomicrograph. Normal capsule of
joint, showing smooth surface of synovia above, and the vascular
spaces.
marrow are the important ones in all cases of acute
arthritis. Some diseases affect one, some both.
Lymphoid marrow is found in the short and flat
bones, in the ends of long bones, and, in children, in
the shafts also. It consists of a delicate reticulum of
connective tissue in whose meshes are cells of various
kinds, and it is these cells which distinguish lymphoid
marrow from the fatty marrow of the shafts.
Synovial membranes resemble so closely the serous
membranes that they are often classified with them.
But, although structurally much the same, they differ
from the serous membranes in secreting a peculiar
fluid — the s\ r novial fluid. In all joints where motion
takes place (diarthrodia) a lubricating fluid is neces-
sary, and this fluid is furnished by the synovial mem-
brane. Every diarthrodial joint is lined with a layer
of synovial membrane, except in the places where the
articular cartilages are in contact. Here there is no
membrane, except at the edge of the cartilages,
which the synovial membrane may overlap for two
or three millimeters before merging into the carti-
laginous structure. Fasciculi and folds of the capsule,
the internal ligaments, and fatty internal protrusions
are all covered by the membrane. The limits of the
synovial membrane an- most easily made out in in-
flammation, when a red collarette is seen surrounding
the while cartilages.
Synovial membranes or synoviie, classed among
structures of the lymphatic system, are connective
tissue membranes, very thin and delicate, whost
limits in health can hardly be defined from the under-
lying fascia or ligament. In disease, however, thf
membrane may became greatly thickened and have c
thickness of perhaps twenty millimeters.
In gross the inner surface of a joint presents p
smooth and shining surface, interrupted, especially
where the membrane folds to pass from one surface U
another, by the synovial fringes (plicce sync
villous structures of varying size and length, some-
what resembling intestinal villi, the largest beine
perhaps one centimeter long. They are richly
supplied with blood-vessels, for each villus contains thi
convoluted twig of an artery. Some of the fringe?,
however, are merely hernia-like prolusions into the
joint of small masses of fat covered with synovial
membrane; these fill up unoccupied spaces. Th;
nerves are derived from the same nerve trunks that
Fig. 408. — Photomicrograph. Capsule of joint, near a recess
showing folds of synovia.
supply the muscles of the limb. The nerve fila-
ments terminate in small plexuses equally distributed
under the synovial membrane. Coloring matter
injected into the joint disappears very quickly, to
reappear in the lymphatic channels of the limb.
Synovia is a clear, alkaline fluid, much like the
white of egg in general appearance; when rubbed
between the fingers it imparts an oily sensation. It
is largely secreted by the cells which cover the -_
vial fringes. In composition it contains albumin,
mucin, some fat, leucocytes, and epithelial cells. A
fluid identical in composition with synovia can be
reproduced by rubbing up a portion of the epidermis
is a weak alkaline solution. This fact suggests that
most of the mucin is derived from the endothelial
cells soaking in the weak alkaline fluid secreted by the
fringes, and this view is strengthened by the fact
that, when joints are quiet, the synovia in them
contains only half as much mucin as when they are iu
motion. 1
Etiology. — Acute arthritis may be caused either
by injury or by infection, though the propriety of
including the first factor as a cause is questionable.
However, as a trauma to the lining of a joint ran
hemorrhage into the joint itself, and as the physical
signs are manifest in the joint, we shall give that
phase of the subject a few words, before taking up
arthritis proper.
6GG
REFERENCE HANDBOOK OF Till'. MKIUt \l. SCIl'.NCF.S
Arthritis, Arutc
Traumatic Arthritis. — The usual cause is a
,-rench, a "strain," a "sprain," or a dislocation.
ures involving the joint form another important
, : penetrating wounds of the joint, if absolutely
septic, a in it her. If the ligament and with il thesyno-
be torn, a greater or lesser amount of blood, and
iter of inflammatory products, is poured out into tin'
.nit cavity, and it is these that cause the symptoms
i thr joint, symptoms persisting until the effusion is
orbed and until the synovia is healed. Much the
ame may be said of fractures which involve the joint
hrough lesion of the cartilages.
Morbid Anatomy. — Besides the actual damage of
joint structures by the trauma itself, the palho-
igical changes are not of great moment. The joint
lins the effusion from the ruptured blood-vessels.
ably the synovia proliferates somewhat, and the
artilage will become more or less fibrillated if the
lint be immobilized. Another result of immobili-
ation is the encroachment of the synovia on the
artilage at its borders. All these changes disappear
ipon the healing of the original trauma and the
esumption of function. If the joint has been
lennanently damaged, as a machine, so to speak, by
lie interference with its function from displaced
nine fragments, it will be exposed to constant in-
even after the fracture has healed. These
i. id bone fragments may keep up a continued
rritation of the joint.
Symptomatology. — Immediately after the injury, or
it a short interval of time the joint becomes painful
• tiff, and swollen. Motion of it causes increased
tain, a id as a rule it contains more or less fluid.
Increase of local temperature and reddening may or
not be present. Frequently in the case of a
torn ligament (or semilunar cartilage in the knee)
.! of lmal tenderness may be made out. After
i few days or weeks these symptoms subside and
leave the joint practically normal.
The prognosis is usually good. Except in the
knee, whose complicated structure predisposes to a
recurrence of the damage, there is little chance of
pse. It is to be borne in mind that whatever
remains behind after the "synovitis" has run its
>e is not due to it but to the injury that caused
it. Again, there is little prospect of the disease
"running into" anything else. Indeed, some writers
maintain that those cases of joint tuberculosis which
seem to have been caused by an injury are only
lighted up by it.
The treatment consists in the first place of hot or
cold applications, or of tight compression by bandages
and a splint, to restrict the effusion into the joint as
much as possible. Afterward rest and support are
indicated. Plaster-of-Paris is rarely necessary, nor
i- rest in bed. If the joint be properly strapped, so as
to exert pressure and to restrain motion, the patient
may usually be allowed to go about.
Massage and hydrotherapy are excellent in the
later stages.
Ankylosing Arthritis. — Another form of traumatic
arthritis, whose exact pathology is not thoroughly
■ stood, has been described by several writers. 2
After an injury a joint slowly becomes stiffened, until
plete bony ankylosis takes place. No fracture
ran be demonstrated by the most careful examination.
Treatment hitherto has been fruitless. A peculiar
deformity sometimes occurring in the spine may be
analogous to this. Shortly after a severe injury, a
kyphosis makes its appearance, and, if untreated,
ly increases. The Roentgen rays show no dis-
and no fracture. The treatment consists of a
well-fitting plaster jacket to control the increase of
deformity. 3
Acute Infectious Arthritis. — Under this head
we include every case of acute joint inflammation not
falling in the preceding class. The infection may be
of the most varied nature. The ordinary pus COCCI
may be responsible for it, the pneumococcus, the
typhoid bacillus, or the gonoCOCCUS. Some '.'.titers
maintain that toxins circulating in the blood ran
cause a joint inflammation. Probably acute inflam-
Fig. 409. — Low Power 1'nuionu
InfectioD — probably gonorrheal —
lymphoid elements.
•lugraph of a Joint with Mixed
showing proliferation of the
matory rheumatism belongs in this category, but it
will be discussed elsewhere.
Penetrating wounds of a joint and infection follow-
ing operation cause not a few cases of the disease.
As might be expected the disease often accompanies
or follows one of the acute infectious diseases, gonor-
Fig. 410. — Same as fig. 409; High Power.
rhea, pneumonia, typhoid fever, scarlatina, smallpox,
and septicemia. Pregnancy and labor favor the
appearance of gonorrheal arthritis in women. In
the arthritis complicating an infectious disease the
microorganism responsible for the joint lesion may
G67
Arthritis, Acute
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
be that of the disease itself, it may be that of a
secondary infection, or it may be mixed.
When an arthritis complicates an infectious disease
its origin is easily understood, but in some cases the
port of entry of the poison, and its appearance in the
joint, cannot be ascertained. A sharp dividing line
i- not always present between an acute and a chronic
infectious arthritis. At the start many chronic
joint diseases appear to be acute. On the other
hand, the disability and deformity remaining after
an acute arthritis must not be confounded with an
active chronic arthritis.
Pathology. — The three essential tissues in a joint
inflammation are the synovia, the marrow, and the
deep layer of the periosteum. Sometimes one is
involved, sometimes another, sometimes all three.
The morbid changes in the bone and in the cartilage
are to be regarded as secondary to those of these three
tissues. Certain infectious agents seem to have a
predilection for one, certain for another of these
tissues; thus, the gonococcus affects by preference
the synovia, and more rarely the periosteum; the
ordinary pus cocci, all three. An arthritis may have
its origin in the marrow and spread to the synovia,
or the process may be reversed. Occasionally a
myelitis of the shaft may spread to the joint, but as a
rule the ordinary infectious osteomyelitis of the
shaft stops at the epiphyseal line. (Infectious
osteomyelitis of the shaft is usually found in adoles-
cence.) If the disease start as a myelitis in the end
of a long bone, it quickly becomes an arthritis.
The ordinary phenomena of inflammation follow
the infection, and an exudate is poured into the
joint. The disease has been classified upon the basis
of this exudate — serous, serofibrinous, purulent, etc.
The synovia hypertrophies, thickens, and may
undergo a marked villous change.
If the infection be a mild one, the exudate may be
absorbed after a longer or shorter time and the joint
may return to its normal condition. If the infection
be more severe, some thickening of the synovia and
adhesions in the joint may remain. In the very
severe infections the inflammation spreads through-
out the joint with great rapidity, killing the bone and
cartilage, perhaps bursting through the ligament,
and destroying the joint. In certain diseases (e.g.
typhoid fever) a marked tendency to dislocation
exists.
Symptomatology. — Pain is usually the earliest
symptom and the most prominent one. It is wont
to be very severe and to be increased by motion. It
is usually in direct proportion with the severity of
the infection. Coincident with the pain appear
local heat, swelling, and change of contour. The
limb is held in the most comfortable attitude — usually
.slight flexion. Fever and constitutional involve-
ment are present in the severer forms. Fluid can
usually be demonstrated in the joint cavity.
In the milder forms the symptoms may soon sub-
side. In the severe forms the march of the disease is
rapid and alarming, and unless timely treatment is
carried out, or in spite of it, the outcome may be
fatal.
Diagnosis. — The fact that a joint is acutely inflamed
is patent to the casual observer. The important
fact to be ascertained is as to the character of the
inflammation, for upon the early recognition of this
may depend the life of the patient.
The milder forms of the disease — those that should
be treated conservatively, those with a simple serous
exudate — are accompanied by few constitutional
symptoms or by none at all. The entire trouble is
local, and the patient is not sick. The temperature
may be slightly above the normal, but not much
above it. The severe forms, on the contrary, are
accompanied by marked constitutional symptom .
as well as by severe local signs — great swelling, pain,
heat, etc. An arthritis following typhoid fever may
668
belong in the former class, and by a secondan
infection may be converted into one of the latter,
The same may be said of a gonorrheal joint and of
others. An acute inflammation in one or more joints
of an adult always should awaken the suspicion of a
gonorrhea. The detection of a lesion in the genito-
urinary tract practically clinches the diagn.
Often the gonococcus may be cultivated from
aspirated fluid, especially in recent cases. Acute
inflammatory rheumatism is always fleeting, and
its high fever, its acid sweats, etc. If an inflammation
remains in one joint it is not due to acute inflam-
matory rheumatism. In case of doubt as to the
origin of the arthritis, careful inquiry should be
made as to the previous occurrence of an acuti
infectious disease. Aspiration of the joint will often
reveal the pathogenic organism. Scurvy might
cause confusion in infants. The history of bottle
feeding, the bleeding gums, the exquisite sensitive-
ness of a joint, without constitutional or marked
local signs, should clear up the doubt. A hemon
into a joint, sometimes seen in hemophiliacs, is not
wont to be accompanied by many symptoms, either
constitutional or local. Tuberculosis is usually slow
and chronic. Sarcoma affects the end of one articu-
lating bone, but not the joint itself.
Treatment. — This depends largely upon the cause
and upon the severity of the infection. Milder ta
are best treated by rest— weight and pulley extension.
splinting, plaster-of-Paris, etc. — by hot or cold
applications, and sometimes by aspiration, though
this last is not often necessary. In the later sta|
massage, passive motion, hot and cold douches, hot
air, are all serviceable.
In the more severe forms aspiration and washing
out of the joint with sterile water, or with a solution
of iodine, boric acid, or carbolic acid have been
recommended. They should not be continued for
long, and too much reliance should not be placed
upon them.
In the ordinary purulent arthritis, the treatment
should be that of any abscess, namely free and early
incision, and thorough drainage.
Gonorrheal arthritis should be treated locally on
the lines laid down. The genito-urinary tract,
especially the prostate and seminal vesicles in a man,
should also receive attention. Often with the curing
of the primary lesion, the joint affection will subside
Antigonococcic serum and vaccine are not always oi
service, but sometimes their beneficial effect i
marked. Leonard W. Ely.
References.
1 Frerichs: Wagner's Handworterbuch der Physiologie, iii. f 1,
146.
2. Murphy: Journal of the American Medical Association, April
27, 1912.
3. Mauclaire et Burnier: Archives Generates de Chirurgie,
March 25, 1912.
Arthritis, Chronic. — The student of chronic diseases
of the joints meets at the outset a very perplexing
problem. He finds the greatest confusion in all aspei ta
of the subject. Various authorities describe different
diseases or types of disease under the same name, and
the same disease under different names. Many differ-
ent classifications have been put forward. One
writer holds fast to infection as a cause of certain
types, and disturbed metabolism as the cause of ot hers;
another writer may reverse these classes completely.
Some maintain that all chronic joint diseases arc
infectious in their nature. To set forth all the various
theories and classifications is not possible lure.
Many of them err as being based on clinical data,
always an unsatisfactory procedure, others again as
based on the Roentgen picture, which can show merely
the results of disease. What follows is based mainly
upon laboratory study, corrected by clinical observa-
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Arthritis. Uiroiilt-
ion. li is not all demonstrated truth, bul it is
imple, easily comprehended, and, if carefully dige ted,
rill furnish' the render with a nidus on which tu
n stallize his nun ideas. In order tn avoid hopeless
, .nfusiim une must perforce have some such working
iasis.
Etiology. — All chronic joint diseases whose cause
lf know are infectious in their nature, and it seem
iesl to regard those whose exact cause we do not know
- belonging in the same category. One after another
diseases have been placed in it. .Nut long
onorrheal arthritis was considered as due to a
irritation'' from the urethral mucous tiieni-
and joint tuberculosis formed a great mystery
uilil its exacl cause was known. Some authorities
laim that "faulty metabolism" is a cause of some
but faulty metabolism in a joint is the result of
, not its cause. It is present in any di i
An increased excretion of lime salts has been
I in the urine of some patients. This is, of
what one would expect with a rarefying
isteitis.
Various observers (Schiller, Banantyne, Fayer-
eather, et al.) have isolated pure cultures of bacteria
rom certain cases of chronic arthritis, and, because
iese bacteria are not always identical, doubt has been
hrown upon the result of the investigations. It
vere better to regard them as authentic, and to con-
lude that different organisms are capable of pro-
lucing the same joint changes, or changes which, in
he present state of our knowledge, appear the same.
< Ither investigators have been unable to obtain any
lacteria from these chronically inflamed joints, but
he organisms may be there, nevertheless. One must
iear in mind that until recently the Spirochwta
escaped recognition, and that it is often
lillieult to find tubercle bacilli in tuberculous joints.
Igain, if the organisms are in the bone marrow
nay easily escape detection.
In many of these patients a possible source of
nfection has been found, and, when this was removed,
ase died out or became quiescent. Diseased
onsils, a purulent otitis, or nasal sinusitis, an intes-
mal indigestion, a suppurating tooth cavity, a
yphilitic or gonorrheal infection, have all been linked
i]) in this way in a causal relation to the di ease.
>i casionally one obtains a history of a severe attack
if "dysentery" which immediately antedated the
ymptoms. The more thoroughly one searches the
ii tory, the more often will one find evidences of an
nfection, so often indeed as to render improbable the
elation of coincidence, and to make the causal rela-
iOD almost certain.
No age is exempt except the earliest infancy,
'orae types are found in the earlier periods of life
nost frequently, and other types in the later periods.
Mental emotion is thought by some to stand in a
ausal relation. This is possible, but the relation is
irobably not a direct one. If we regard intestinal
lection as a cause of the disease, we can easily see
tow mental emotion might predispose by disturbing
he digestion.
It is not likely that occupation is a factor. Chronic
irthritis affects the rich and the poor, the hard-
working and the idle.
cently the influence of the ductless glands —
thyroid, pituitary, suprarenal — has been
I 'bated, but nothing has yet been established.
I tic thymus gland particularly has been held responsi-
ve, and the administration of its powdered extract
has been recommended in some cases as a cure, but
i I ick of the secretion of a gland which normally has
ed to functionate can hardly be regarded as a
cause of the disease.
Finally, let it be said that certain of the changes
occurring in some types of the disease are analogous
to those often taking place as age advances. Indeed,
the nodes found on the terminal phalangeal joints—
Herberden's nod.- are aid to !»' an evidence of
longevity. Beitzke in a series of consecutive autop-
found localized ero ion ol the cartilage in a very
large proportion. 8
Classification. — It is manifest that if our theory
of t he infect ions nut ure of every case of chronic art hri-
tis is correct, no form of classification we 'an adopt
will stand until we liml out everj infection that will
cause the disease, and i he exact pathological changes
that each causes. This we have doni 01 i i g
in tuberculosis, but not in all, and our task will not
be lightened by bestowing meaningless and im
terms such as arthritis deformans, rheumatoid •<•
tie, metabolic arthritis, etc., upon the whole class or
u I ion certain divisions ol it . For the present it seems
wiser, if possible, to classify upon a pathological
basis, and this we can do.
All, or almost all, cases of chronic arthritis fall
into one of two I ipe, and while some present the char-
acteristics of both types in t he same joint or in differ-
ent joints, the preponderance oi Set of changes is
usually so great as to leave no doubt as to the type in
which the joint should be placed.
In our study of joint diseases we come to deal with
five tissues, namely the red or lymphoid marrow and
the trabecular in the ends of the bone, the articular
cartilage, the synovia, and the ligament.
The marrow consists of a delicate reticulum of
connective tissue and fat, in whose meshes are many
cells of various kinds. It is these cells which distin-
guish the marrow in the ends of the long bones of
adults from that of the shafts. In children the
marrow in the shafts also is of the lymphoid variety.
The custom has been to regard the marrow as more
or less of a "filling" for the bones and of compara-
tively slight importance in bone diseases. On the
contrary, it is probably the tissue of prime importance
in all bone disease, as can be seen by a study of
specimens under the microscope. From the marrow
the bone trabecular derive their nutrition (they have
no blood-vessels of their own) and any changes in it
are reflected in them. A mild irritation in the
marrow is wont to cause an hypertrophy of bone, a
stronger one, an atrophy, and a severe inflammation
results in death of the bone. Certain forms of
degeneration of the marrow, as we shall see, are also
follow-ed by an hypertrophy of bone. Various
authors have mentioned the marrow changes in bone
disease, but as a rule have failed to attach much
importance to them.
All bone tissue is the same, and that in the ends of
the long bones and in the short and Hat bones — can-
cellous bone — differs from that in the shafts — compact
bone — only in its arrangement and in its amount.
Bone is not subject itself to inflammation, or directly
to disease. The changes in it simply reflect the pro-
cesses in its contained marrow. The trabecular be-
come thicker and more numerous from the action of
-mall round cells called osteoblasts, that may be seen
under the microscope lining their surface — produc-
tive osteitis. The bone atrophies by the action of
osteoclasts, giant cells, which lie in small excavations
in the trabecular — Howship's lacuna'. This form of
absorption of the bone is known as rarefying osteitis
or rarefaction. Again, the bone may atrophy by
the absorption of lime salts.
The articular cartilage, like the bone, is a connec-
tive tissue structure, and like the bone again, has no
blood-vessels, but draws its nutrition from the sub-
jacent bone marrow, and, to a lesser extent, from the
synovia, with which it is continuous at its periphery.
The transition from the structure of the cartilage to
that of the synovia is a gradual one, and immobiliza-
tion causes an encroachment of the latter on the
former. When motion is resumed in the joint the
cartilage again pushes out its borders. Lack of
669
Arthritis, Chronic
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
motion is said to be the cause of the fibrillation one
often sees in the cartilage of diseased joints. Possi-
bly this fibrillation may also be caused by the inter-
ference with the nutrition of the cartilage by disease
in the subjacent marrow.
A proliferation of the bone marrow causes an atro-
phy of the cartilage, and sometimes an erosion, but
the cartilage is never attacked by diseases from the
joint side. An exudate in the joint is without effect,
on the structure of the cartilage. The precipitation
of "layers of fibrin," if it exists, is not of great
importance.
The synovia, a connective tissue structure, lines
the joint except that part of it formed by the articular
cartilage. It is a delicate membrane consisting of a
single layer of cells, and produces the fluid which
lubricates the joint. Its reduplications, folds and
villi, are said to be in direct proportion to the amount
of motion required of the joint. In inflammations
the synovia usually
proliferates and be-
comes thickened,
spreading out over
the cartilage, and
partially hiding it
but seldom if ever,
becoming attached
to it. As the mem-
brane proliferates,
it encroaches on the
substance of the
cartilage at its per-
iphery, and often
causes an erosion of
it, but it is probably
true that no amount
of proliferation or
disease in the syno-
via avails to dam-
age the cartilage
from its joint sur-
face. There is a sort
of reciprocal rela-
tion between the
synovia and the
cartilage where they
meet at the circum-
ference of the latter:
as one advances the
other recedes. Hy-
pertrophy of the
one is followed by
atrophy of the other
and vice versa.
The ligament con-
sists of bundles of
fibrous tissue, and
is continuous with
the superficial layer of the periosteum. The deep or
cellular layer of the periosteum, on the contrary, par-
takes more of the nature of the subjacent bone marrow
and seems to be affected by the same diseases.
In the study of joint diseases the bone and cartilage
have hitherto received most attention, but with
confusing results. It is probable that these two tissues
play a passive role in all joint diseases. They form
the '"stroma" of the joint, so to speak. For a better
understanding of joint disease we turn to the active
tissues — the "parenchyma" — and these the synovia
and the lymphoid marrow constitute. If we focus
our attention on these two tissues we can compre-
hend the changes in the others, and upon the changes
in these two we base our classification, dividing all
chronic joint diseases into two main types:
Type I. Cases characterized by a proliferation of
th^ synovia or of the lymphoid marrow, or of both,
with a resulting atrophy of bone and cartilage.
Type II. Cases characterized by an inflammation
670
Fig. 411. — Bone Tuberculosis. Note the two isolated tubercles (n), surrounded by
apparently healthy marrow. They are merely a part of an extensive disease in
the bone. This photomicrograph shows well the futility of attempting to eradi-
cate the disease with a curette. The ordinary bone curette, magnified propor-
tionally, would be about as large as a shovel.
and degeneration of the marrow and synovia, with
a resulting hypertrophy of bone and cartilage.
Under the first heading we place tuberculosis
the 'various forms of chronic synovitis of obscure
origin, intermittent hydrops (probably), syphilitic
synovitis, Still's disease, and that large group of
cases known by various names by different writers—
the atrophic arthritis of Goldthwait, the proliferate e
type of Nichols and Richardson, the rheumai
arthritis of the English writers, etc.
The second group includes those cases variously
known under the terms osteoarthritis, hypertropl
form (Goldthwait), degenerative form (Nichols and
Richardson), etc. In this group would be placed
Heberden's nodes, also morbus coxa? senilis, and
probably Charcot's joint.
Type I. Tuberculosis. Etiology. — The disease is
caused by the tubercle bacillus, which is brought to
the joint ale
invariably in
blood stream, ac-
cording to our
present knowledge.
Autopsies show in
the great majority
of cases some otli r
tuberculous foi
in the body. En-
vironment and
heredity play the
same rule here as in
tuberculosis of
other organ-.
Trauma is decidedly
subsidiary as a
cause. It may be
responsible to a cer-
tain degree in an
occasional case of
synovial origin, but
even here its action
is probably that of
lighting up a latent
disease. The
trauma is a strain
or a wrench. Frac-
tures and disloca-
tions are not fol-
lowed by tubercu-
losis. Anon-tuber-
culous inflamma-
tion does not "run [
into" a tubercu-
lous one. The dis-
ease is much more
frequent in child-
hood than in adult
life. The reason for this we shall presently see. The
two sexes are about equally afflicted. Roughly the
joints may be said to be affected in proportion to
their size. The sacroiliac joint forms an exception to
this; disease of this joint is rare. Various observers
differ in their estimate of frequency of involvem
of the various joints, but following is the appoximate
order: Spine, hip, knee, ankle and tarsus, \vri>t,
shoulder, elbow, fingers. Other joints are rarely
involved.
The question as to the relative number of cases
caused by the bovine and by the human type of
tubercle bacillus is not yet definitely settled. Some
writers maintain that the bovine type is responsible
for the great majority, others deny this.
Pathology. — The primary focus is always locate.]
in the synovia or in the lymphoid marrow, and at no
time are any other tissues directly involved, so long
as the infection is a simple unmixed one. The d
layer of the periosteum forms an exception to this
REFERENCE HANDBOOK OF THE MEDIO \ I. SCIENI ES
Arthritis, i In. ,i,l.
In all bone diseases this layer seems to
lake of the nature of the subjacent mar-
aud to !"• vulnerable to the same dis-
When we speak of the marrow here-
rv,
i es.
jjer this layer of the periosteum is to be
i luilecl. The disease may remain indefi-
elj in its original seat, or it may spread
I ,,i' the synovia to the marrow or from the
to the synovia. .Many authorities
, :,,, thai the primary affection is often
by a tuberculous plus in an end
This may be so in some cases, but
it is rare.
infection here, as in most organs in
is by a bacillus or by several
I illi that are thrown out from the blood
earn. This brings us to the vexed ques-
. by tuberculosis occurs in the region
lints and not in the shafts of the long
les. Tuberculosis is essentially a disease
ymphoid tissue (endothelial and epithelial
also) and ill the region of the joints
two lymphoid tissues, the synovia
red or lymphoid marrow. When
30 two tissues disappear from the joint
el a bony ankylosis, spontaneous or oper-
jve, the disease disappears, provided
(vays there has been no secondary infec-
| n. If a secondary infection be added, the
: 'I'bid process may attack other tissues pre-
msly invulnerable. This is why tuber-
affects children more often than
: ults — their bones contain more red mar-
a. The synovial form is comparatively
H2. — Bone Tuberculosis, Showing the Spread of the Tubcr-
'rocess under the Periosteum and Cartilage; Specimen from the
xternal Condyle in a Twelve-year-old Child. The joint is not yet
I; X 8 diameters A, Articular cartilage; B, epiphysis; C,
)iphyseal line; D, periosteum; E, area of tuberculosis.
Fig. 413. — Tuberculosis of Boue Marrow at Margin of the Articular Cartilage.
rare in children, but much more frequent in adults,
but again in infants, whose bone ends are com-
posed mostly of cartilage (immune to tuberculosis)
Rovsing declares that the disease is always synovial.
The shafts of children's bones contain red marrow.
Various observers have described primary tubercu-
losis of their long bones. It will simplify our com-
prehension of tuberculosis of the bones if we regard
it, not as an osteitis but as a myelitis. Tuberculosis
exists in bone but not of it.
Let us briefly' trace the disease from its start,
taking up first the cases with a bony focus, and then
those with a synovial.
The tubercle bacilli in the marrow cause a certain
reaction of the tissues, which results in the formation
of the characteristic tubercle, with its tendency to
break down at the center and to spread at the
periphery. On the other hand, nature strives to
wall off the disease by the production of fibrous
tissue and by the strengthening of the bone about
the tuberculous area, and according as one process
or the other is more active, the disease tends to
spread or to be circumscribed. New tubercles form
in the marrow, spreading in all directions, and
coalescing. Away from the joint the disease may
extend as far as the lymphoid marrow extends, out-
ward to the periosteum, and toward the joint, to
the cartilage. When the tuberculous granulations
reach the periosteum, they are arrested, and must
turn aside to follow along underneath it, in its deep
layer. In this ray they may reach the joint and
break into it. Very rarely they break through the
periosteum, and never reach the joint. When the
tuberculous granulations make their way to the
cartilage, as they usually do, they interfere with its
nutrition. The cartilage degenerates, either in a
small spot, or, if the spread of the granulations
under it has been rapid, in a wide area. This
degeneration of the cartilage permits the disease
to reach the joint, but a normal cartilage is a bar
to the disease.
In children the march of the granulations
is arrested, for a time at least, by the epi-
physeal cartilage. The primary focus may
C71
Arthritis, Chronic
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
be located on either side of this cartilage. Stiles of
Edinburgh maintains that it is always on the "shaft
side," in what he aptly terms the metaphysial We
see, then, that the joint may be involved either at
the periphery of the articular cartilage or through an
opening in the cartilage itself. When the tuberculous
Fig. 414. — Lifting off of Cartilage. Disease of subjacent bone marrow. The
cartilage near the joint surface has undergone fibrillation. This is probably
what has been mistaken for fibrin.
granulations have reached the joint, they infect the
synovia, and now, instead of a simple tuberculous
myelitis, we have a tuberculous joint. Previous to
the irruption, the joint may have been the seat of a
serous exudate.
The next step is usually the involvement of the
other bone of the joint, and the attack must be made
at the periphery of the cartilage where it joins the
synovia, for, as normal cartilage is a barrier to the
disease, and as the cartilage of the other bone is until
now normal, the disease must make its way into the
bone where it is not protected by cartilage. When
the tuberculous granulations have made their way
into the other bone, the morbid process is repeated
in it.
The granulations in the marrow interfere with the
nutrition of the bone trabecule and kill them as they
do the cartilage. Sometimes one may see evidences
of a productive osteitis in the neighborhood of the
disease, but the essential process is a rarefaction, and
an "eating away." If the spread be rapid, the bone
may be killed in large pieces with the formation of
sequestra, if slow, then in small pieces — bone sand.
The cartilage, as it degenerates, becomes fibrillated.
Under the microscope the tuberculous granulations
can be seen pushing their way up through it. A
quite characteristic picture is that of a thin layer of
granulations pushing their way along immediately
under the cartilage, but, in the early stages, showing
no tubercles. We have never been able to identify
the "layers of fibrin" described by some authors as
precipitated en the surface of the cartilage, and doubt
i heir existence.
The synovia when attacked becomes thickened
and is often thrown into folds. It tends to spread
672
out over the cartilage and to hide it, especially at tin
margins. It encroaches on the cartilage, but prob
ably does not often become adherent to it. Tin
characteristic change in the synovia is a villoui
hypertrophy, seen by the naked eye, and ven
beautifully under the microscope. Instead of thi
membrane consisting of a thin delicate lavei
of cells, hardly distinguishable under "thi
microscope from the fibrous connective tis^n.
beneath it, it attains an appreciable thick
ness, perhaps up to a quarter of an inch. lik.
moss on a rock. In the substance of thi
membrane the tubercles may be seen. «
acute inflammation. Again, at any time before
secondary infection takes place, the contents may be
absorbed and the abscess may spontaneously disap-
Fig. 415. — Whin- Swelling; Small
Focus in Upper Epiphyseal Line of
Tibia. Synovitis of joint, but no
tuberculous process aparl from the
focus as noted; a, epiphysis; >>,
primary focus; c, shaft. (Nichols.)
REFERENCE HANDBOOK OF THE MEDICAL SCIENt I S
Arthritis, Chronic
,. a r. The walls of an uninfected tuberculous abscess
,-,'• composed of the necrotic tissue of the structure in
hich it lies. The walls of an infected abscess are
ijckened, porky, suppurating, and contain tubercles.
fter an abscess has opened spontaneously or
as been opened by the knife, it almost invaria-
K becomes secondarily infected.
. ,dies. — These are small, hard, slippery,
nooth, shiny bodies resembling melon seeds,
uiue- found in tuberculous joints (and
mi sheaths), especially in the synovial forms
f relatively benign course. Their origin has
disputed. In one joint, evidently diseased
I years before, I found a collection of them
acked in a capsule, like the seeds in a pome-
ranate, and from study of this unique specimen,
am inclined to regard rice bodies as the result
urative process of nature which walls off
..m lenses the tuberculous granulations.
— As has been said, nature attempts to
ure a tuberculous joint by walling off the gran-
lations with fibrous tissue, and in the bone by
ing the bone trabecules and by the forma-
new trabecule. This process often goes
and in hand with the extension of the disease.
i- therefore inexpedient to attempt the divi-
m of the disease into periods of invasion and
The damage often is spreading in one
if the joint, and is undergoing repair in
tiother part. It is seen also that whereas rare-
iriiiu, is the characteristic change in tubercu-
ius bone, the process of repair will cause areas
tdi nsation of bone.
In children complete cure is probably possible
ith good function. Fibrous ankylosis, or,
arely, bony ankylosis, may be the outcome.
(.my ankylosis only occurs after a secondary
ifection, or after operation. In adults cure without
radical operation, except perhaps in the mild
ynovial forms, never takes place. Function is
badly damaged in adults, and bony ankylosis
ever occurs, except after operation.
tilled with necrotic material, especially directly
beneath the cartilage. It may cut easily with a
knife and float, in water, or it may be denser than
normal. Drops of fat may follow the saw on section —
Fia. 416.-
-Fibrillation of Cartilage; Granulation Tissue Pushing its
Way Through.
The net result, of a tuberculosis may be summed
up as follows: The bone contains grayish or yellowish
ireas surrounded by hyperemic zones. It has a
worm-eaten appearance, and often presents cavities
Vol. I.— 43
Fig. 417. — Entire Thickness of Tuberculous Synovia — 40 mm. objective.
fatty osteomalacia. The cavities may contain
sequestra; abscesses may be found in the joint or
near it. The cartilage is degenerated and eroded.
In bone cases the erosion is often located near the
center of the cartilage. In fairly early synovial
cases, the erosion may be mostly at the periphery.
On the other hand, when a badly diseased tuber-
culous joint (synovial or bony) is opened for
inspection the cartilage may appear practically
normal. The joint cavity may be the seat of an
abscess or may contain one of several kinds of
fluid, or it may have practically disappeared,
leaving little else than a mass of fibrous adhesions
binding the ends of the bones together. The
synovia may be thickened and succulent, or
fibrous and dense. It may present villous hyper-
trophy or not. Cheesy tubercles may be evident
to the naked eye or they may not be evident.
The secondary effects of the morbid process in
the joint upon the rest of the limb are marked.
Although a slight primary lengthening may be
perceived by careful measurement in a growing
child (due to the stimulation of growth by the
irritation near the epiphyseal line) this soon gives
place to a shortening. All the tissues of the
affected limb are atrophied and ill-nourished.
Symptoms and Physical Signs. — A thorough
knowdedge of the morbid process in joints
enables one to foretell with a fair amount of
accuracy what the symptoms and physical signs
will be. The inflammatory process in and about
the joint causes pain. Nature attempts to place
the joint at rest by tightening up the muscles —
muscular spasm. The inflammatory products,
the pain and the muscular spasm cause limitation
of motion and often a fixed position in the most
comfortable attitude of the joint — usually semi-
flexion. From these factors result disturbance of func-
tion, and muscular atrophy. If the joint be superficial,
change of contour, sensitiveness to pressure, and in-
creased temperature may be perceived. If fluid be
673
Arthritis, Chronic
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
present in the joint it can be detected by palpation,
abscess formation also. Constitutional involvement
and secondary infection will give their
peculiar signs. Amyloid degeneration of the
viscera sometimes follows prolonged second-
ary infection. Deformity is the sum of the
muscular spasm, the inflammatory products,
the muscular atrophy, and the change in
contour.
Pain is almost invariably present in some
degree, and varies from a slight pain upon
use to the most agonizing paroxysms. It
is greater in the bony than in the synovial
type, and is usually worse during the forma-
tion of an abscess, while the contents are
under tension. The pain is often peculiar
during the earlier stages of the disease, by
reason of its presence in the morning when
the joint is first being used, wearing away
during the day. Again, the pain may come
on during the night when the muscular
spasm relaxes, waking the patient up, often
with a cry — the notorious "night cry" of
tuberculous joint disease. The pain may
be felt in the joint itself or at a point some
distance off, whose nerve supply is the same
as that of the joint — referred pain. Thus,
in hip-joint disease the patient for a long
time may refer his sensation to the knee,
or, in disease of the spine, to the lower ex-
tremities.
Muscular spasm is an early physical sign
and a most important one in the diagnosis.
It is greater in the bony forms of the disease
than in the synovial, and is to be viewed as
a conservative process of nature — an at-
tempt to put the joint at rest. It is well
brought out by attempting to put the joint through
its arc of motion. All muscles passing over the
joint take part in the .spasm.
ankylosis, and is wont to persist even after the dis
ease is cured. If due to muscular spasm it disappear;
Fig. 418. — Tuberculous Synovia, Showing Well-marked Effort at Encapsula-
tion of the Tubercles — Discrete Tubercles.
Limitation of motion is also an early sign, varies
from a slight limitation at the extremes, to a complete
Fig. 419. — Synovial Tuberculosis, with Little Tendency to Encapsulation.
on the administration of an anesthetic, but not il
due to inflammatory products.
The change in attitude is more or less complex ii
its causation. It is partly due to thi
mechanical effects of the inflammatory
products and partly due to the muscuiai
spasm. The most logical explanation ol
the muscular factor has been set forth by
Mark Jansen. 4 Jansen reasons that th<
muscles that pass over the diseased join'
alone are those which often give it it-
early attitude. These soon atrophy, and
then the attitude is determined by the
polyarticular muscles.
Disturbance of function of course mani-
fests itself in various ways. If the upper _
extremity be affected the patient will be
awkward in its use, and will use the other
vicariously; if the lower extremity, he will
limp. Very young children may refuse to
use the diseased joint at all.
Muscular atrophy of a certain degree
would naturally be expected in a limb
which is put more or less at rest from any
cause, but the degree of muscular atrophy
which accompanies tuberculous joint dis-
ease, especially the bony type, is greater
than that of any other, and has never been
explained satisfactorily. It is so charac-
teristic a sign of this disease that its pres-
ence should always be sought carefully, by
comparing the actual circumference of the
limb above and below the joint with that of
the opposite limb. A tape measure is re-
quisite for this. The eye is not reliable
enough. The difference in the circumfer-
ence of the two limbs may amount to two
or three inches. The bones of the affected
limb after a while lag behind in their
growth and are not only shorter than on the normal
side, but atrophied as well.
674
REFERENCE HANDBOOK OF THE MEDICAL 8CIENCES
Arthritis, ( lirnnlc
Change of contour will usually be easily dc-
i,,l in the superficial joints. The normal
mcavitii's will have disappeared, and .swelling
,,ften present. Of ten the bones look enlarged,
ii this enlargement is only apparent, and is due
, the atrophy above and below the joint, and. in
Id oases especially, to the shrinking that ensues
, the contraction of the new fibrous tissue.
welling Of some degree is almost always present
the early stages except in the shoulder. In
ie limbs the swelling is often distinctly fusiform.
aess to pressure and increased tempi ra-
often significant. The sensitiveness may
e localized or it may be present all about the
Fluid is often present but not always. A
" infiltration is more frequent. Abscesses
, 'bin' the joint and without it, will give signs
f fluctuation. The character of fluid in the
lint cannot be told without aspiration.
\ peculiar appearance of some tuberculous
lints, especially of the knee, has given a name to
his disease — white swelling. It is frequent in
with a profuse proliferation of the synovia.
lie so-called fungous type. Swelling is marked
osiform, the skin is pearly white, the veins
re dilated.
Constitutional involvement may be due to
econdary infection with pus germs. Fever and
maciation may then be marked. Tuberculous
in ningitis is a fairly frequent complication,
dly in children, and is invariably fatal. Pulmo-
iary tuberculosis is frequent in adults.
Poncet describes a disease which he terms "tuber-
ulous rheumatism," due probably to the action of
Fig. 420. — Tuberculosis of the Elbow; synovial type, showing the
tuberculous process making its way through the periosteum into the
bone under the margin of the articular cartilage. Section through
the corouoid process ; X about 20 diameters.
Flo. 421. — Portion of Wall of Tuberculous Bone Cavity.
"attenuated bacilli," but in spite of great insistence,
he has not yet succeeded in establishing the truth of
his position.
Under the head of symptomatology it is proper to
mention also the reaction that patients with tubercu-
lous joints give to the various tuberculin tests, and to
describe the appearance of joints in a Roentgen
picture.
The tuberculin tests are suggestive but not con-
clusive. Usually a patient with a tuberculous joint
will react, but not always. Again, patients with non-
tuberculous joint lesions may give the reaction.
A skiagram of a tuberculous joint may or may not
be very valuable. If it shows anything it will show
the lesions characteristic of cases in Type I of the
chronic arthritides, and these are: a thickening of
the synovia, a rarefaction of the bone, and a thin-
ning of the cartilage. Old cases may show areas of
thickened bone. Rarefaction of bone appears as
dark areas in the plate, thickening as light areas.
The cartilage sometimes disappears, but more often
is present in spots, though thinned. The bone has a
"worm-eaten appearance.
The diagnosis is to be made on the basis of a
chronic disease with characteristic symptoms and
physical signs, and upon the Roentgen picture.
These will evidence a lesion of type I. If the lesion
be uniarticular and if the tuberculin test be positive,
the joint is almost certainly tuberculous, especially
if the patient be a child. The injection of some aspi-
rated fluid into a guinea-pig is a most valuable aid.
In the past a tendency has existed to call every
chronic uniarticular joint disease tuberculous. This
is an error and is responsible for many therapeutic
systems. No pains should be spared in making a
diagnosis that will stand the test. A careful history
is essential, and the patient should be stripped, if a
man or a child. If the patient be a woman, access to
most regions of the body is possible, and the history
should bring out any essential matters of disease in
the others.
Differential Diagnosis. — From other uniarticular
diseases in type I joint tuberculosis may be ex-
tremely difficult to differentiate. Often a number of
examinations may be necessary at intervals of two or
three months. In the meantime the joint should be
immobilized if the bone be affected. The tuberculin
675
Arthritis, Chronic
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
tests are suggestive, the animal test may be final, if
fluid can be drawn from the joint. Cold abscesses or
tuberculous sinuses will clear up the case.
A piece of the wall of an infected sinus will
show tubercles under the microscope In
the spine an angular kyphosis occurring in
a chronic joint disease means tuberculosis.
Secondary infection never occurs in the
other diseases of this type. In children the
chances are heavily in favor of tuberculosis.
Often evidences of the specific infection of
other disease may be detected, such as
gonorrhea.
A uniarticular arthritis of type II may
simulate tuberculosis, especially in the hip,
but the obstruction to motion is mechanical,
and not due to muscular spasm. The x-rays
show a production of new bone and cartilage.
Syphilis is wont to affect the shafts. If
it affects the ends of the long bones, the
joint is seldom if ever involved. A form of
synovitis is occasionally met in tertiary
syphilis, which resembles synovial tuber-
culosis. The patient will show a reaction to
the Wassermann or Noguchi tests, and will
quickly react to antisyphilitic treatment.
Sarcoma may be located in the bone end,
but does not affect the joint itself or the
other bone. Fractures occur frequently, and
the Roentgen picture reveals a growth on
the bone, or a destruction of large masses
of it, not the "worm-eaten" appearance of
tuberculosis.
Charcot's joints are practically painless.
In them disorganization is evident but not
inflammation. Masses of loose bone and
cartilage can be felt in the joint, and appear
in a skiagram. Evidences of a cord lesion
can be easily made out, if sought.
Tuberculous joints are often treated for long pe-
riods under a diagnosis of rheumatism, but the diseases
are so different that the mistake is inexcusable.
Acute infectious arthritis (suppurative) accom
panies one of the acute infectious diseases, such a
Fro. 422. — Uninfected Tuberculous Sinus. No tubercles were found in the
walla of this sinus, but the joint from which it came was demonstrated to be
tuberculous.
Fig. 423. — Cross Section of Old Infected Tuberculous Sinus, Showing
Tubercles in the Walls. Contrast with Fig. 422.
scarlet fever, pneumonia, and typhoid fever, or
follows it shortly. It occurs also without antecedent
disease. The acute nature, the pyrexia, great pain,
leucocytosis, and early abscess formation will dis-
tinguish this disease from tuberculosis.
Gonorrheal arthritis is usually acute in
its onset, and is accompanied by great pain
and swelling. When the disease has run
its course, the joint is left more or less
damaged, but w-ithout active symptoms.
The history and the examination of the
urethra and the urine are most important.
Scurvy comes on acutely, especially in
bottle-fed children, and is accompanied by
great pain and sensitiveness of one or i
more joints. The child cries on being
moved, and may have swollen, bleeding
gums. Fruit juice internally causes a
rapid abatement of the disease. Joint
tuberculosis in children is rare during the
first year, the age when scurvy most often
occurs.
Symptoms of fracture in the neighbor-
hood of a joint follow immediately on an
injury or at a very short interval. The
skiagram is most important in the diag-
nosis.
Sprain. — Frequently a child is seen who
complains of pain in a joint, and shows
marked limitation of motion in it. A
diagnosis is not always possible at the firs;
examination, but if the joint be immobilized
the symptoms disappear, and force the
conclusion that a sprain or a wrench was
at the bottom of the trouble.
Hemarthrosis. — The patient will com-
plain that on one or more occasions one or
more of his limbs has been greatly swollen,
without any known cause, and usually
without much pain. An examination
67G
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Arthritis, ( (ironic
iows marked swelling and a large amount of fluid in
ie joint, but no muscular atrophy nor spasm. A
ireful questioning will brine out the fact that the
t is a "bleeder." In the later stages
the absorption of the fluid, the joint
he seat of dense fibrous adhesions.
Hysterical Joints. — A marked dispropor-
m is present between the subjective and
ie objective symptoms. A certain amount
dstance to motion, but no true muscu-
-m is present, and the resistance dis-
iU the patient's attention be diverted.
jperficial sensitiveness is often present, and
ysterical stigmata. No definite anatomical
ran be detected. A diagnosis of
ysterical joint should never be made until
id examinations have failed to reveal
" al pathological change.
Prognosis. — In general this may be said to
e good quoad litam, but bad so far as func-
concerned. A joint tuberculosis
ithout secondary infection presents no
nmediate danger to life, but we must not
irget that the presence of the disease in
lie joint shows a vulnerability to tuber-
and a probability that some other
sists in the body. The chief dangers
berculous involvement of other organs
lungs, meninges, etc.) and secondary infec-
ion. Abscesses always make the prognosis
but if they can be kept from ruptur-
hey rarely do much damage, except in
he spine.
Tuberculosis of the lungs or of the men-
nges carries off many patients even after
lealing of their joint lesion. Secondary
nfection is always a dreaded complication,
tid adds greatly to the danger. Amyloid
{(•generation is almost invariably fatal. Tubercu-
■ sis of the spine is more serious than tuberculosis
>f the smaller joints. Tuberculosis of the sacro-
liac joint is usually fatal. As to function, this may
are wont to recover with better function than the
larger. In adults spontaneous bony union never
occurs, and a movable Joint seldom if ever, fibrous
Fig. 424. — Rice Bodies In their Capsule. 40 mm. objective.
vary in children from good motion to complete
ankylosis, according to the location of the disease,
and the efficacy of treatment. The smaller joints
Rice Body. Zeiss objective aa. ocular 3.
ankylosis is the rule with them. In adults Pott's
disease always has a bad prognosis, especially if
any destruction of bone has taken place.
Constitutional Treatment. — We must keep in mind
always that the joint tuberculosis as a rule is a
comparatively harmless local manifestation of
a very serious constitutional disorder, and that
while we are giving the joint its proper local
treatment, we must at the same time endeavor
to treat the patient himself. We therefore insist
upon fresh air all the time, and upon plenty of
nourishing food. The patient should live out of
doors, and sleep out of doors except in the
bitterest and most inclement weather. If this
be impossible, his windows should be wide open
day and night. Sun parlors are an abomination.
The child is better off in a tenement than in the
wards of the ordinary hospital. The influence
of climate does not seem as important as in pul-
monary tuberculosis. It is doubtful if any
climate is specific. Many of the younger patients
do well at the seashore, but possibly this is be-
cause most children thrive at the beach. I doubt
if the course of the disease is shortened there.
Drugs are of little use in the disease. Cod-
liver oil is a well-tolerated form of fat for the
winter months. The bowels should move regu-
larly, of course. The mouth and teeth should
be kept in good condition. The tonsil is consid-
ered to be a frequent port of entry for the tuber-
cle bacilli. Therefore enlarged tonsils should be
enucleated. Occasionally tuberculous nodules
will be found in them, especially in the medium
sized, tough ones. Adenoids also should be re-
moved. Frequently these operations will have a
favorable effect upon the cervical adenitis often
present in children. Although the statement
may sound heretical, I believe that radical opera-
tions for cervical adenitis in children are rarely in-
dicated. Without wishing to seem jocular, I think
077
Arthritis, Chronic
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
they are like the attempt to kill a dog by cutting off
his tail.
Local Treatment. — If we have properly digested
the morbid anatomy of joint tuberculosis we have
perceived two things; first, that the entire patho-
logical process may be interpreted as an effort of
nature to deprive the joint of function, and second,
that the uncomplicated disease is strict ly localized,
affecting but two tissues, namely, the synovia and
the lymphoid marrow, but that when secondary
infection has been added other tissues are involved,
and the danger is greatly increased.
From these facts we draw our two main rules
of treatment: (1) deprive the joint of function;
(2) avoid secondary infection.
Certain other facts should stand out also. Cure
of tuberculous joints in adults is very rare under
conservative treatment, if it ever occurs. The
best that can possibly be attained in them is a
stiff joint under any form of treatment. Radical
treatment cures the disease in a few months,
while conservative treatment, granting that it
ever cures, takes years. Therefore, we say that
the treatment to be pursued among adults is
almost invariably radical, and the object of the
radical treatment is to destroy function in the
joint. The red marrow and the synovia owe their
presence in the joint to function. If function be
destroyed they disappear, if they disappear the
disease dies out. There can be no joint tubercu-
losis where they are not. The disease gets well
because it has no food. It is starved out, so to
speak. If this destruction of the joint cannot be
done, then the operation must be planned to re-
move every particle of infected tissue. We modify
this rule of radical treatment by the statement
that, as the diagnosis is often uncertain, a six
months trial of conservative treatment is advisable,
and that, if secondary infection is present, a vigorous
effort should be made to overcome it before proceed-
ing to operation.
Among children the case is different. In their
children have red marrow in their bone shafts. Henet
to destroy the joint in them is not necessarily to curt
the disease.
Again, radical operations on children's joints, bj
Fig. 426. — Section through Rice Body. Zeiss objective C.
joints conservative treatment often yields good
function, and frequently cures the disease. Radical
treatment, even properly carried out, often fails to
cure, and the reason of this is that, unlike adults,
678
Fig. 427.— Old Calcined Tubercle in Bone.
interference with the center of growth, cause a marked
lagging behind in development, and a resulting
deformity of great degree as the child grows up.
The treatment of joint tuberculosis in children,
therefore, is almost invariably conservative. We
follow it in the face of all obstacles until all hope of
saving the child's limb is gone, or until amyloid
degeneration begins, and then we amputate.
In adolescents the treatment is as in children,
until they have attained their growth. Then, if
the disease is not cured, we adopt radical measures.
Conservative Treatment. — The main object of con-
servative treatment is to deprive the joint of func-
tion, and the measures that will most effectively
deprive the joint of function are the measures we
adopt. We are forced, however, to compromise.
Complete deprivation of function means rest in
bed with apparatus in addition, but the knowledge
that we are dealing with a dangerous constitutional
disorder makes us eager to get the patient up and
about in order that his nutrition may be maintained
at par.
There are two general methods of carrying out
conservative treatment: 1. Recumbency, with ap-
propriate apparatus; 2. Ambulatory treatment,
with apparatus. The first is an excellent routine
treatment for the disease in its early stages, say
for the first six months or a year, especially in
children, for the acute painful exacerbations, and
to meet special indications, such as large abscesses.
It is not ordinarily practicable for adults for any
length of time.
Ambulatory treatment with apparatus is the usual
means we adopt for most cases. In general the
apparatus comes under two classes; plaster-of-
Paris, and steel "braces." Some prefer one, some
the other, but plaster seems to be making its way as
the preferred form in this country. It is cheap, fits
accurately, can be changed and thrown away, is
obtainable everywhere, and cannot be removed by
the patient without the surgeon's knowledge. It
REFERENCE HAND HOOK OF THE MEDICAL SCIENC1 -
Arthritis, Chronlo
oeds some skill for its application, but so
;ll . s u brace. Braces are heller to meet
.tain indications. They are much prefer-
blein the presence of sinuses. \o patient
, u l,l e i er be en( to a brace-maker with
istructions to gel a brace. The surgeon
peoify the kind of brace he wislies,
ml must oversee the application. If un-
to do this lie should use plaster, if
knows what he wants, a. blacksmith and
essmaker can carry out his instruc-
ts. The task of measuring for a brace
implified by taking a ca>t of the member
ien by having the brace made over
lis.
\n brace nor plaster dressing should be
upon to correct deformity. The de-
Tinity should be corrected before the ap-
aratus is applied.
iith.r Methods of Conservative Treatment.
treatment, passive hyperemia
lungshyperaemie"), is based on the
that venous stasis is hostile to the
[opment of tuberculosis. Its method
nation is by an Esmarch bandage
above the joint just tightly enough
. cause a reddening of the part, and a
armth of it. It must not cause pain nor
lake the part cold. The bandage is ap-
lied for about two hours daily. This
i;it meat is designed especially for the
[bow. the wrist, and the ankle and tarsus.
iMy is of use in some cases, but too
inch should not be expected of it. It is
.•r tor in open eases, i.e. those with sinuses,
tian in closed ones. Klapp has devised a
odification of the treatment by the use of
i apparatus — glass chambers into
liich the member is inserted, and from
hich the air is exhausted. This is sometimes used
ir tuberculosis of the bones of the hands, especially
be lingers, and of the feet. Klapp also recom-
Fio. 428. — Old Encapsulated Tubercle in Bone. It lay directly under
urtilage. Its site could be told from the joint side by a dimple in the
artilage. Note the fibrous capsule, and outside of this the strengthening
f the bone trabecular. The dotted lines lead to two small islands of
arulage. Although we possess no history of the resected adult knee
rum which this specimen was taken, it is evidently a case of fighting up
f an old process.
Flo. 429. — Old Encapsulated Cheesy Tubercle, from Ankle-joint of a Boy
about Eighteen Years Old. The joint had been treated conservatively for a
number of years, and was supposed to be well. A resection was done because
the joint had again become painful. The ankle was found full of fibrous ad-
hesions, and in a recess of the joint this tubercle was discovered after a pro-
longed search. The hospital laboratory had reported "chronic arthritis, no
tuberculosis."
mends his treatment by suction cups for tuberculous
abscesses.
Focal Operations. — These were designed with the
idea of cutting down on an early tuberculous
bone focus, and of removing it before it had in-
volved the joint, but our study of the pathology
will teach us why they are so rarely successful.
The focus is almost never discrete, but ramifies
in the marrow, and there is no known way of
telling its full extent. Again, one of the favorite
locations of the tuberculous granulations is di-
rectly beneath the articular cartilage, and if we
attempt to eradicate them, we immediately
destroy the nutrition of the cartilage, and give
the disease access to the joint.
Tuberculin. Vaccines, etc. — Much has been ex-
pected of this, but up to date the expectations
have not been fulfilled. Possibly the future may
make us reverse our opinion, but for the present
tuberculin treatment should be pursued very
cautiously at least. It seems to have little bene-
ficial effect, if any.
Treatment by Injections. — Certain observers
have asserted that they could influence the course
of a joint tuberculosis by the injection of various
substances in and about the joint. Here again
our knowledge of the morbid anatomy teaches
us scepticism. No substance injected into the
joint can influence in any way the disease in the
bone, while blindly to inject fluids into the
circumarticular structures, with the idea that
they will pick out the diseased tissues and leave
the healthy ones, seems irrational. There is no
known specific against tuberculous granulations.
Again, in many tuberculous joints there is prac-
tically no joint cavity at all. The joint is a mass
of fibrous adhesions, and what synovial mem-
brane is left contains tubercles deep in its sub-
stance. Formalin, carbolic acid, iodine, iodoform
679
Arthritis, Chronic
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Fig. 432. — Tuberculous Knee, Anteroposterior View. Child
about ten years old, treated conservatively for about three years.
Discharged cured from Sea Breeze Hospital, with a fair amount
of motion.
Fig. 430. — Tuberculous Elbow after About Eighteen Months of
Treatment by Plaster of Paris. Note disorganization of joint,
erosion of cartilage, and areas of rarefaction and condensation of
bone.
Fig. 431.— Same Case as Fig. 430, Side View. Note the atrophy
of the humerus. Patient about twenty-five years old. The
pictures of this elbow may be said to be more or less typical of
joint tuberculosis.
Fig. 433. — Tuberculosis of the Knee, Lateral View of Joint shown
in Fig. 432.
680
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Arthritis, Clirnnfr
!'[,:. 434.— Tuberculous Knee in Adult. About ten years dura-
Mi. Note disappearance of joint cartilage and the areas of
and condensation of the bone. These were demon-
rated at operation. Fatty osteomalacia was present to a
larked degree.
Fig. 436. — Bone Syphilis; duration four or five months. Pain,
sensitiveness, etc., but no involvement of joint. Distinct history
of paternal syphilis. This child had shown other symptoms of
syphilis.
Fig. 435. — Tuberculous Knee, Lateral View of Preceding Case.
These skiagrams are more or less typical of a well advanced case
of long standing.
Fig. 437. — Sarcoma of Femur; Operated on for Tuberculosis.
681
Arthritis, Chronic
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
have all had their vogue. Whatever use they possess
is from their irritating properties. Possibly they
Fig. 438. — Old Hemarthrosis of Knee.
increase the production of fibrous tissue and so help
to deprive the joint of function. Function may be
abolished by much quicker means.
Roentgen rays have their advocates, but as yet
they have not proved their efficacy.
The application of any substance whatever to the
surface is without effect. This includes heat and
cold. Massage and passive motion are distinctly
contramdicated.
Treatment said to
iread along
nder the an-
trior liga-
■ •n t s and
an. A
■ ■structionof
lie vertebral
ody often re-
ti Its, and of
he interver-
cbral discs.
"he support
f the super-
m p o s e d
olumn is re-
noved and it
wings forward on the articular process as on a hinge,
ansing a protrusion of the vertebral spines at the
evel of the disease — the so-called "knuckle," or
cyphosis, or humpback, almost diagnostic of Pott's
ise. Sometimes one vertebra is affected, some-
imes two or more. The bending of the spine causes
til manner of deformities of the chest, and displaces
he contents of the chest, and, to a lesser extent, of
he abdomen. A peculiar facies often ensues. The
runk is shortened as a whole. The arches of the
iertebra are sometimes involved, with their articula-
tors. The region most frequently attacked is the
iumbothoraeie. According to the location of the dis-
it is known as cervical, thoracic, or lumbar
Pott's disease. The sacrum is seldom affected alone.
Fig. 440. — Tuberculosis of the Seventh Cervical Vertebra.
Abscesses are frequent. They usually form on the
rior aspect of the -pine and make their wa
surface by the lines of least resi d by
gravity. Those of the upper cervical region appear
in the back of the throat, and fficulty in
ig. They may then appear on the aid
the neck, or in the ! A. Schmidt).
Abscesses of the lower cervical region pass into the
posterior mediastinum, follow the aorta downward,
and may appear in the thigh. Al tho-
racic spine rarely penetrate the pleura, but usually
sink by the side Of the aorta, and reach the pelvis.
Later they pass under Poupart's ligament into the
thigh, or occasionally through the great sciatic fora-
into the
glu;>
Abscesses of
the lumbar
region follow
the course of
the iliopsoas
muscle under
Poupart's lig-
ament. All
sorts of devi-
ations from
these courses
are met.
Sometimes
the ab
disappears
without
reaching the
surface. In
disease of the
vertebral
arches the ab-
scess usually
appears in the
back.
The spinal
cord may be
damaged by
the pressure
of the prod-
ucts of in-
flammation in
the vertebral
bodies, but
rarely if ever
by the pinch-
ing of the cord
by the angu-
lar deformity.
The lumen of
the canal is
not dimin-
ished.
A kyphosis
once formed
is permanent.
It may be re-
duced some-
what by persistent treatment, but cannot be made
permanently to disappear.
Symptomatology. — Spasm of the back muscles is
early and prominent. The attitude of the patient
is often changed, and the normal contour of the spine
disappears. Sometimes the kyphosis appears early,
sometimes late. The patient stoops awkwardly,
and sits and stands stiffly. Sensitiveness to pressure
is not ordinarily present, for the diseased portion of
the spine is deeply located. The pain is occasionally
felt in the back, but more often, on account of the
involvement of the spinal nerves, shoots down the
arms, around the trunk or down the lower extrem-
ities, according to the location of the disease. The
knee-jerks are often exaggerated, the gait spastic.
683
Ahrtritls, Chronic
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Fig. 441. — The Whitman-Bradford Frame.
Paralysis of the lower extremities (Pott's paraplegia)
is fairly frequent, and the functions of the bladder
and rectum may be compromised, causing incontin-
ence or retention of the feces and of urine. Respi-
ration may also be ab-
normal; grunting respi-
ration or a peculiar
"futile" cough may be
present. The spine may
show a lateral curvature.
Diagnosis. — In rotary
lateral curvature the apex
of the curve is on the
ribs, not on the spine
itself. Pain is absent or
practically so, spasm
also. There is no true
kyphosis in this disease.
Spinal fractures are often
followed by a kyphosis,
but the symptoms follow
immediately on severe
injury. Certain injuries
of the spine without
demonstrable fracture
are also followed by a
slowly developing
kyphosis, and may sim-
ulate Pott's disease, but
the signs of active dis-
ease are absent. T;/-
phoid spine follows ty-
phoid fever, is wont to
be very acute and pain-
ful, and very rarely is
Fig. 442. — Ordinary or Old-fashio
jacket on the left fails to
accompanied by a kyphosis. The psoas abscesses of
Pott's disease may be mistaken for appendicitis but
they are less acute in their course, and have not the
684
symptoms of an inflammatory lesion.
Chronic non-tuberculous arthritis is wont to involve
a large segment of the spine, and other joints of the
body. Masses of new bone may often be detected
in the skiagram.
Rickets, new growths,
hip disease and nem
must also be carefully
excluded. "Lumbagi
and "sciatica" are often
caused by Pott's disease.
Progn osis. — T his is
somewhat more grave
than in tuberculosis of
other joints, especially
in adults. The length
of time necessary for a
cure by conservative
means ranges from two
to about ten years.
Disease of the cervical
region runs a somewhat
shorter course than that
of the thoracic and lum-
bar regions, but has an
added danger in the
proximity of vital struc-
tures. Relapses are fre-
quent. Often the ap-
pearance of an ali-
long after the apparent
cure, shows the activity
of the process.
Radical Treatment. —
Until very recently all
fruitless, but the work of
ned Jackets. Observe how the
control the deformity.
radical treatment was
Hibbs 7 and Albee 8 in the line of producing complete
bony ankylosis promises a future for it. Albee splits
REFERENCE HANDBOOK OF THE MEDICAL Si II NCES
Arthritis, Chronic
ie spinous processes and grafts into them a piece
bone removed from the patient's tibia. The
Deration is based on sound pathological principles,
n,l should be a success in adults, for ii destroys mo-
on i" 1 1"' spine, and hence must cut off the pabulum
ir the disease.
rvative Treatment. — The best routine treat-
the firsl six months or a year is by recuro
Flo. 443. — Application of the Calot Jacket wiih Officer's "Collar";
trimming the jacket.
bency in a jacket or on some rigid form of apparatus,
■ 7. the Whit man- Bradford frame or a plaster-of-
I 'aris bed. The Whit man- Bradford frame is composed
of an oblong frame of gas-pipe with elbows at the
corners. Over this is stretched a canvas cover
I up the back. The frame is bent backward
at the seat of the disease, and the patient is strapped
to it by means of an "apron'' over his chest. He is
rpermitted to sit or to stand for an instant from
I lie time the treatment is begun until it is finished.
The frame is also suitable for cases with large abscesses,
or for those complicated by paraplegia, and for all
cases when the pain cannot be checked by other
means. It finds its greatest usefulness among children.
Ambulatory treatment is useful during most of the
di ease. Ii ran be carried ouf by plaster jackets
or bv brace
Plaster jackets arc of two kind-, thai devised by
Sayre the ordinary jacket and thai by Calol \
jacket to be of use must extend well beyond the -eat
of disease in both directions in order to obtain
proper leverage, it must l»- padded over i in- bony prom-
inences, must be strong enough to stand the -train,
but must not be '> thick a to be unwieldy. It
should be applied over a seamless shirt. It may be
put on while (he patient is strung up, or while i,, i
prone or supine. The first is the usual method.
Ordinary plaster jackets may be supplied with a
''jun ma i ' tu support the head in disease of the
cervical region, but this is not a very efficacious
met ho, I ol I real i ne 1,1 A " window" may be cut in I lie
plaster over t he abdomen to provide for the increa e
in size after eating. A strip of linen under the shirt-
ing in front and back adds to the comfort of the
patient by giving his skin a rub under the plaster,
aided by dusting powder. An excoriation imme-
Fig. 444. — Grand Calot Jacket. Anterior View. This was a
case of subluxation of the atlas, wrongly diagnosed at first as
cervical Pott's disease.
diately makes its presence known by a foul odor,
(are should be taken not to permit any foreign body
to slip down inside the jacket.
The Calot jacket (see illustration) is an excellent
means of treatment for disease of the upper thoracic
and of the cervical vertebra?. It needs considerable
practice for its proper application.
Braces. — These are the original brace devised by
Fayette Taylor, and the various modifications of it.
The brace consists of a pelvic band, and of two
upright steel bars springing from it. one on either
side of the spinous processes. The brace is held to
the body by its attachment to an apron in front
and by shoulder straps. In cervical disease it is
685
Arthritis, Chronic
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
provided with various kinds of head pieces and chin
pieces.
Tuberculous Hip-joixt Disease. — (Coxitis, Mor-
bus coxarius). Pathology . — The primary focus may
be in the head, or probably in the inner portion
of the ueck, in the acetabulum, or in the synovial
Fig. 445. — Early Hip Disease of Right Leg, Showing Abduction.
membrane The head may be almost entirely eaten
away, but rarely sufficiently to cause a luxation.
The acetabulum may be perforated, giving the prod-
ucts of disease access to the pelvis. The spasm of
the muscles in a set attitude (adduction and flexion)
crowds the femoral head against the upper portion of
the acetabulum, and often by pressure wears it more or
less away, so that the upper borderis pushed upward and
a subluxation takes place — "wandering acetabulum".
Symptomatology. — Pain and limp are early and
prominent symptoms. The pain may be felt in the
hip or in the knee. In the latter case the disease
in the hip is often entirely overlooked. At first the
thigh may be in an attitude of extension and abduc-
tion, but this soon gives place to the characteristic
attitude of flexion, adduction, and internal rotation.
Sensitiveness of the head of the bone to pressure may
or may not be present. Abscesses when present
usually break through the joint at its weaker lower
portion and appear on the front of the thigh.
Diagnosis. — In lower Pott's disease, the thigh may
be held in semiflexion, but limitation of motion as
a rule is manifest only in the direction of extension.
In some cases the diagnosis can be made only after
several examinations. In non-tuberculous arthritis
of Type II, muscular spasm is absent, the obstruction
686
to motion is purely mechanical, the Roentgen ra\
show the production of new bone, and as a rule th
thigh is in abduction. Sprains in childhood cles
up after the hip has been put in plaster for a few week
Fracture of the neck, and epiphyseal separation ar
differentiated by the history and by the use of th
x-rays. In coxa vara the thigh is in extensioi
adduction and external rotation, and the skiagrai
shows the bend in the femoral neck. CongeniV
Fig. 446. — Severe Hip Disease, with Adduction.
dislocation gives a history of existence since the time
the child began to walk, absence of pain or signs of
inflammation, and free motion in all directions except
abduction. Examination and the Roentgen rays
reveal the femoral head out of the acetabulum.
Conservative Treatment. — The first indication is a
reduction of the deformity. The desired position
is one of extension and slight abduction. Then
one may use any of several kinds of apparatus. A
good routine treatment is by the short plaster-of-
Paris spica with or without crutches and a high shoe
on the sound limb. The traction brace in one of it?
numerous forms has enthusiastic advocates. The
Thomas brace is sometimes used, but is difficult to
fit, and seems to possess few advantages over the spica.
In Germany the long plaster dressing is much used.
Treatment in an ordinary case should be continued
for about three years. Toward the end the brace ia
left off at night, "then one or two hours a day, and the
joint is carefully watched for symptoms of a return
of the disease. If spasm and pain reappear, the ap-
paratus should be reapplied.
Radical Treatment. — It is quite manifest that no
operation has been devised that could certainly
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Arthritis, Chronic
Fig. 417. — Traction in Hip Disease
remove nil infected tissue, fur the ot innomina
offers do field fur extensive a. The re
after hip-joint resections has been said to be bad,
I'm tin- i- perhaps because drainage has been used
and the joint has been secondarily infected. Our
sole object must be to d< troy the joint. This may
be done in either one of two ways. 1. The head of
the femur may he removed, causing a dislocation.
In this ca>e the joint as such ces
to exist, and the stump of the
femoral neck is slung by the liga-
ments upon the ilii. Vari-
ous routes of access to the joint
have been proposed. Possibly the
simplest is through the anterior
incision downward from the ante-
rior spine, going outside the
Nr-J
Ha. 448.— Hip Splint in Use at the Children's Hospital. Boston.
(Courtesy of Dr. Bradford.)
lorius in order to avoid
the branches of the crural
nerve. Drainage is not
necessary. A plaster
spica should be worn for
two or three months
afterward. The func-
tional result is usually
good. The shortening
amounts to about two
and one-half inches, and
the patient walks fairly
well with the aid of a
high shoe and a cane.
Albee, of New York, has
proposed an ankylosing
operation which appears
to be quite efficacious
(see page 697). The
ankylosis resulting from
it should give a better
result for walking than
the dislocation, but not
so good for sitting.
Tuberculosis op the
K.vee. — (White swelling,
etc.). Pathology. — The
primary focus may be in
any one of the three bones,
or in the synovia. The
most frequent bony site
is in the head of the tibia.
The proliferation of the
synovia is sometimes
more marked in this joint fi G . 449..
than in any other and
causes great swelling, giv-
ing the disease its common names of "joint fungus"
or "white swelling." On the other hand, the synovia
may be fibrous and contracted, causing the bone ends
to stand out and to look enlarged. The enlargement
is only apparent.
Symptoms and Physical Signs. — Atrophy, both of
the thigh and calf, especially in the bony type, is
early and marked. The knee is held in semiflexion.
In this attitude the flexors work at an advantage
over the extensors, and often pull the head of the
tibia backward, subluxating it on the femoral con-
dyles. At the same time the leg is rotated some-
what outward. The ligaments adapt themselves
to this position, so that even if the hamstrings be
divided and manual force be exerted to extend the
leg, the normal attitude is not attained, but the
-Long Traction Splint
Applied.
687
Arthritis, Chronic
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Fir,. 450.— Thomas' Hip
Splint, Single. (Itidlon.)
head of the tibia is levered backward, and the bone
adopts a position in a plane posterior to that of the
femur. Sensitiveness of the
synovia can often be detected
if the joint be semiflexed. Fluid
may be present or it may not.
The patella may float. A boggy
feel of the soft parts is charac-
teristic of the cases with great
synovial proliferation.
Diagnosis.- — The special diffi-
culty presented in this joint is
the differentiation between
tuberculosis and the non-tuber-
culous forms of Type I. Fre-
quently one can decide only
after months of observation,
unless the animal test be used.
Conservative Treatment.- — If
one elects the traction treat-
ment, one applies the Thomas
knee brace, made two or three
inches longer than the limb, to
swing the foot clear of the
ground, and provides the other
foot with a high shoe to com-
pensate. If one elects immob-
ilization, one encases the limb
in a plaster-of-Paris dressing
reaching from the perineum
to the malleoli. In the late
stages of the disease the
Campbell brace is useful,
jointed at the knee to allow the desired amount of
motion.
Radical Treatment. — The sole object of this is to
stiffen the knee. An
excellent means of do-
ing this is to saw
through the patella, to
dissect this out, and
then to remove by the
chisel and saw a small
slice from the tibia and
from the femoral con-
dyles. No time should
be wasted in dissecting
out the synovia. If the
semilunar fibrocartil-
ages be removed the
subsequent pain will
probably be less. The
wound should be sewn
up without drainage,
and the limb should be
put up in full extension
in plaster-of-Paris. 9
Ankle and Tarsus.
— Pathology. — The dis-
ease is complicated in
this situation by the
presence of a number
of small spongy bones
and of six or seven
synovial cavities. A
focus in one bone may
soon involve two or
three synoviae, and the
disease may run riot
through the other
bones and synovial
membranes. The pri-
mary focus is most
often located in the
talus. Abscess forma-
tion in these joints is
early and frequent.
A peculiar form of the disease, found most oftei
in children, is located in the anterior portion of th>
calcaneus, ruptures externally, and shows litt],
tendency to involve the joint. Sequestra are oftei
formed in disease of the calcaneus.
Symptomatology. — The foot may be in any one of :
number of different attitudes. In disease of thi
ankle, the patient often walks on his toes — equinus
In disease of the midtarsus the attitude is frequent!'
calcaneovalgus.
Fig. 451.— The Lorenz Short Spica.
A Sea Breeze Case.
1
Fig. 452. — The Lorenz Short Spica. Note the calf develop-
ment on the affected side, and the excellent condition of the
children.
Diagnosis. — Painful flat-foot with rigidity may
simulate tuberculosis, but it lacks all signs of acin<
inflammation. A peculiar puffiness under the exter-
nal malleolus seen often in normal women is not to
be mistaken for disease.
Conservative treatment is carried out by a plaster-
of-Paris dressing reaching from the level of the head
of the fibula to the toes. Inasmuch as the impfti I
of this dressing with the ground would soon destroy
it, the foot must be swung clear by the use of a
Thomas knee brace. The other foot must be pro-
vided with a high shoe. The treatment by Bier's
hyperemia is supposed to be especially adapted for
use in this region. Conservative treatment is usually
very efficacious in children.
Radical Treatment. — If the disease be diagnosed
early enough, while still located in one bone, befi
synovial involvement, it may possibly be cured bj
the simple removal of that bone. Otherwise the
most extensive resection will be necessary, removing
every particle of infected tissue. This will often be
css
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Arthritis, ( hroiilr
possible, and we shall be obliged to amputate,
tie-joint alone be involved, the disease may
en be cured by ablation of the talus and dostruc-
the joint. The operation of curetting for
berculosis of the ankle and tarsus can be based only
an ignorance of the underlying morbid process.
Iiif Wrist. — The pathology and principles of
:atment in disease of this joint are much the same
those already laid down for the ankle.
must be differentiated from Duplay's bursitis — sub-
deltoid or subacromial bursitis. In this the limitation
of motion is always in the direction of abduction and
externa] rotation. The skiagram is most important,
in t he different iation.
Conservative treatment consists in bandaging the
arm to the chest, or in the use of apparatus to restrict
its motion. The value of the popular shoulder-cap
is illusory.
Radical treatment consists of subperiosteal re
tion, which gives anankylo-
sis, a fairly useful result on
account of the mobility of
[in- capula.
-t
i
158. — From Left to Right: Schultze Pelvic Rest, Authors' Modi6eation of the Lorenz
Plevic Rest, Loreuz Stirrup, Head and Shoulder Rest.
The Elbow. — Disease of the elbow possesses cer-
in peculiarities. There are two joints here, one of
Inch may be affected alone or both together. The
ses with bony focus are said to begin most fre-
in the ulna. The attitude of the elbow is
ually semiflexion. If the radio-ulnar joint be impli-
i the forearm is in semipronation.
i motive treatment is carried out with the elbow
Id by a plaster bandage at a right angle. A sling
- the patient to bear the limb with comfort.
the case comes under observation
it h the elbow at a greater angle of
-ion, it should be flexed under
sthetic, or better still, it should
i slung from the wrist about the
ick with the patient's head well
xed. As he slowly straightens his
ick up he will flex the elbow. This
rocedure is repeated each day until
le required amount of flexion is
'tired.
Radical Treatment. — Either one of
vo conditions results from a resec-
on, a rather loose, movable, and
lirly useful relation of the two bones
h other (it is probably not an
ticulation in the usual acceptation
:" the word), or a bony ankylosis.
he latter is said to result if the joint
e put up for a week or two in exten-
di and then be flexed. Resection
"ild always be done subperiosteally, and care
lould be taken to avoid injury- of the ulnar nerve,
"ine operators insist on the use of apparatus for
while after the plaster is removed.
The Shoulder. — This is the joint in which the
»rm of the disease known as caries sicca most
ften occurs. The head of the humerus in this is
aten away, without the formation of abscess. It
The Sacroiliac Joint. —
Tuberculosis is a very serious
disease in this joint, but a
very rare one. The pain is
Located at the seat of disea e
or runs into tin- buttock or
down the thigh. A marked
limp is present, and the trunk
is inclined toward the sound
side. Abscesses are a fre-
quent complication, are prone
to early infection, and bur-
row in every direction.
Sometimes they rupture into
the pelvis, sometimes exter-
nally. Fluctuation may be
detected by inspection, or by
the finger in the rectum;
sensitiveness also. The prog-
nosis is bad. The conserva-
tive treatment is best car-
ried out by a plaster spica,
crutches, and by a high shoe
on the opposite extremity. Radical treatment might
meet with better success than it has in the past if it
were undertaken early and strove only for ankylosis.
The Fingers and Toes. — This is known also as
tuberculous dactylitis and spina ventosa. In adults
the joints themselves are usually diseased, in children
the shafts of the bones. To the latter the term
spina ventosa should be limited. The disease often
affects two or more fingers. Abscess is usual.
Fig. 454. — Subluxation in Tumor Albus.
Spina ventosa must be differentiated from syphilitic
dactylitis — not always an easy task. The problem is
sometimes solved with the aid of the Wassermann
and the tuberculin tests, by the examination of a
piece of the wall of an existing sinus, or by a course
of antisyphilitic treatment. In disease of the meta-
tarsophalangeal joint in the adult gout must be
excluded by the .r-rays and by the course of the
disease.
Vol. I.— 44
689
Arthritis, Chronic
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
The treatment in children consists largely of clean-
liness, and sometimes of suction by hyperemia. It
is usually efficacious if persisted in.
Radical Operations. — Extirpation of the diseased
bone, and bone grafting have been practised with
success."
In tuberculosis of the finger-joints of adults the
question arises as to the advisability of resection or
\ »
k
Fig. 455. — The Tin
Knee Splint.
Report.)
(Children's Hospital
of amputation, and this question must be decided
according to the importance of the member and the
severity of the disease. If secondary infection
have already taken place an amputation is probably
preferable.
NON-TUBEHCTJL.OTJS ARTHRITIS OP TYPE I. All
the other forms of disease included in this type shade
into one another without sharp dividing line, and to
various of them special names are given; thus, Still's
disease is a form occurring in young children, but
a similar disease exists in adults. A synovitis may
occur as a tertiary manifestation of syphilis, but if
the marrow in the bone ends be involved then the
disease comes under the head of chronic arthritis.
It will be best therefore to take up first the main
group, and later to describe the special forms, and in
order to avoid confusion we shall simply consider
this main group under the name of chronic non-
tuberculous arthritis of Type I.
Pathology. — The morbid anatomy is much the
same as that of joint tuberculosis, lacking only the
characteristic tubercle, the areas of necrosis, and
the formation of cold abscesses. Hale White" shows
a photomicrograph of a section of a joint obtained at
autopsy which needs only the presence of tubercles
to be characteristic of tuberculosis.
The main features of this type are a proliferation
of the synovia and of the lymphoid marrow. Some-
times one occurs alone, sometimes both occur together.
690
In the latter case, some writers say that one is t
earlier manifestation, some say the other. We i
justified in believing, then, that both may be right'
the cases they have examined, and that either t
synovia or the marrow may be first affected.
This proliferation in the synovia and in the mam
is the essential factor of the disease, and all bony a
cartilaginous changes are to be reckoned as due to
The synovia is thickened and inflamed. It
thrown into folds and shows marked villous hyp<
trophy. Parenthetically it may be said that tin
is do such clinical entity as "villous arthritis." T
formation of synovial "tags" is rather frequei
Under the microscope the ordinary signs of chroi
inflammation may be seen, namely", thickened blon
vessels, round-cell infiltration, etc. The synovia
stead of consisting of a single layer of cells,
posed of a layer of lymphoid tissue. It reminds o
of moss on a rock.
Not only is the synovia thickened and in fok
but it extends its border at the expense of the arti
ular cartilage.
The .Marrow. — Various changes have been d
scribed by different writers. Hale White" fout
foci of recent inflammation. Nichols ami Richai
son 12 regard a proliferation of the connective tissi
as the chief change. Nathan 13 describes a cyst l
mation and the formation of dense conneeti\<
in spots like "foci."
The proliferating marrow impairing the nutritif
of the overlying cartilage bursts through it and ii
vades the joint. Here it meets the proliferatii
synovia and the proliferating marrow from tl
other bone of the articulation, and forms adhesio*
with them. Sometimes the joint is but a mass
adhesions. This proliferating cellular tissue lati
may change to fibrous tissue.
Fig. 456. — Tuberculous Disease of the Ankle; Advanced Stage.
Most writers affirm that the synovia is the first
tissue to show proliferation, but Nathan assert-
that the marrow changes precede those in the synovia.
The Bone. — The essential feature of the bone change
in this type is an atrophy. Although, accord-
ing to Nichols and Richardson, in the early stages
no evidence of this atrophy can be seen under the
microscope, nevertheless the bone is distinctly more
permeable to the Roentgen rays. Usually the re-
sult of the morbid process is seen in thinning of the
bone trabecules.
REFERENCE BANDBOOK OF THE MEDICAL SCIENCES
Arthritis, Chronic
||„. Curtilage. -The cartilage is aiVeeled in a man
, perhaps mere striking than any other of the
sues.
It becomes thinned, atrophic, ami. de-
• * \
I i.:. 457. — Tuberculosis of the Tarsus. Talo-navicular joint lai'l
Note erosion of articular cartilage.
rived of its nutrition by the proliferating marrow,
rates, and is perforated by the granulations in
marrow. It is probably never lifted
md .hrown off in a leaf, as in tubercu-
isia. At the same time it is assaulted, so
ik. by the synovia, and suffers a
■ linking of its borders. As a result of a
motion or of a disturbance in nutri-
.11 or of both, the cartilage undergoes a
illation, and as the result, again, of the
tree processes just detailed, it may disap-
e:ir more or less completely. Sometimes
mall islands or strips of cartilage are seen
•abedded in granulation tissue.
\s the cartilage disappears a fibrous
nkylosis is formed in the joint. Accord-
ig to some writers, an occasional complete
r bony ankylosis takes place.
The ligaments are said to be thickened.
Symptomatology and Course. — It is neces-
ary to keep in mind the difference be-
a joint that has been the seat of an
disease, and in which, after the sub-
idenceof the disease, stiffness and loss of
unction remain, and a joint which is the
eat of an actual chronic disease or of a
isease which manifests itself by a series
■f acute exacerbations. It is only the lat-
er type of joint disease with which we have
o deal here.
The onset of the type under discussion
nay be sudden, with high fever and con-
titutional disturbance, or it may be slow
nd insidious. One joint may be affected
lone, or many joints may be involved,
it her at the same time, or one after another
n quick succession, or at long intervals.
\fter a joint has been invaded the symp-
oma and physical signs in it do not clear
ip completely when other joints are in-
olved, as they do in acute inflammatory
heumatism, but the joint is permanently
lamaged by the structural changes in it.
In what may be termed the classical
onn of this type, the tendency to involve-
nent of many joints is marked, the char-
icter is wont to be symmetrical, and in a
leneral way the disease manifests a " cen-
ripetal" nature, that is, the joints of the
hands and feel suffer fir t, then the knees ami elbows.
The proximal interphalangeal joints and the meta-
carpophalangeal, are often affected.
The hips often escape, bul the
pine i \ ulnerable. In anol her
the spine and hip
seal "i disease— ■■ on I iechtei ■
i j pe. \ arious write] - ha\ e at-
tempted to build up clinical etiti-
i- of locality of the
joint inflammation — such as von
Bechteiv npell-
Mai ie' di ea e, etc.— bul t heir
claims have not received general
recognii ion.
The anemia which so often ac-
com] tanii evi re fi inns of the dis-
ease is hard to explain. 1 1 may
be said i e i arac-
teristic bl 1 changes. Si >me ob-
ser\ ers ha-, e found a decrea
red blood cells, but as a ruli
number is about normal Leuco-
i'\ ti -is may or may not be pi i
Except possibly in its mild
forms this type is wont to be
multiarticular.
Sometimes the onset is pre-
ceded by various local nervous
dist urbances — tingling, numbness,
stiffness, weakness, hyperesthesia,
and circulatory
muscular cramps,
Fig. 45S. — Tuberculosis of the Calcaneus.
691
Arthritis, Chronic
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
change in color, etc. In other cases the onset is
unheralded.
The affected limbs may be atrophic or they may
be the seat of a sort of pseudoedema. The skin
and nails often show trophic disturbances. Extreme
sweating may be present, and various paresthesias.
Pigmentation of the skin is occasionally seen. The
occasional coexistence of Raynaud's disease, exoph-
r
Fig. 459. — Tuberculosis of the Carpus.
thalmic goiter, nephritis, paralysis agitans, and arterial
sclerosis has been observed. 11
The general condition of the patient varies. He
may be able to go about with more or less comfort,
especially in the intervals of the paroxysms, or he
may be completely bedridden, and unable to move
hand or foot. Often with the steady progression of
the disease, the patient becomes gradually more
helpless.
Contractures are often present
in the affected limbs, and the
reflexes are wont to be exag-
gerated.
Local Symptoms and Physical
Signs. — Pain is almost invariably
present, and ranges from mild to
very severe. The slightest motion
may occasion great agony. Stiff-
ness and loss of function accom-
pany the pain. The joints are
swollen, and often reddened. In
the later stages of the disease the
swelling may give place to a
shrinking and atrophy, which
gives a certain constriction at the
level of the joint. The charac-
teristic swelling is "boggy,"
caused less by the effusion in the
joint than by a thickening of the
synovia. Where the synovia is
accessible to the examining finger,
sensitiveness can be elicited. The
usual deformity is flexion.
Motion in the affected joint is
limited, not only by the pain, but
also by the products of inflam-
mation. Creaking and grating
can often be detected.
The severe "classical" form of the disease is really
not the common one, but represents the morbid
process carried to an extreme. In the majority
of cases of this type the patient experiences more or
less pain, stiffness, and disability in one or two joints.
The skiagram of the joint reveals what one would
expect after a study of the pathology. If the in-
flammation is confined to the synovia, this will be
seen thickened and swollen. If the bone is affected,
it will show in the picture as rarefied, and the car-
tilage as thinned and eroded. Bony hypertrophies
and exostoses do not belong in this type.
Differential Diagnosis. — At the start the differ-
entiation may be impossible between acute inflam.
matory rheumatism and the chronic forms of arthritis
which begin acutely, but the subsequent course will
always suffice. A higher tempera-
ture is the rule with rheumatism, and
its acid sweats are probably peculiar
to it. Heart complications are rare
with chronic arthritis. Above all,
rheumatism flits from joint to joint
involving one at a time, and leaving
no trace behind.
A gonorrheal joint inflammation i.>
wont to run a distinctly acute course,
and, when it subsides, to leave the
joint damaged, but not the seat of a
progressive, active disease. On the
other hand, it is probably a fact that
a gonorrheal joint may closely simu-
late the disease under discussion,
and possibly may be pathologically
so allied to it as really to belong in
the same class. The condition of
the genito-urinary apparatus may
enable us to place the gonorrheal
joint in its proper class, or perhaps
the cultivation of the gonococcus
from some aspirated joint fluid.
We have seen that the pathological process i:
tuberculosis is almost identical with that in the ordi-
nary proliferating type of arthritis. It follows, then,
that the symptoms and physical signs are the same,
or so nearly the same as often to prevent a diagnosis
from them alone. The skiagram is also the same.
The main points which distinguish tuberculosis clin-
ically are its slow and steadily progressive course, its
almost invariable uniarticular nature and its tendency
[
Fig. 460. — Tuberculosis of the Carpus.
to produce abscess. The tuberculin reactions are
not of conclusive value in adults, but the animal test
or a laboratory examination of a piece of the synovia
are of much more importance.
The chief difficulty in diagnosing this type o(
chronic arthritis will be found in the very mild ■
in which the synovia alone of one joint is involved,
and which occasion practically no symptoms exi
moderate pain of more or less constancy, and it is
G9L'
REFERENCE HANDBOOK OF THE MEDICAL SCIENI ES
Artlirltl-. Chronic
these cases that the painstaking complete
Mica] examination is most important. In
,'. m . often the detection of the source of the
'ection and its removal, not only cures the
disease, but clears up the diagnosis.
Tin- prognosis is fairly good if one can find out
e of the disease. If it cannot be cured
may at least be checked, and t lie patient may
restored to a fair degree of health. The
|ut more or less general, and
produces cartilaginous outgrowths and spurs, which
may later undergo transformation into bone, The
bone under nca ih the articular cartilage hypertrophies
at t ho --a mo time. Now , i he cartilage draws its nutri-
tion from the marrow, and when this nutrition has
I n loit oil' i.\ i he \ bone, t he carl ilage degener-
ate . and wears away, often leaving the bone exposed
and ebumated, grooved in the line of joint motion.
The peripheral portions of the cartilage, drawing their
nutrition probably from (he synovia do out suffer
in this manner, bul maintain their hvpertrophiod
condition, and give (o the bone end an enlarged and
flattened contour, adding to the distortion, .-11111
sometime causing subluxations. Between the ebur-
nated bone ends there is no tendency to ankylo is
as in Type I, and there is no proliferating marrow
to break through the cartilage. Whatever obstruc-
tion to motion is present, is purely mechanical.
Symptomatology. — As a rule the onset of the dis-
ease is insidious, with moderate pain and stiffness,
and the course is more or less progressive, until the
process is finished, when the joint is left more or le 3
damaged functionally. The pain is rarely great, and
lesions of this type are not so severe in their effects
as are those of Type I. The joints as a rule are not
much swollen, but the bone ends show irregular en-
largements. Subluxations are frequent, on account
of the change in shape of the articulating surfaces.
Sensitiveness to pressure is rarely present. In the
hip the usual deformity is flexion, abduction and
external rotation; in the knee, flexion; in the fingers,
lateral distortion. Creaking and grating can be dis-
tinguished on palpation, and motion is limited. The
atrophy of disuse may be detected with the tape.
Disturbed digestion is often present, but no fever nor
other constitutional disturbances.
Roentgen rays show the bony and cartilaginous
growths, the thickening of the cartilage and of the
bone near the joint, and the wearing away of the
cartilage near the center, in the line of joint motion.
Diagnosis. — Cases in Type I. are wont to be ac-
companied by more constitutional disturbance, are
more painful, and show more acute manifestations.
A skiagram shows a rarefaction of the bone, no bony
nor cartilaginous growths, and a thinning of the car-
tilage. Inflammation is more marked in cases of
Type I, and bony and cartilaginous growths do not
occur in it.
Tuberculosis may be hard to differentiate from the
Fiu. 166.-
-Dactylitis in Boy of about Nine Years. He had a distinct history of a syphilitic
parent, but the lesions did not heal up under anti-syphilitic treatment.
695
Arthritis, Chronic
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
uniarticular forms, but tuberculosis also shows more
signs of active disease and inflammation, more mus-
cular spasm, and greater pain and sensitiveness as a
rule. The tuberculin reaction may be present.
One misses in tuberculosis also the cartilaginous and
bony spurs. The obstruction to motion in tuber-
Fig. 467. — Photomicrograph, Low Power, Showing Bizarre
Appearance of Cartilage, from Knee with Mixed Infection.
culosis is caused by inflammatory products and by
muscular spasm; in cases of Type II, by mechanical
impediment. The Roentgen rays are the most useful
means of diagnosis. Sometimes the differentiation
can be made only by several examinations at intervals
of time.
Fig. 46S.-
-Low Power Photomicrograph Showing Fibrous Change
in the .Marrow.
The prognosis quoad vitam, unless the spine is
involved, is good; as to function it is bad. The dam-
age once done to a joint is permanent, and a return
to perfect function usually impossible.
Treatment. — Here, as in other forms, one endeavors
to find a source of infection, and to remove it. If
this be possible, one may arrest the march of tt
morbid process. Intestinal fermentation is to t
corrected, and also enteroptosis. Passive motion an
massage are contraindicated. They harm the joir
by the trauma they inflict through the medium i
the rough bony surfaces. Sometimes a well-fittii
Fig. 469. — Photomicrograph of Marrow Cyst from Hip Joint.
brace, which allows motion through a painless arc
may enable the patient to use the affected joint witl
a reasonable degree of comfort. If one or two bom
spurs be identified as causing most of the restrictioi.
they may be chiseled away, in the uniarticular form:
especially. In the case of a badly damaged singk
Fig. 470. — Low Power Photomicrograph Showing Degeneration of
Cartilage in Type II — the so-called Cartilage "Tatters."
joint a stiffening operation may be thought advisable,
for a perfectly stiff, painless joint is far preferable
to a painful one with a small range of motion. In the
knee this may easily be done by the removal of the
articular cartilages, with a small slice of bone. In
the hip Albee's operation is perhaps the best resort.'"
696
REFERENCE HANDBOOK OF THE Ml I'M \I. SCIENCES
Arthrllls, < hniiilr
yibee removes the upper part of the head of the
cmur the upper portion of the acetabulum, and as
nuch'as possible of the cartilage from the head of
he femur, subluxates the femur upward, and puts
lie thigh up '" slight abduction and flexion until
>ony union takes place. With the destruction of
he joint, the disease disappears.
Fig. 471. — Same as tig. 470; High Power.
Special Forms. — Hebcrden's nodes are small
bony growths usually occurring at the terminal inter-
phalangeal joints of the fingers, and have been said
to be an evidence of longevity. They occasion
slight discomfort, and slight interference with func-
tion. The deformity resulting is usually lateral, in
Fig. 472. — Lower Power Photomicrograph Showing Irregularity of
Joint Cartilage.
contradistinction to the flexions caused by lesions
of Type I. The latter form affects more often' the
proximal interphalangeal joints or the metacarpo-
phalangeal. Treatment of Herberden's nodes is not
often necessary.
Spinal Form. — The lesions in the spine are wont to
be severe, not only from the extent of the damage,
and its crippling effect, l>ut also on account of the
effect upon the vital means through the interference
with their function. A part of the spine maj be
involved or the whole column. Of ten the two upper-
most joints escape. The joints become ankyli I
more or less c pletely. Sometimes masses of bone
form on the anterior aspect ot the -pine, turnii
into a bony ma I'lie intervertebral discs may be
lied, or the joints may persist, though surround-
ed by masses of bone. If they persist the spine may
lose its normal curve and be converted into a more
or less straight rod — "poker pine." If they be
absorbed tie- spine may possess one long, rounded
posterior curve.
The symptoms are pain, disability, stiffness, and
weakness. The pain is caused by pressure on the
spinal nerves, and is felt not only in the back, but
Fig. 473. — Charcot's Disease. (Weigel.)
also down the limbs and about the trunk. The knee-
jerks are often increased. The disability may be
extreme, especially if a complicating lesion of other
joints be present.
Probably the best form of special treatment is by
the use of a brace, or better still, of a plaster jacket,
to prevent the increase of the deformity if not the
spread of the disease. It is seen that if the ante-
rior bowing of the spine be prevented, while the inter-
vertebral discs are being absorbed, but before bony
union has taken place, the subsequent condition of
the patient will be bettered. Of any attempt to
break up bony union here there should, of course,
be no thought.
Charcot's Joint, Trophic or Neuropathic
Joint. — This form of joint disease probably belongs
in this tvpe. though it possesses features of both types.
It sometimes complicates a tabes or a syringomyelia.
G97
Arthritis, Chronic
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
The knee is most frequently affected, then the hip,
then the ankle, then the spine. The joint becomes
badly disorganized, and often contains loose pieces of
bone and cartilage. Pain is absent, but the swelling
and loss of function are marked. The joint becomes
very lax, and motion is possible in abnormal direc-
tions. The conservative opinion seems to be that
operative measures are useless in this affection. A
jointed brace affording limited motion gives the best
prospect of relief.
Poncet's tuberculous rheumatism is a form
of joint disease which Poneet has considered to be due
to a sort of attenuated virus acting upon the tissues
of the joint. He thinks that a large proportion of
cases of chronic rheumatism are due to this cause, but
as yet his observations are viewed with some degree
of scepticism. It is possible that the fleeting joint
symptoms often observed in tuberculous patients
are due to a secondary infection.
Bier Treatment (Stauungshyperaemie). — In various
forms of chronic arthritis, tuberculous and other, a
Ankylosis. — After any chronic joint disease has
run its course, or indeed, after any acute one, a
certain amount of stiffness is wont to be left behind
and to this stiffness the name ankylosis lias been
applied. It is necessary to have a thorough com-
prehension of this subject if one would undertake
the after treatment of these joints, and to know the
exact pathological condition in them. Otherwise
one risks disaster in attempting to mobilize them.
Two kinds of ankylosis are recognized, namely,
true or complete or bony, and false or incomplete or
fibrous. Fibrous ankylosis may be so firm as to simu-
late the bony variety, and may possibly be differen-
tiated only by an examination under ether, or by a
Roentgen picture.
First, let it be said that immobilization probably
never causes ankylosis by itself. If a normal joint
be immobilized for a length of time, the synovia
encroaches upon the joint cartilage and the latter
becomes fibrillated. Some stiffness will be present
when the dressing is removed, but this stiffness will
disappear upon the resumption of function, and
Fig. 474. — Patient in Bed on Fixation Frame, with Traction in Line of Deformity.
treatment, named after its originator, has been
advocated, which consists of the production of a
venous stasis in the limb, to be continued for one hour
to three hours daily. The stasis is brought about
by the application of an elastic band above the joint,
which should be applied just tightly enough to make
the portion of the limb distal to it bluish-red and
warm but not -painful. Klapp, Bier's assistant,
devised a modification of the treatment for use in
tuberculous joints with open sinuses or open absces-
ses. He used specially devised cupping glasses. To
i*duce a suction hyperemia in a limb he inserts it in
a glass chamber, whose open extremity is provided
with an open cuff for bandaging on the limb. The
air is then exhausted from the air chamber.
The Bier treatment at one time had a wide vogue,
but seems to be falling into disrepute. It certainly
merits a trial in some cases, but too much should not
be expected of it. The amelioration of the symptoms
of pain and sensitiveness, which often takes place,
may lie due to a reduction of the disease process, or
possibly may be due to simple pressure on the nerves.
some observers have said that the obstruction to
motion in this case is located in the tendons, and
disappears when they are divided. This fact should
be kept firmly in mind.
The principles governing the treatment of ankylosis
vary according to conditions, and according to the
disease which has caused it, but no mobilizing opera-
tion should ever be undertaken in a tuberculous joint
while the disease is in its active stage or when it has
run its course, and is apparently well. When the
disease is active it will be aggravated by motion, and
one can never tell when it is well." An old, appar-
ently healed joint usually contains encapsulated foci of
tuberculous material, which occasion no disturbance
until trauma or ill-advised operations set them free,
and light up the trouble afresh. If, in the active
stages, one undertakes the treatment of a tuberculous
joint in a faulty attitude, one should reduce the de-
formity as gently as possible, either by gradual cor-
rection by plaster-of-Paris, by traction in bed, or pos-
sibly, if "the obstruction be not very resistant
reduction under ether. If the disease has run its
698
REFERENCE HANDBOOK OF THE MEDK \l. SCI] \< ES
Arthrology
h
nurse, and the fibrous ankylosis is very firm, an
steotomy should be the corrective operation, fol-
,,,1 i,\ plaster-of-Paris. Fibrous ankylosis is the
je. Bony ankylosis probably never follows tuber-
losis in an adult, and only a mixed infection in
i. Bony ankylosis requires an osteotomy
,,. its correction, with subsequent retention of the
,1, ,n pla ter for several months. Division of con-
ted tendons may be :essary in addition. The
,.iiiinv should not lie done through the joint, for
chiseling into an old tuberculous focus.
Cases in Type 1. — After the disease has
ached its quiescent stage, attempts to restore mo-
in the joint are permissible. If the ankylosis be
much may often be done by the use of me-
apy, hot and cold douches, massage and pas-
otion. Occasionally this may be preceded by
reaking up the adhesions under an anesthetic and
lien by putting the joint up in an entirely different
ttitude in plaster for a month or two, especially
■ hip. The use of muscle flaps, animal membranes,
has its advocates here as in bony ankylosis. Var-
IUS surgeons have reported excellent results
< /',/" II. — All attempts to increase motion
orce here are decidedly contraindicated, and do
In some instances the use of animal mem-
iranes, or muscle flaps would seem indicated; in others
obstructions may be chiseled away. In still
rs an operation to produce bony ankylosis is
able.
If the surgeon will picture to himself the exact state
[fairs in any old, diseased joint he will hardly go
istray. It is the lack of exact knowledge which is
. sponsible for most errors. Leonard W. Ely.
References.
1 Allbutt'a System of Medicine, 1901. vol iii
2. Beitlike Zeitschrift fur klinische Medizin, 1912, S. 215.
3. Stiles: Journal of the American Medical Association, Feb.
,. 1912
4. Jansen: Archiv fur klinische Chirurgie, November, 1911.
" Heck: Transactions of the Sixth Inter. Congress on Tuber-
190S.
6 Wallace Blanchard: Medical Record, May IS, 1912.
7 Hibbs: N V. Med. Journal, May 27, 1911; Journal Am. Med.
Us'n. Aug. in, 1912.
8 Albee: X V Medical Journal. March 9, 1912.
9. Ely: Tuberculosis of the Adult Knee. Transactions of the
>n on Surgery of the American Medical Association, 1912:
loiat Tuberculosis, Wni. Wood & Co., 1911.
111. Stubenrauch: Munch, med. Woch., 1909, No. 36. Ahrens:
Berliner klin. Woch., 1909. No. 48.
11. Hale White: Guy's Hospital Reports. 1902.
12. Nichols and Richardson: Journal of Medical Research, vol
\\i. No. 2.
13. Nathan: American Journal of the Medical Sciences, June,
1909.
I t. Llewelyn Jones: Arthritis Deformans. Win. W T ood it Co.,
IV Still: Allbutt's System of Medicine. 1901, vol. iii. See also
Llewelyn Jones, Arthritis Deformans, 1909.
16. Albee: Surgery, Gynecology and Obstetrics, March, 1910.
17. Ely: Joint Tuberculosis, IVm, Wood & Co., 1911.
Arthritis, Deformans. — See Rheumatoid Arthritis.
Arthrology. — That part of anatomy which treats
of the joints or connections between the denser parts
if the skeleton. By means of these joints, or articu-
lations, the skeleton, originally an apparatus for
support, becomes an apparatus for locomotion. In
its primitive condition the human skeleton is without
joints, being represented, in the human fetus before
the fifteenth day, by a simple non-jointed rod of
condensed embryonic tissue called the notochord,
a form permanent in the lowest vertebrate (amphi-
is). This becomes ensheathed with tissue (Fig.
175), which changes to cartilage at regular intervals,
thus becoming segmented (Fig. 476). Vestiges of
the notochord are found in the adult as pulpy masses
within the discs which unite the vertebra?. Else-
where in the human body joints are formed in a
similar way. I • laid down and then seg-
mented by the differentiation of certain port
into cartilage, which may aftei ify. The
structures by which union is effected at thi joint
may, therefore, be considered as the altered remains of
the original skeletal matrix. Ground the segnu
this matrix remains as fibrou ti ue, termed the
perichondrium, becoming periosteum when ossifica-
1 1 1 ■ 1 1 i ;i ue . and i <• I ei □ the gments it occui ■
Notl "lion!
Skeletogen-
oua layer.
I ii .
I ,< moinsox
uotochord. ,
176. — Joints Derived from
It. tChUd at birth.)
Fio. 475. — Notochord without Fit;
Joints. (Fetus fifteen days.)
similar fibrous tissue, changing to fibrocartilage in
certain cases. When in the form of bands, straps,
or membranous sheets, these transegmental struc-
tures are termed ligaments. They may unite not
only the apposed ends of segments, but also Un-
related sides. Sheets of this sort passing laterally
from one bone to another in the same plane are known
as interosseous membranes. Examples are seen
between the radius and ulna, and between the tibia
and fibula. The entire ligamentous system is
closely connected with the fasciae, of which it may be
considered a specialization.
The prime characteristic of joints is, therefore, the
movements which become possible by reason of seg-
mentation. These movements vary according to
the varying functions of the segmented members,
and thus produce corresponding modifications of
structure in the parts composing the joint. Upon
these modifications the classification of joints de-
pends. In all joints there is originally sufficient
intersegmental tissue to permit slight and limited
Periosteum
Bone
Intersutural \
ligament. J
Periosteum
Bone . . .
Cartilage .
suture.
Fig. 47S. — Synchondrosis.
motion. Such are called primitive or amphiarthro-
dial joints. Examples occur in the adult between
the bodies of the vertebra;. In the course of de-
velopment the osseous or cartilaginous tissue of the
segments usually tends to encroach more and more
upon the intersegmental structure. If no alteration
occurs in this, the joint becomes less and less movable
until complete fixation ensues. It is then termed
synarthrodial or immovable. Examples are seen
in the adult skull. The process may be carried so
G99
Arthrolojry
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Segment.
far a* wholly to obliterate the joint. When the
connecting substance is fibrous, the joint is termed
a suture (Fig. 477); when cartilaginous, a synchon-
drosis (Fig. 478). Strictly speaking, the union of the
shaft of a long
bone with its
epiphysis is a
s y nchondrosis.
There being no.
strain caused
by movement
i:i this class of
joints, the peri-
osteum [lasses
over the inter-
segmental tis-
sue without
thickening into
ligamentous
structures.
Sutures are
found only be-
t w e e n bones
that are developed in membrane, like those of the face
and the vault of the skull. They form a special class
of articulations, their function being not so much to
permit movement of the parts united as to separate
those parts and thus allow for the expansion of the
inclosed structures. They are classified according
to the manner of apposition of the edges; when
these are nearly smooth the articulation is called an
harmonia, when
Segment
i li.lllii'illll
Fig. 479. — Formation oi the Synovial Cavity.
Interarticular \
ligament.
Vertebra.
Rib.
they are cut
obliquely and
override in a
marked degree
it is a sutura
squa?nosa, when
they interlock
by toothed
edges a sutura
serrata, when
an edge is re-
ceived into a
groove and en-
sheathed, as occurs w-ith the sphenovomerine artic-
ulation, it is a schindylesis.
Some authors describe the articulation of the
teeth with their sockets as an additional form of
synostosis, giving it the name of gomphosis.
In by far the greater number of cases the inter-
segmental tissue of the joint becomes altered. Be-
tween certain of the cells, vacuoles or small cavities
form (proba-
Synovial \ ,
cavities. /
Fig. 480. — Costovertebral Joint.
Synovial cavities.
bly by the en-
largement of
the 1 y m p h
lacunae of the
connective
tissue), and
these join to-
gether, mak-
ing a larger
cavity or
cleft. The
cells immedi-
ately around
the cavity
form a secret-
ing surface,
the synovial
membrane
(stratum syn:
oviale), the
product of secretion being a glairy fluid called
synovia. The membrane resembles the similarly
formed serous membranes of the body, though it is
not lined with endothelium. Like the serous mem-
700
m
Interarticular cartilages.
Fig. 481.- — Formation of Arthrodial Joints.
branes, it is very vascular and is liable to suddei
and dangerous inflammations. Synovial cavitie
are formed not only between the apposed segment
of a joint (Fig. 479), but also where tendons ml
over hard surfaces, or where the skin is closel-
applied to such surfaces and friction is frequent (se
Bursce). Small and imperfect synovial cavitie
exist in a few amphiarthrodial joints, but usualh
the joints where such cavities occur are freely mov
able throughout their extent, and are, therefore
called diarthrodial. The intersegmental tissue mai
Perios
teum
Bone
Cartilage.
Perios- )
teum. j
Bone.
Fig. 482. — Fully Developed Arthrodial Joint.
not be wholly obliterated by the cavity. When the
movement of the segments is perfectly regular and
small in amount, it may remain as a central band
with a cavity on each side and ligamentous structures
surrounding the whole, forming a capsule or envelope.
This is a peculiarity of the articulation of the heads
of the ribs with the spine (Fig. 4S0). When the
movement is such that the articular surfaces do no
correspond, a synovial cavity is sometimes formed
along the surface of each segment, leaving an inter-
vening disc of fibrous tissue, which becomes partly
cartilaginous and is then known as an interarticular
Fig. 4S3.-
-A Sesamoid (Knee
Joint).
Fig. 484. — Planiform or Glid-
ing Joint (Patellofemoral).
Sliding and coaptative motion
only.
fibrocartilage (meniscus articularis) (Fig. 481),
Example, lower jaw joint. The disc may become
thinned and disappear in the center, leaving a ring
(Fig. 4S1 shows this in vertical section). This
occurs in the knee-joint. Its complete disappear-
ance is shown in Fig. 482.
Joints may be formed under pathological condi-
tions, the process being similar to that just described.
After fracture the ends of the bone are first united
by fibrous tissue, constituting an amphiarthrodial
joint, which may remain permanently, or by process
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Arlliniliity
| repair be converted into synarthrodia! and finally
jsappear; or, if mobility of the apposed ends be riot
strained, there may be developed a false arthrodial
tat with synovial membrane and ligaments formed
,,m the surrounding connective tissue.
II, ,. action and relations of muscles are important
in shaping and otherwise modifying joints.
mounding they afford protection, and also
lively assist the ligaments in holding together the
i ends of the segments; differing in this, thai
nsion can be adjusted to the stress placed on
rments. They are invariably attached so as
,ort the articular surfaces with reference to
ich other, never pulling them apart. Dislocations
therefore more likely to occur if the force is
pplied suddenly, before the muscles can be put in
Transv. ngt
Syn. cavities.
|85. — Pivot Joint (Atlauto-epittrophic).
A, top view; B, front view.
Rotation only.
etion, and are rare among professional athletes,
v, (vantage is taken of this peculiarity of the muscles
ng a dislocation, this being much more easily
en the patient is taken off his guard, or
ulution of muscular force is produced by an
thetic. Expansions from the tendons of mils-
strengthen and support the joints, uniting with
! iint capsule. When the strain put upon these
insions is habitually great, as in case a tendon
o er the angle made by the two segments,
he connective tissue of the tendinous expansion is
■ to take on some denser form, as cartilage or
>one. These appear as small nodular bodies known
samoids, and possess true articular surfaces.
patella is the largest and most notable example
■f these (Figs. 483 and 484).
First meta-
carpal.
• . -Hinge Joint (El- Fir,. 487.— Saddle Joint (Thumb).
tow). Angular motion in one Angular motion freest in two
plane. planes.
Comparative anatomy shows that a considerable
number of the ligaments of adult joints represent
muscles that have undergone a phylogenetic change
in location and character. Thus the internal lateral
ligament of the knee (lig. collateral tibiale) represents
a former extension of the adductor magnus, the ex-
ternal lateral ligament (lig. collaterale fibularc) an
insertion of the peroneus longus, the great sciatic
ment (lig. sacrotuberosum) an insertion of the
biceps femoris.
The shapes of articular surfaces depend mainly
upon the direction and preponderance of the muscu-
lar force applied to the segments. The simplest
movement possible is the sliding of one nearly plane
-urface upon another. This is the ordinary move-
ment of the sesamoids. Joints in which this is the
prevailing movement are called planiform or arthro-
dial (Eig. -LSI). There are, however, no articular
surfaces that are perfectly plane, there being no .-it na-
tion where a pulling force i^ applied in a continuous
straight line throughout the extent of the move-
ment. For this rea on there i al o found in plani-
form joints a slight rolling of convex surfaces on each
other. This is called coaptation. When the sur-
faces are markedly curved a variety of movements
may take place. Motion around an axis passing lon-
gitudinally through one of the segments is called
rotation. Pivot joints (trochoides) possess only this
Thumb.
Fig. 4SS. — Pommel Joint (Wrist) . Angular motion in all planes.
movement, and are exemplified in the atlanto-epis-
trophic and proximal radio-ulnar articulations (Fig.
185). Bending the segments so as to alter the
angle they make with each other is called angular
movement. When lateral, to or from the axis of the
body or limb, it is further distinguished as adduction
and abduction; when forward or backward, folding
or unfolding the segments, as flexion and extension.
A hinge joint (ginglymus) is one in which such motion
is allowed in a single plane only. The elbow is the
best example (Fig. 4S6). The shape of the surfaces
may allow free angular movement in some directions
'?n\ Hip bone.
Fig. 4S9.— BaU-and-Socket Joint (Hip). All movements.
while limiting it to some extent in others. In the
saddle joint (articulatio sellaris, Fig. 4S7), and the
pommel joint (articulatio ellipsoidea, Fig. 48S), the
motion is freest in two planes at right angles to each
other. In the former, each surface is convex in one
plane and concave in the other; in the latter, the sur-
faces are reciprocally ellipsoidal. These two classes
of joints allow all "movements except rotation, it
being possible to perform circumduction or such
swinging of the distal segment through a series of an-
gular positions as to make it generate a conical sur-
face. When the joint consists of a head nearly spher-
701
Arthrology
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
ical received into a closely fitting cavity, it i.s known
as a ball-and-socket joint (enarthrosis, Fig. 489), in
which great freedom of motion is allowed, all move-
ments being possible.
The following table shows how joints may be classi-
fied according to a genetic system:
Patellofemoral.
Tibiofibular.
Tarsal, except talonavicular and calcaneo-
cuboid.
Tarsometatarsal.
Intermetatarsal.
CLASSIFICATION OF JOINTS.
Primitive Joints (Amphiarthroses).
Without Synovial I
With Synovial Cavity.
Immovable Joints > Synarthroses).
United
by cartilage.
Synchondroses.
United by
connective tissue.
Suture.
Freely Movable Joints (Diarthroses).
Motion sliding or coaptu
surface- nearly fiat.
I'la.mform.
Motion curvilinear,
surfaces curved.
XoN-PLANIFORM.
Edges smooth.
Edges
Edges
Edges en-
Rotation
Hakmonia.
i iverlap.
toothed.
sheathed.
only.
StJTURA
StJTURA
SCHINDYLE-
Pivot Joints.
Squaw ISA
Serrata.
SIS.
Angular Angular Angular All movements
motion one motion freest motion all Ball-and-
plane. in two planes. planes. Socket Joints.
Hinuk Joints. Saddle Joints. Pommel Joints.
The following is a list of the joints of the human
body arranged upon the foregoing principles of clas-
sification. As in all natural classification, perfectly
clear and sharp distinctions do not exist, many joints
being somewhat mixed, blending the characters of
two or more classes.
TABLE OF THE JOINTS.
Order I. — Primitive Joints, or Amphiarthroses.
Class 1. — Without a Synovial Cavity.
Intervertebral — of bodies.
Lumbosacral.
Sacrococcygeal.
Sternal.
Class 2. — With an Imperfect Synovial Cavity.
Sacroiliac.
Interpubic (symphysis pubis).
Order II. — Immovable Joints, or Synarthroses.
Class 1. — Sutures.
Joints between the bones of the skull, ex-
cept occipitosphenoid and ethmovo-
merine.
Class 2. — Synchondroses.
Occipitosphenoid.
Ethmo vomerine.
Chondrosternal of first rib.
Costochondral.
Order III. — Movable Joints, or Diarthroses.
Class 1. — Planiform Joints, or Arthrodia.
Intervertebral, of articular processes.
Lumbosacral, of articular processes.
Costovertebral (costocentral).
Costovertebral (costotransverse).
Chondrosternal, second to seventh ribs.
Interchondral, sixth to ninth costal carti-
lages.
Sternoclavicular.
Acromioclavicular.
Radioulnar, distal.
Carpal — between single bones.
Carpometacarpal, except thumb.
Intermetacarpal.
702
Class 2. — Pivot Joints, or Trochoides.
Atlantoepistrophic.
Radioulnar, proximal.
Class 3. — Hinge Joints, or Ginglymi.
Elbow-joint (humeroulnar).
Phalangeal, of hand.
Knee-joint (femorotibial).
Ankle-joint (talocruraltibia and fibula with
astragalus).
Phalangeal, of foot.
Class 4. — Saddle Joints.
Carpometacarpal, of thumb.
Calcaneocuboid, of ankle.
Class 5. — Pommel Joints (Condyloid).
Temporomaxillary (mandibular) .
Atlantooccipital.
Radiocarpal.
Intracarpal (os magnum with semilunar
and scaphoid).
Class 6. — Ball-and-Socket Joints (Enarthrodia).
Shoulder-joint (scapulohumeral).
Metacarpophalangeal.
Hip-joint (coxal = coxofemoral).
Tarsal, (talonavicular).
Metatarsophalangeal.
An examination of the intimate structure of adult
joints involves, (1) the ends of the segments (usually
bones); (2) the articular cartilages which protect
them; (3) the fibrocartilages which, when present,
adapt the surfaces to each other; (4) the ligaments
which prevent their separation; (o) the synovial
membranes which by their secretion lubricate the
surfaces.
At joint surfaces pressure and movement occasion
a modification in the ordinary structure of bone.
The ends are enlarged and the surfaces are of ex-
tremely compact tissue, protected by a layer of hyaline
cartilage, the remains of the original cartilage from
which the bone was formed. Acting as a buffer to
break shocks and to prevent wear, it is invariably
thickest where the pressure is greatest (see Fig. 482).
Under normal conditions it never ossifies, although
in old age and in persons of inactive life it becomes
thinned and infiltrated with lime salts. Should it
REFERENCE HANDBOOK OF THE MEDICAL 3CIENCES
Artlirolncy
&
ly
'%
B M
■i i
K'i
V
7 .
3!
egg
ough, the bone becomes rapidly worn smooth
burnated) and the joint is disabled. The super-
nal cells of tlic cartilage are
■d. but in the deeper parts
iey multiply in the line of the y j -.
stress, and arc therefore
I in columns perpendicu-
, to the articular surface (Fig.
which directions sudden
may cause the cartilage to
ilit. The fibrocartilages found
joints arc composed of while
tissue, n ith -parse elastic
to impart the necessary
siliency. Their usual form is
■ 'discs or rings attached
ainlv to the more movable sen:
either by. their edges (knee,
or by the edge and one
irfaoe (hip, shoulder). The
be i completi enlarg-
es the cavity on one side only
ih&langi
original capsular arrange-
lent of the ligaments remains
s in which the joint is
e|| protected by muscles and
ie strain is evenly distributed.
a most joints, however, the
ring much greater in
>uie directions than in others,
capsule becomes thickened
> counteract it, forming bands
Inch nave received special
aines. Atmospheric pressure,
.ting against the force of grav-
sists in keeping thearticu-
ir surfaces in apposition, thus
re venting a constant strain
pon the ligaments. An im-
ortant office of the ligaments is to limit the motion
f the segments and prevent the shocks which would
otherwise occur from the sud-
, den contact of bony surfaces.
In some cases they greatly
economize muscular force by
holding the joint in a set
position. Thus but little
force is required to maintain
the body erect, as it is sup-
ported mainly by the tension
of the ligaments of the spinal
column, by the iliofemoral
ligament at the hip, and by
the posterior, lateral, and
crucial ligaments at the knee;
these lying always on the
convex side of arcs subtended
by the line of the center of
gravity (Fig. 491). Owing to
their function as limiters of
motion, it follows that the
position of greatest relaxation
for all the ligaments of a joint
is one midway between flexii in
and extension. In case of the
distention of a joint cavity by
a morbid effusion, the patient
involuntarily places the joint
in such a position.
Synovial membranes origi-
nate as continuous and closed
sacs, but over the articular
surfaces, where pressure oc-
curs, portions of them disap-
pear; so that, at the latter
part of fetal life, they merely
line the capsule and extend
m
X- •
Fig. 490. — Articular Cartilage. .4, Flattened
cells; B, cells in column-; C, region infiltrated
with lime; Z>, bone. (After Sappcy.)
Fig. 491. — Ligaments
Supporting Erect Posture.
A, Anterior set; B, poste-
rior set.
but a shorl di tance upon the cartilages of the joint.
In adult age they frequently are further extended by
< ' ' ' m 1 1 1 1 1 1 r i i . ■ ; i ! Km u illi I he -\ ],.,\ ial
cavities of neighboring bu
; -~ " . .-- and nil ci ii be-
come re i " quenl and exten-
more lax than the surroum
ligaments, being thrown into
folds to increase the blood supply
and In pad 0U( i
~ , a isted in this by interstitial
deposits of fat. Along the inter-
articular lines lln vil-
.} '. Inns pr or fringe-, some
of which contain cartilaginous
les (Fig. 492).
It is at or near the joints that
at \ ascuiar trunk- di
an arrangement \\ hich is p
bly connected with the centrip-
etal development of bl I-
vessels and the bud-like forma-
tion of limbs in the embryo.
The immediate supply of the
joint is obtained from small
vessels that anastomose freely
with otn anot her. By them the
collateral circulation is estab-
lished when the main trunk is
occluded. From these vessels a
rich arterial network penetrates
the capsule to supply the syno-
vial membrane. Abundant cap-
illaries lie in loops along the
synovial folds, and by exudation
from them the synovia is ap-
parently formed. The articular
cartilages and the compact layer
of bone immediately contiguous
are normally destitute of vessels, but capillaries rapidly
extend into them during inflammation. The fibro-
cartilages are stated by Sappey to contain vessels, and
may therefore take an active part in inflammatory
processes. Lymphatics are numerous near joints.
Klein considers
the joint cavity
itself as a
lymph space
communicating
directly with
the lymphatics.
The nerves of
joints are dis-
tributed mainly
to the synovial
membrane and
the ligament-
ous structures.
It is probable
that in these sit-
uations special
nerve endings
e xist, as de-
scribed by
Krause and
Xicoladoni, for
it is difficult
otherwise to ac-
count for the
peculiar sensi-
bility of the
structures. A
ligament or a synovial membrane may be touched, cut,
or pinched without giving much pain, but if it be
stretched beyond its physiological limit, threatening
the integrity of the joint, the suffering is excruciating,
as is well known to those who have suffered from a
FlQ. 492. — .Synovial Fringes. X 200.
(Modified from Henle.)
703
Arthrology
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
sprain or a dislocation. Articular cartilage has no
nerves, and the gnawing pain which occurs during its
ulceration is probably caused by inflammatory
products affecting the nerves of contiguous tissues.
A remarkable law of correlation has been noted by
Hilton with reference to the nerves of joints, viz.,
that they also supply the muscles w-hich move the
joint and the skin over the insertion of such muscles;
the whole apparatus being thus under the control of
associated central influences. There is besides
strong clinical evidence of this. Remak and Bene-
dikt have pointed out the strong probability that
many diseased conditions of the joints originate in
irritable states of the spinal cord and of the sym-
pathetic, and Charcot has published some cases
showing remarkable atrophy of the muscles of a
joint after an injury to the articular surfaces com-
£aratively slight and inadequate to such a result.
ocomotor ataxia is usually accompanied by joint
lesions.
For the anatomy of special joints see the following
heads: Ankle Joint; Elbow Joint; Foot, Joints of;
Hand, Joints of; Hip Joint; Knee Joint; Pelvis,
Joints of; Shoulder Joint; Skull; Thorax; Wrist.
Frank Baker.
References.
Besides the systematic work on anatomy by Quain, Gray, Allen.
Morris, Piersol, Cunningham, Sappey, Cruveilhier, Henle, Hyrtl,
Gegenbaur, Testut and Poirier, the following authorities have
been consulted in preparing this article:
Morris, William: The Anatomy of the Joints, London, 1S79.
Turner: An Introduction to Human Anatomy, Edinburgh,
1SC7.
.Marshall: Anatomy for Artists, London, 1SS3.
Humphry: The Human Skeleton, including the Joints, London,
1S58.
Henke und Reyher: Ueber die Entwickelung der Gelenke,
Sitzungsber. der Wiener Acad, der Wissensch., Bd. lxx.
Aeby: Der Bau des menschlichen Korpers, Leipzig, 1S71.
Martin: Ueber die Gelenkmuskeln beim Menschen, Erlangeri,
1874.
Meyer: Die Statik und Mechanik des menschl. Knochengeriistes,
Leipzig, 1873.
Fick, Rudolf: Handbuch der Anatomie und Mechanik der
Gelenke, Jena, 1904-1911.
Arthropathy. — Hypertrophic Osteoarthropathy.
Unider this head it has until lately been the custom
to nclude a variety of disorders with osseous hyper-
trophy, more particularly of the ends of the long
bones. General hyperostosis, osteititis deformans,
acromegaly, and chronic pulmonary osteoarthro-
pathy have been fully described by Freidrich,
Paget, Marie, Emerson, and others and their forms
of bony change and enlargement have been ascribed
to syphilis, tuberculosis, disease of the hypophysis,
and toxic influences.
Hypertrophic Pulmonary Osteoarthropathy describes
the condition more familiarly known as "clubbed
fingers" which is found in patients suffering from
pulmonary tuberculosis, or chronic disease of the
lungs and of some other organs, such as bronchitis,
bronchiectasis, empyema, pleurisy, malignant and
gangrenous disease, as well as cirrhosis and congenital
cardiac affections, and as the result of toxic absorption
of various kinds. It is generally considered to be
directly due to bacterial changes.
The striking appearance of the fingers or toes of
such patients is quite characteristic, being due to
enlargement, which is found on both sides of the
body. This is associated with changes in the nails
which are incurved or flattened, with resulting de-
formity. The root of the nails is elevated and when
pressure is made there is the feeling as if fluid was be-
neath. The nails are often brittle and sometimes cre-
nated. The curving may be longitudinal, or again
only the ends are bent downward. The onset of the
disorder is attended by pain, which may be acute, and
704
by awkwardness of movement and stiffness, and an in
ability to flex and close the hand. This is not due t
muscular paresis but is rather the result of mechanics
difficulty, due to the thickening of tissue and en
largement. In aggravated cases there is a "paw
like" appearance of the hand, which resembles tha
of an animal.
Sternberg and others have sought to classify th
symptoms, but as Emerson 1 has pointed out," it j
probable that the three divisions of this observe
are but different periods of the disease. A shor
acute stage ordinarily precedes the chronic, and it i
Fig. 493.
-The Hand in Hypertrophic Pulmonary Osteoarthro-
pathy.
quite possible that the remarkable bony enlargements
that are subsequently found are but an advance in
the conditions. Marie's cases, however, are so striking
and the hypertrophy so general as to suggest acrome- ,
galy. All the large joints except the hip may he '
involved, and the inclusion of the vertebrae in the
process may give rise to a kyphosis. The deformity
of the hands in well marked and advanced examples
is remarkable.
The metacarpal joints seem to be the favorite site
of the enlargement rather than the phalanges, but the
whole finger may have a "drumstick" appearance.
The skin is likely to be wrinkled and blue, tense and
glossy.
There seem to be variations in the amount and
degree of the swelling proportionate to the activity
and gravity of the purulent disease; in empyema the
clubbing may appear in a few weeks and disappear
when the pus is removed by paracentesis, and sub-
sidence or cure of other conditions leads to diminution
of the hypertrophy.
The advanced disease when at all formidable,
resembles acromegaly, but there are decided differ-
ences. The mental condition of the latter as well
as the polyuria and glycosuria, optical changes,
peculiar enlargement of the lower jaw with prog-
nathism, squareness of the face, prominence of the
malar bones, elongated appearance of the upper
lip, and swelling of the tongue are all features of
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Arthropathy
■romegaly but not of the arthropathia condition,
he nails are .small in acromegaly and neither cur\ ed
,r deformed.
Hypertrophic pulmonary osteoarthropathy is some
mes mistaken for arthritis deformans because of
the presence of enlarged nodes in
the fingers corresponding to the
insert ion of t he extensor tendons,
but the diagnosis should not be
difficult.
An examination with Roentgen
rays shows the new bone forma-
tion and considerable swelling.
The ends of the long bom
especially the ulna and tibia, are
found to be increased in size.
The disease is rarely found
among negroes, and as a rule is a
condition affecting adult males.
The prognosis depends upon
the course of the underlying dis-
ease, for if the latter is cured, the
enlargement often subsides. The
pain and swelling of the fingers
in the acute stage may be best
relieved by moist heat, or by the
e of a mixture of Fuller's earth and glycerin, which
sold as a proprietary article known as antiphlogis-
tic, or as cataplasma kaolini (U. S. P.).
Arthropathies of Neurotic Orioin. — As far
ick as 1S31 the elder Mitchell 2 first described
i uliar joint troubles that affected individuals who
id suffered from cerebral disease; and in 1846 Scott
lison' of London more fully described these
quote, presenting several cases in which the joints
194 Arthro-
uliy of Right Knee
I Buzzard.)
the par
iritis lie
(iritis tie believed to be due to a condition of the
ticular surface which results from the diminished
itality of the paralyzed parts and the presence of
ric acid, which under such circumstances acted as
u irritative agent.
hater, Brown-Sequard 4 and Charcot 5 directed
I tention to the really important nature of such com-
lications of organic paralysis, and the early researches
I Alison, Durand-Fardel, Valleix, Grisolle, and
have been collected and carefully considered
y them. Buzzard later investigated these arthro-
athies, especially in connection with locomotor
:i\ill.
It would appear that such morbid changes are
sually associated with those forms of cerebral and
final disease in which the sensory tracts are most
ively invaded, though this is by no means the
[variable rule. They are common in posterior
■ I sclerosis and rare in essential spinal paralysis,
ii affection in which disorders of sensibility are the
xception. They are rare in cerebral disease without
ome ascending degeneration symptomatized by pain,
ad the observations of Charcot regarding the
■ntral lesion would bear this out. Arthropathies
nay be either cerebral or spinal, and the former are
nuch more rare than the latter. They have been
1 'served in connection with coarse brain disease, such
3 softening with hemorrhage, tumor, or sclerosis;
.iid are usually early symptoms of established cerebral
ii i ttief; especially is this true in the matter of
lemorrhage. After a period of from fifteen days to
■ oral months after the acute central trouble we find
hat the joints of the paralyzed hand or foot become
ected — the former more often (Charcot) — coin-
idently with the contractions which mark the
vdyent of rigidity and secondary degeneration. In
uison's cases the knee and ankle were affected.
Symptoms and Course. — The joint disturbances
"'gin in one of two ways: (1) Suddenly, the large
"hits being affected; (2) slowly, the joints of the
land and foot being the parts attacked. In the first
Vol. I.— 45
form there develops rather suddenly, within a few
weeks, a swelling which is unattended by any marke I
rise of tempera! ure al lea t by anj uch n
would expect to find in an acute arthritis of purely rheu-
matic origin. There are but little local heat and pain,
but a great deal oi soreness when the limb is moved.
Jarring produces only incon iderable sniveling. 1
have never met with the degree of pam described by
Urown-Sequard. There is more Or fe pain produci I
by pressure over the tendons, the sheaths of which
seem to be involved. The joint is greatly swollen,
the enlargement being made much more prominent
in old cases by reason of the atrophy of muscular
ma es in the vicinity. There seems to be a deep
involvement of the joints and of adjacent parts, and
though t here may be a synovitis, il is of a low grade,
and, as Buzzard" has pointed out, there is really great.
tumefaction, which characterizes the familiar form of
chronic synovitis, in which there are three points of
swelling, viz., above the patella, and on either side of
the ligament um patella.
The appearance of the affected joint is peculiar.
The swollen limb. shows a duskiness and hardness in the
beginning, and a cold, "white hardness" in the old
cases. In some cases there is, after a few days or
weeks, a .subsidence of the swelling, and I hen certain
osseous changes, to be presently described, take
place.
The occurrence of spinal arthropathy may follow a
variety of conditions. As has been pointed out by
Mitchell, it may be connected with Pott's disease,
with myelitis (Gull), with tumors of the gray sub-
stance of the cord (Buzzard), with posterior spinal
sclerosis (Charcot), and with traumatic injury of the
cord (Vignes and Joffroy).
Fig. 4U5. — Progressive Atrophy Resembling Acromegaly.
According to Charcot the condition is often an
earlj' complication of tabes dorsalis, but others think
that it belongs to the late stages of the disease.
It is quite true that in acute myelitis we may have a
rapidly developing arthropathy, but in cases in which
it is associated with a tumor of the cord or with
locomotor ataxia the affection is a much more slow
affair. Charcot believes that those arthropathies
which affect the upper extremities in the disease
under consideration are always secondary to others
involving the lower extremities, and come only late
in the disease as a result of extension of the morbid
process. Buzzard reports a case which contradicts
this, and the author has seen others.
The enlargement in the chronic variety is slow,
and a point is finally reached when deep destructive
processes begin, the articular surface of the bones
705
Arthropathy
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
being worn away or absorbed, so that movement of
the joint on manipulation will produce a peculiar
creaking or cracking sound; and when the joint has
for some time been the seat of the trouble it is com-
mon for luxation to occur. The position of the ex-
tremity upon the bed is peculiar, and the patient
often presents a most strange deformity. Happily
the arthropathy need not always go on to this stage
and it occasionally happens that cures are made.
On the other hand, the erosion and destruction may
be very rapid: Charcot says: "Even within two
weeks, or sooner, the 'craquements' may be detected,
which indicate a profound alteration in the articular
surfaces." At the end of three months the head of
the humerus, in one of his cases, was found to be
almost completely destroyed.
Progressive Arthropathy. — There is a form of
arthropathy of a progressive nature of which I have
seen but one true case, and I do not know that any
other has been reported. In the patient who came
under my notice, a sudden swelling of both ankles
occurred, with little or no pain, and in less than one
year both thumbs and ring fingers became in turn
affected, and ultimately both little fingers. The
metacarpal joints were the seat of a hard and quite
extensive swelling, with some general edema, more
marked on the palmar surface. The patient could
a'
Fig. 496. — A, A', Right and left anterior horns; B, posterior
gray commissure and central canal; C, anterior fissure; 6, b' , an-
terior internal group of great cells; a, a', anterior external group
of great cells; can be inserted the various imple-
ments required. Almost any tool or agricultural
implement can be used efficiently; in some cases they
are inserted into the hand, and in others they take
the place of the hand. The attachments are generally
by means of a screw or the "bayonet lock."
An artificial limb should be applied as soon as
possible; that is, as soon as the wound is healed, and
there is a good healthy stump. When amputation
has been performed for disease a longer delay will be
710
necessary than when traumatism has been the caus
of the mutilation. As soon as healing is complet
and there is no longer any tenderness, the stum
should be prepared by daily bathing and massage
followed by bandaging. This will give a firm stum
without superfluous adipose tissue. Joints shoul
receive passive motion, not only to prevent ankylos^
but also lest the muscles by contracting should limi
motion. In case of delay the stump is apt to becom
flabby and enlarged, and while in that condition i
totally unfit for the application of an artificial linil
Ordinarily a limb can be applied in from one to thre
months.
With regard to the stump most suitable for th
application of artificial limbs it may be said thai
while the general rule in amputation has been to sav
all that is possible, this should be interpreted somi
what laxly with regard to the lower extremity. I
the upper extremity any, even the smallest remaining
part of a hand is far more useful than any arti:>
appliance; but in the lower extremity the loss of ft
extra inch or two is of no moment compared with
serviceable stump. An artificial arm applied to th
shoulder, and artificial fingers, have merely a cos
metic effect, and cannot be of much service. A
artificial arm of considerable utility can be appliei
to a stump when the amputation has been made any
where between the upper third of the humerus am
the wrist. In the lower extremity, amputations a
the hip do not allow of the application of a limb tha
can be of much use. In thigh amputations, a service
able stump can be obtained anywhere between a poin
within five inches of the hip and one situated witliii
about three inches from the knee. Amputation
within three inches of the knee, either above or bekn
the joint, should (from the prosthetist's point of view
be avoided.
Whenever possible the patient should be measure,
for and fitted with the artificial limb by the mami
facturer. It is true that many makers are willing ti
have the physician or even the patient or some lai
friend take the measurement, and they will si
full directions for the purpose; but every effort shoul
be made to have the manufacturer himself assiinu
this responsible task. An artificial limb is not !
luxury, to be indulged in for a short time, but h
meant to be a daily companion for many years, ant
if it is not comfortable and does not fit properly, i
will never be of much use. To the writer it seem
rational to order an artificial limb from one's owr
measurements, as it would be to order a set of artificia
teeth in the same manner; doubtless it could be donr
but fortunately there are other and better ways.
In choosing an artificial limb, bear in mind the re-
quirements of the patient; the weight and construc-
tion of the limb are more important than the price.
As a rule, the simpler the apparatus the greater it-
utility. A complex piece of mechanism which can-
not be got at without taking to pieces the whole limb,
and which is liable to be constantly in need of atten-
tion, adds considerably to the cost, and in the case ol
a laborer keeps him from his work. Generally, it v\ ill
be found best to obtain the catalogues of various
makers in the vicinity, and, on selecting one, to be
guided largely by his opinion. A reputable maker
cannot afford to supply a poor limb, and as a rule
he knows a great deal more about the matter than the
average physician.
There is no reasonable limit to the possibilities of an
artificial leg. Not only do patients stand, walk, and
run on it, as well as attend to their daily avocations,
but many also dance, skate, and ride a bicycle
with apparently as much ease as before they -
crippled. Without indorsing the glowing descriptions
put forth by some makers, which would make one
think that their productions are improvements even
on the natural limbs, one cannot but recognize the
truth of the following: 2 "It is of no small advantage
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Artificial Ti-oth
idiIi in surgeon ami to patients to realize
: ii the loss of a limb is not necessarily a disfiguring or
in;,' affair, but that very frequently an artili-
il limb well lifted will he of vastly more sen ice and
mble and annoyance than a member already
by disease, or left in a condition where life
en is thereby threatened. In other words, the art
instrument maker has done very much to
the surgeon, and to make patients willing to un-
. i ions operations who otherwise would be very
i lose SO useful a part of their bodies as one
limbs. It has done much also to alone for
irrible injuries and mutilations inflicted by
v and other accidents."
K ight of an artificial limb is a matter of some
race. Legs vary from two or three pounds to
or eight pounds. It is a mistake to buy one
too light. One must bear in mind the weight,
rupation, age, sex, and stature of the patient.
liings being equal, a heavy leg lasts longer than
one. Some patients prefer a fairly heavy
ithers a lighter one. As a rule, it is well to
leg sufficiently heavy to bear more than any
ai n that is likely to be put upon it. Beyond this
would have the leg as light as possible. It must
■ noted that it is the weight of the foot which makes
apparently heavy limb.
The cost of an artificial limb varies according to the
iker and the length of the limb. The present
arket price of a first-class leg, thigh amputation, is
.1111 $100 to $150; below the knee, about $50 to $100;
ot, $30 to $50; arm and hand, above the elbow,
5 to S100; below the elbow, $50 to $75.
The durability of artificial limbs is quite variable.
ime will last fifteen years or even longer, others, by
• same maker, only three or four years; the differ-
ice depending mainly on the amount of care and
i cation bestowed upon the limb; much, too, de-
■nds on the habits and occupation of the wearer.
oni five to seven years may be taken as the average
ife" of an artificial leg; an arm lasts ordinarily
ioat twice as long. Alterations in the stump
ten necessitate, if not a new limb, some modification
the socket. Many limbs are cast aside, not because
ey are worn out but because the wearer wishes for a
wv one. The United States Government, with
irked generosity, supplies its pensioners with new
nbs every three years. R. J. E. Scott.
I Scirntific American, Supplement, No. 1374.
-'. Trunx: Johnson's Encyclopedia, vol. v., p. 270, 1S94..
Artificial Respiration. — See Resuscitation.
Artificial Teeth. — Even before the foundation of
orae, B. C. 753, the dental art flourished among
le Etruscans or Toschi, a highly civilized people
>ing in that part of middle Italy known now as
.-. Although the Etruscans learned dentistry
urn the Egyptians and Phoenicians, they far out-
ripped these nations in skill and ingenuity. In
lite of cremation and other destructive agents
tive during the ages, a number of prosthetic pieces
Etruscan workmanship have been preserved to us.
In one appliance the Etruscan dentist of 3,000
"ars ago replaced missing incisors with an ox tooth.
uman teeth were not used as the dead w-ere con-
dered sacred and such an act would doubtless have
■en thought to be sacrilegious. The dentist had
rooved the ox tooth in order to give the appearance
f two teeth. The tooth was firmly anchored to
16 encircling gold band by means of two rivets.
he second bicuspid was also artificial and was
led by a rivet.
Another Etruscan dental piece now in the Civic
luseum of C'orneto is formed of two bands of rolled
ild soldered together at the ends. Four partitions
lock out five square spaces. In two of these the
atural teeth fill and support the appliance. The
other two arc riveted teeth, li is believed that the
original teeth, lost by alveolitis, were replaced by
this arrangement.
Another type of Etruscan dental appliance con-
sisted of a small horizontal bar of gold .soldered to
two rings thai embraced the left upper canine and
the left middle inn or respectively. The intervening
tooth which was missing was not replaced, but by
this Contrivance the remaining teeth were held in
normal position and any tendency to convergenci
was prevented. This appliance is now called a
splinl and is in general use. In the Etruscan pros-
thetic pieces made for holding teeth the appliance
was not supported by the gum, but constituted
veritable bridge work.
Long before the existence of the medical profession
dentistry was practised in Rome. In 1007, in Italy
in a Greek-Roman necropolis was found a very
ingenious dental appliance. This piece consi ted
of three ring> of laminated gold wire wound around
the teeth and soldered. It dales back lo a period
between the third and fourth centuries B. C. The
dentist who fashioned the appliance was quite pos-
sibly a Greek.
One of the first Roman writers to speak definitely
about artificial teeth was Martial. These teeth were
fashioned of ivory and bone and without much doubt
were made both in partial and in full sets, and it
may be inferred were remarkably well constructed.
It is interesting to note that artificial teeth antedate
artificial eyes.
A most ingenious appliance representing crown
work has been recently excavated at Satricum.
As the Etruscans made a crude bridge work so the
ancient Roman dentists made crown work.
Par6 in the sixteenth century speaks of artificial
teeth.
The first mention of models in dental prosthesis
was made by Matthias Gottfried Purmann, 1648-
17121. It may be inferred that this model was not
taken from a cast. It is probable that the wax
model was both worked by the hand and carved
until the fit was satisfactory. It was then ready for
the craftsman, who reproduced it in bone or ivory.
Anton Nuck, 1650-1602, a brilliant Dutch surgeon
and anatomist, was greatly interested in dental sur-
gery and prosthesis. Calling attention to the fact
that ivory teeth soon turn yellow under the influence
of food, drink, and saliva, he advocated the use of
the hippopotamus tusk for artificial teeth, saying
that this material preserves its color for seventy
years.
In the same century Dionis, in speaking of the
composition of artificial teeth, tells us that they were
made of ivory or ox bone. He also describes a com-
position devised by one Guillemeau that was made
by the fusion of white wax and a little gum elemi to
which was added ground mastic, powdered white
coral, and pearls. In this description we see the
beginning of mineral teeth.
In the eighteenth century Johann Adolph Goritz
of Regensburg advocated the preservation of the
natural teeth by every known means. He also
expressed disapproval of artificial teeth. If neces-
sity should arise he suggested filling in the gaps by
an "imitation" made of soft wood.
The invention of mineral teeth was introduced at
the end of the eighteenth century. The credit of
this work must be ascribed to two men, one a French
chemist, Duehateau, the other the dentist, Dubois de
Cliemant. . The former being annoyed by the dis-
agreeable odor of the hippopotamus ivory denture in
his own mouth was the first to conceive the idea of
using porcelain for dental prosthesis. Dubois de
Chemant put the idea to practical use. It was the
latter who after years of experimentation finallv
attained satisfactory results, and thus, although
there was long controversy as to whom the real merit
711
Artificial Teeth
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
of the invention belonged, Dubois de Chemant may
with truth be considered the inventor of mineral
teeth.
Among those who first manufactured mineral teeth,
at the same time adding improvements, were Dubois,
Foucou, and Fonzi, the latter Italian by birth but
Parisian by adoption. Fonzi invented the terro-
metallic teeth which were single teeth applied to a
base by small platinum hooks. He also attained to a
certain extent the translucent effect of natural teeth.
America, however, stands at the head in the manu-
facture of mineral teeth. Among the leaders in
this work were Charles W. Peale, Samuel W. Stockton,
James Alcock, and Dr. Elias Wildman. The most
distinguished of all in the improvement of mineral
teeth, however, was Samuel S. White.
While in ancient times the dentist, were he barber
or blacksmith, was chiefly concerned with the pull-
ing of teeth, the trained dentist of modern days
rarely extracts. Rather does he bend all his energies
to the preservation of teeth.
The three great functions of teeth, beauty, speech,
and mastication, demand that these organs receive
the best of care. The art of caring for the teeth
has now become a science. If a tooth is lost it should
be replaced.
The chief modern appliances in relation to arti-
ficial teeth are (1) dentures (artificial teeth), (2)
crowns, (3) bridges.
A denture consists of plate and teeth. The plate
is made of a thin sheet of metal or rubber so mod-
eled as to fit perfectly the hard palate. Among the
metals used for dental bases are gold, platinum, and
aluminum. Whatever is used should be of the best
material. The most common and also the most
serviceable material is hard rubber. This is colored
to the tint of the gums. The plate is made from a
model taken from an impression of the mouth.
Various materials are used for taking impressions,
the most important being wax, guttapercha, modeling
compound, and plaster-of-Paris, the latter two being
the most desirable. Many delicate manipulations
and processes are concerned in the perfect adjust-
ment of plates. The firm position of the plate is
greatly aided by adhesion and air-pressure — com-
monly called "suction." The hard palate and
plate are two perfectly occluding surfaces. By
their contact the air between them is driven out,
giving full play to the action of adhesion and
atmospheric pressure.
The teeth are anchored to the plate to correspond
as far as possible to the natural denture. The teeth
are made of porcelain which is a composition of silex,
feldspar, and kaolin. This material is tinted to a
cream white.
Certain objections have been raised against the
employment of artificial dental appliances. Some
individuals are ashamed to wear artificial teeth.
Again, it has been urged that such appliances taint
the breath and destroy the sense of taste. The
superstition that artificial teeth are taken from the
dead has been entertained. Some feared that a
dental prosthesis could not be firmly retained in
place. In a word, these objections are groundless.
The attachment of artificial crowns (pivot teeth)
is probably one of the first dental operations at-
tempted. The terms "pivot teeth" and "pivoting"
are misnomers and are gradually being replaced by the
correct terms " artificial crowns " and crown setting."
The crown is attached to a badly decayed tooth or
to the root by a piece of metal which is a* veritable
dowel or dowel-pin. Tne latter term is defined as
" a piece of wood or metal used for joining two pieces
by inserting part of its length into one piece, the rest
of it entering a corresponding hole in the other."
This is a perfect description of the dental piece con-
necting crown and root. Various methods of mount-
ing and a number of crowns have been devised.
712
As a rule thin gold in the form of a cap is used fa
crowning back teeth, although all-porcelain crowi:
may be employed. For front teeth porcelain crowi
or crowns with a porcelain face are commonly en
ployed. If there is left a firmly embedded root th
tooth can be artificially and satisfactorily i-i
If there are two or more sound teeth or roots lei
in the mouth plates may be dispensed with, tin
place being taken by bridge work. A bridge i
crowns is fitted into the space left by the missil
teeth, the median crowns being soldered to each otbi
while the terminal pieces are securely fixed to th
sound roots or teeth. The special construction of th
bridge should be appropriate for the individual casi
Skill and ingenuity on the part of the dentist ai
necessary to adapt the appliances to the particula
needs under consideration, for there are many methoi
of bridge construction. By the employment of crow
and bridge work teeth that otherwise would dcmai
extraction are preserved.
The appliance of crown and bridge work has reaclie
a high degree of perfection, and when correctly mad
and fitted offers the closest approach to the natur:
teeth that modern science affords.
Emma E. Walker.
Arylarsonates. — An arylarsonate is an aromatic ai
sonate or salt of arylarsonic acid, that is to say, oil
of the organic arsenic compounds containing a radici
of the aryl group. Arsonic acid is a derivative i
arsenic acid in which one of the hydroxyls (HO) ha
been replaced by an organic radical, either an alphj
radical (i.e. one of the fatty or aliphat series) or a
aryl radical (i.e. one of the aromatic series), the lal
ter being arylarsonic acid. The arylarsonates ar
employed therapeutically chiefly in the treatment c
diseases due to trypanosomes or treponemas, suck B
the African sleeping sickness, syphilis, and
The best known and most commonly employed of it
arylarsonates are atoxyl (soamin) and salvarsa
{q.v.). T. L. S.
Asafcetida. — The gum resin obtained by ineisin
the roots of various species of Ferula, particularly I
Asafcetida Linn6 and F . foetida (Bunge), Regel (Fan,
UmbeUiferae). (U. S . P.) The adulteration of asafel
ida has been so general, and its forms so varied tlia
none knows which of its elements are normal am
proper. The Pharmacopoeia says "various
of Ferula," but not one of its editors knows whetln
a perfect asafetida ought to contain the prodmt o
more than one of these species.
Over the desert steppes of Western Asia grow ii
great abundance a variety of gigantic perennial
of Umbelliferce, which perpetuate themselves durin:
the long dry seasons by very large fleshy roots pro
tected against decay and foraging animals by aim
septic and obnoxious resins and volatile oils. S(
abundant are these plants that immediately aft i
the occurrence of the first rains, it is their germinatini
leaves which, according to the traveller Aitchisoti
chiefly impart the tinge of green to the land-rap'
Later, these huge leaves interlace so thickly as t<
become obstructive to travel, and huge flower stalk
shoot up to the height of many feet. These, liki
their branches, terminate in great umbels of sum!
greenish or yellowish-white flowers. Among thesi
plants are numerous species of the genus Ferula L
It is fairly well established that asafetidais collectei
from the two species named above, assuming thi
be distinct. It is probable also that the produrl >i
F. narthex Boiss., and perhaps also of F. attiac
Boiss. and F. pcrsica Willd. is added, but whether foi
the betterment of the resulting product, or purely Si
a fraudulent and injurious adulterant, is not known,
Asafetida is also largely adulterated with ammoniac.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
As;i|irnl
ie young leaves and shoots of these plants are used
rbs in their native home.
fhe history of asafetida in Europe before the
century is not clear, although it has been held
have been an article of commerce from near the
iiiniiinti of tlir Christian era; but, from the twelfth
ntiirv down, there is no doubt of its presence in
n drug lists. On the other hand, of it
Asia there is evidence in Arabian and Sanscrit
ritinss of groat antiquity.
The principal supply of this drug is collected in
fgbanistan, and exported tn India (Bombay),
it conies to Europe or America. It is usually
in large cases, but sometimes in bags or
mats."
Our knowledge of the collection of asafetida rests
incipally upon the evidence of two travellers, who
id the fortune to see it at an interval of nearly two
1 years from each other. The first of these
celebrated Kaempfer, who observed it in the
■rsian province of Laristan. His description has
in repeatedly quoted, and is, in the main, as fol-
\ I m nit the middle of April, when the leaves
nine growing, the fields are visited by the
ts, who dig away the ground around the
klcr roots, tear off the leaves from the crown, and
ii n carefully cover it up with earth and leaves,
i protect it from the rays of the sun. After leaving
■ plants in this way for several weeks, they again
them, remove a portion of the top and
them again, being careful that nothing touches
v newly cut surface. In one or two days more
ided juice is scraped off with a knife, a fresh
irface is made by cutting off a thin slice, and the
overing is repeated. This is continued until the
10I ifi exhausted, the product growing better as the
eason advances. The soft juice is mixed with earth
o give it body."
the other authority is Staff Surgeon Bellew, who
afetida collected during a visit to Afghanistan
i ls.">7. The process was something like that ob-
erved by Kaempfer, but it was done at a season when
lie young leaves were sprouting, and instead of
itting off the top of the root they cut or gashed it in
era! places; the digging away of the earth and the
overing of the roots to keep off the heat of the sun
were the same in both cases. Mr. Bellew states that
he juice is mixed with gypsum or flour, although
some very fine juice, obtained from the bud, is usu-
illy sold pure. This latter, like the fine juice of
Kaempfer's later cuttings, rarely reaches the Euro-
markets.
Good asafetida. when the cases are first opened,
is a moderately soft, yellowish-gray, rather tenacious
mass, of a not very homogeneous texture. Sometimes
whitish or yellowish tears are common in the
mass; oftener coarse impurities are the cause of its
unevenness. Upon exposure, this light-colored asa-
fetida turns first pink, or reddish plum or violet pink,
and then gradually becomes brown. Its odor is
characteristic; strongly alliaceous, penetrating, and
ent. It is exhaled, like that of onions, in the
breath of persons taking it. The taste is bitter,
acrid, and nauseous. When in lumps, even if long
kept, asafetida is usually not quite brittle, but if
finely broken and dried it can be ground to powder,
in the cold. This, however, involves the loss of its
volatili oil, the most valuable constituent.
The quality is considered fine according to the
abundance of clear, whitish tears which it contains,
and the absence of impurities and insoluble residue.
Occasionally specimens are met with, consisting
wholly of tears, but these are rare. These tears are
of two varieties, one of which does not turn red on
exposure. The U. S. P. requires that not less than
forty per cent, of asafetida should be soluble in
alcohol, and that it should not yield more than thirty
per cent, of ash. This was done by the Committee
of Revision for the definite and expre <-d purpo e of
authorizing adulteration with about five
per cent, of mineral matter. Many lot ha
offered which were nol nearly so good, from eighty
ety per cent consisting ol
When it is considered thai the chief cosl of the
article is the result of its long transportation, much
of it over very expert ive tagi , it will be n
nized as exceedingly wasteful to import a consider-
able percentage of sand and crushed stone. Polisek
in 1897 determined the composition of a -ample of
asafetida that he believed pure to be as follows:
"Ether-soluble resin (ferulic acid ester of asaresinol
tannol, r.,11 ; m, mil), 61.4; ether-insoluble resin
(free asaresinol tannol), 0.60; gum, 25.1; volatile oil,
(i.7; vanillin, 0.06; free ferulic acid, 1.28; moisture,
_'.:'>f.; foreign matter, L'.o." This composition is by
no means constant, as the relative proportions of
resin and gum, and to a less extent of the oil and
vanillin, are quite variable. The impurities and ash
should not exceed ten or fifteen per cent. The gum
is mostly insoluble in water. The resin yields resorcin
when fused with potassa, and umbelliferon and oils
when subjected to destructive distillation. The
oil is light yellow and possesses very strongly the odor
of the drug. It is related to the volatile oil of mus-
tard, but is not, like it, a strong local irritant. It is
of a very complex composition, which has not yet
been perfectly worked out. It contains about
twenty-five per cent, of sulphur.
Ammoniac and galbanum are common adulterants,
and it has been claimed that the ammoniac is added
in Hamburg. The best test of purity is the deter-
mination of the lead number of the re- in.
Asafetida is a typical antispasmodic, as well as one
of our best carminatives. It stimulates the appetite
and the gastric secretions and movement-, as well as
the internal functions. As an antispasmodic it is par-
ticularly useful in hysteria, and is sometimes useful
in spasmodic affections of the respiratory organs,
as pertussis and asthma. It frequently permits
sleep by allaying excitement, and especially by
removing intestinal irritation. It is very largely
used in veterinary practice. The dose is gr. v. to xx.
(0.3 to 1.5). Three preparations are official: The
Pilulae Asafcetidae contain each 0.2 gram (gr. iij.)
asafetida and three times as much soap; the Pilulae
Aloes et Asafcetidae, formerly official, contain 0.09
gram (gr. 1$) each of aloes, asafetida, and soap;
the Emulsum Asafcetidae (formerly "Mistura") has
a strength of 4 per cent, and the dose is fl. 5 ss. to i.
(15 to 30). This preparation is remarkably effective
when used as an enema, in which case the dose may
be doubled. The tincture has a strength of twenty per
cent, and the dose is fl. 5 ss. to i. (20 to 40). Asafet-
ida is frequently used externally in plasters, being a
mild rubefacient.
It may be added that asafetida renders bait attrac-
tive to certain fishes, notably bullheads.
H. H. Rusby.
Asaprol. — Abrastol-betanaphthol-alphamonosul-
phonate of calcium — C 10 H„.OHtSO ) ( 'a +3H 2 0. An
aqueous solution of betanaphthol-alphamonosul-
phonie acid is saturated with calcium carbonate, and
the salt crystallized out. It is a white or pale reddish
crystalline powder without odor and soluble in one
part and a half of water and three parts of alcohol.
It is of neutral reaction, is not changed by heat, and
is incompatible with the sulphates, and with quinine
and antipyrine. It is antiseptic, antineuralgic, and
antirheumatic, and is eliminated by the kidneys in
the form of a naphthol sulphuric ether. It may be
detected in the urine by the formation of a blue ring
on the addition of ferric chloride. As an antirheu-
matic it is claimed by Dujardin-Beaumetz, Buck,
Stackler, and others that asaprol is equal in value to
•13
Asaprol
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
the salicylates, and at the same time does not cause
headache, buzzing in the ears, and depression of the
heart. It has been tried with moderate effect in
influenza, malaria, and chorea, and with relief of the
pain in neuralgia.
Locally, as antiseptic, astringent, and styptic it
may be applied in one to four-per-cent. solution or
ointment, and in whooping-cough a one-per-cent.
solution may be sprayed into the throat. Internally
it may be employed as an antiseptic in intestinal
indigestion, enteritis, and typhoid fever. The dose
internally is gr. xv. to lx. (1.0-4.0) or more, three
times a day, given in gaultheria water or elixir of
orange, or in capsules. W. A. Bastedo.
Ascaridse. — A family of round worms. The body
is relatively thick, the mouth is surrounded by three
lip lobes, one of which is dorsal. All are intestinal
parasites. The principal genus is Ascaris, in man and
other mammals. See Nematoda. A. S. P.
Ascaris. — An important genus of parasitic round
worms, containing more than 200 species. The three
lip lobes are prominent; the males have two penial
setae; the vulva is in advance of the center of the body.
A. lumbricoides is the common round worm of children
and has a world-wide distribution; the embryos may
live within the egg-shell for as much as five years
after leaving the host. Sometimes this worm bores
through the wall of the intestine into the peritoneal
cavity. A. canis, usually found in cats and dogs,
and another species have also been found in man.
See Nematoda. Arthur S. Pearse.
Ascites. — (Synonyms, Hydrops ascites, Hydroperi-
toneum, Dropsy of the peritoneum.)
Definition. — Ascites is an accumulation of free
fluid in the peritoneal cavity.
It is either (1) a part of a general dropsy involving
the pleurae, pericardium, and subcutaneous tissues of
the body, or (2) a strictly localized dropsy caused by
disease in the peritoneal cavity. Class (2), if of long
standing, may secondarily cause edema of the legs, as
a result of the anemia which usually develops, or as a
result of pressure upon the iliac veins. Class (1)
depends upon diseases of the heart, kidneys, lungs, or
blood. Class (2) occurs with atrophic and hypertrophic
cirrhosis of the liver, cancer and syphilis of the liver,
amyloid liver, atrophy of the liver due to external
pressure or growth, abscess or echinococcus of the
liver causing pressure upon the portal vein. Tumors
of the stomach and pancreas, peritoneal adhesions
and enlarged lymphatic glands may cause ascites by
pressing upon the portal vein. Thrombosis of the
portal vein or of the inferior vena cava likewise may
cause ascites. Chronic peritonitis, either simple,
tuberculous, or cancerous, and perihepatitis chronica
(icing liver, sugar-coated liver) are causes of ascites.
Leukemia and splenic anemia are occasionally asso-
ciated with this condition ; and so also are intrathoracic
growths and mediastino-pericarditis. A small as-
cites may occur in apoplexy; it has also been noted in
intestinal obstruction. Occasionally on the post-
mortem table there have been found, in the different
cavities of the body, collections of fluid which had not
been demonstrated by physical signs during life.
Immediately preceding death there is an intense con-
gestion of the viscera which frequently results in an
outpour of serum. This condition, when involving
the peritoneal cavity, is termed preagonal ascites.
Pathology. — From an etiological standpoint all
varieties of ascites (chylous ascites is discussed under
the heading Lymphatic vessels, diseases of) may be
classed under three heads:
714
1. Ascites due to stagnation of blood in blood
vessels.
2. Ascites due to interference with the escape o
lymph.
3. Ascites due to disturbance of capillary secretioD
i.e. alteration in the walls of the capillaries.
In certain diseases we have combinations of th
above causes; for example, a chronic heart disi
with incompensation may secondarily produc
changes in the capillary walls, as a result of lack o
nourishment resulting from the imperfect renewa
of blood.
The third class is distinctly a conception of moden
pathologists and will require more detailed discussion
The former belief that the process which resulted
dropsy was merely a filtration of fluid through an ani
mal membrane has been discarded. It is now heli
that the capillary walls are to be regarded as living
organs with a capacity for secretion. The prompt
passage of the crystalloids from the blood and tlu
lymph is accomplished with the aid of a force inherent
in the capillary walls. The fact that the proportioi
of salts or of sugar in the lymph is often greater that
that in the blood suggests a capillary secretion. Tin
fact that the proportion of albumin in pure transu-
dates in different parts of the body varies considerably
points to a differing constitution of the vessel wall in
these several regions. According to Reuss' table,
transudates in different parts of the body give the
following percentages of albumin:
Pleura 22.5 pro mille.
Pericardium 18.3 pro mille.
Peritoneum 11.1 pro mille.
Subcutaneous cellular tissue 5.8 pro mille.
Cerebral and spinal fluid 1.4 pro mille.
Heidenhain believes that the specific function of the
capillary w r alls plays a controlling part in the forma-
tion of lymph. Whenever the removal of lymph
fails to keep pace with its formation, dropsy results.
This investigator has demonstrated that the forma-
tion of this material can be influenced by various sub-
stances present in the blood. Subcutaneous injec-
tions of an infusion of crabs or leeches so increa
the transudation of water from the blood-vessels into
the lymph that the quantity of lymph flowing from
the ductus thoracicus was increased even to fifteen-
fold. This exciting substance must stimulate the
specific functions of those capillary cells in the capil-
lary walls which secrete the lymph. Class 3 inclui
the varieties of ascites usually termed inflammatory
and cachectic. In the majority of cases, the chant
in the vessel walls are the result of protracted ische-
mia, of imperfect ox}'genation, or of chemical changi s
in the blood, or are due to the effect of high or low ti
perature or to active traumatism. It is also probable
that either irritation or paralysis of the vasomotor
nerves may lead to an increased vascular secretion.
The exact changes in the vessel walls are not known,
but there are probably alterations of the endothelial
cells and of the cementing substance between them.
It is quite possible that Class 3 may include Class 1
and that our so-called pure transudates of obstruct "d
circulation are capillary secretions rather than nitra-
tions, the capillary cells being stimulated to secretion
by irritating substances circulating in the blot
In cases of hydremia with edema. Ziegler looks
upon the increase in the amount of water in the blood
as only one factor which is favorable to the occurrence
of edema. In cachectic and nephritic subjects edema
occurs often when no hydremic plethora is present,
and conversely edema may be absent when hydremic
plethora is present. So it is held that the edema of
cachectics and nephritics is due to alteration in
vessel walls caused either by the hydrated condition
of the blood or by a poison circulating in the blood.
Two factors are present as causes of ascites in in-
flammatory changes in the peritoneum, viz., altera-
•REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Ascites
ina in the walls of the bloods essels and thedesl ruc-
,., ,,i g large Qumber of lymphatic vessels through
the fluid, secreted in excessive amount, should
■ carried. The ascites almost invariably associated
ith perihepatitis chronica is to be explained by the
existence of a chronic peritonitis. In some cases of
[hepatitis in which there is no ascites, general
mitis is absent.
/ is cither a transudate or an exudate.
idates are found in non-inflammatory condi-
id are usually light yellow in color, while exu-
ites are found in inflammatory conditions and are
irker in eolor. There are essential differences in
imposition, a fact which may be of aid in diag-
Peritoneal transudates have a specific gravity
trying between 1.005 and 1.015, while that of
es frequently reaches 1.030. The difference
. the specific gravity is due to the difference in the
nount of albumin; exudates contain from four to
l per cent., while transudates contain from one to
vo and a half per cent. Transudates do not coagu-
lontaneously; in exudates a coagulum is fre-
lently observed after standing for twenty-four
ours.
Microscopically the transudate shows only a few
1 leucocytes and endothelial cells derived
om serous surfaces and undergoing fatty degenera-
on. Exudates contain many more formed elements
od may be serous, serofibrinous, seropurulent,
undent, putrid, hemorrhagic, chylous, or chyloid. In
■,io cases the ascitic fluid contains mucoids the pres-
ace of which is due apparently to degeneration of
eritoneal endothelium. Cholesterin crystals
tetimes seen in it. The protein content varies
reatly in different cases of ascites, being especially
i cardiac eases.
wing the administration of potassium iodide
ossible to obtain the iodine reaction in ascitic
uids.
r.noLOGT. — Atrophic cirrhosis of the liver is the
ommon cause of ascites. It is less commonly
Kind in the hypertrophic form. The frequency of
in diseases of the heart and kidneys is illus-
i :>• the statistics of 300 cases of general" dropsy . as
evealed after death, taken consecutively from the
lostmortem books of St. George's Hospital, London,
rom 1SS8 to 1897. One hundred and sixty-three of
were due to affections of the heart or aorta.
Vs regards ascites, 1 in 2.5 of the cardiac cases and
in 2.2 of the renal (not lardaceous) cases presented
his condition. Any of the organic heart lesions
vhen incompensated may be followed by ascites. It
s most frequently associated with mitral stenosis.
I he pleura 1 and peritoneum are especially liable to
liopsical invasion with the large white kidney of
lepnritis and the advanced granular kidney in which
econdary cardiac changes have been added to the
enal. Diseases of the lungs, such as emphysema and
ibroid changes, may cause ascites by obliterating
Pulmonary vessels. This results in an increase of
Pressure in the right heart, and secondarily in the
:ind capillaries, with transudation.
Diagnosis. — Inspection. — In ascites of moderate
legree with the patient lying down, the abdomen is
full at the sides and flat on top; in the upright posi-
tion it projects belo.w the navel. If the ascites is
enormous there is a uniform distention and little or
no change of shape with change of position. The super-
ficial abdominal veins become enlarged in cases of
Ion? standing. In cirrhosis of the liver the veins
-unwinding the umbilicus may become very promi-
nent and form the so-called caput medusae. When the
amount of fluid is excessive there is a marked hernial
protrusion of the navel.
Palpation. — Fluctuation is obtained by placing one
hand flat upon one side of the abdomen, and tapping
gently on the opposite side with the other, as in direct
percussion. A similar sensation may be felt, how-
ever, if the abdomen !"■ very fat or tympanitic. In
order to exclude this pseudo-fluctuation, an assistant
presses the edge of his hand along the linea alba; this
maneuvre does not interfere with the transmission
of the wave in ascites, but effectually interrupts it
in the other conditions mentioned.
Percussion. — In the horizontal position there is
duli less at the sides, and tympany over tic upper arid
middle portions of the abdomen. The fluid seeks
the dependent parts and tin' intestines float to the top
so far as the mesentery will permit. The area of
dulness changes with the position of the patient. On
assuming the side position, dulness is obtained over
the lower side and tympany over the upper. If the
ascites is enormous, the intestines and stomach do
not reach the surface, consequently there is dulness
over the entire abdomen. The amount of fluid neces-
sary for demonstration varies with the size and sex of
the patient.
Toma's sign has been employed to distinguish be-
tween an exudate and a transudate, or inflammatory
and non-inflammatory conditions. In inflammatory
conditions of the peritoneum the mesentery contracts,
drawing the intestines over to the right side. As a
result, the patient assuming a horizontal position,
tympany is elicited over the right side and dulness
over the left.
Exploratory puncture is the crucial test, and should
always be employed before operation.
Differential Diagnosis. — The ascites of heart
disease is associated with a dusky skin, while that of
Bright's disease is associated with a pale skin.
Diseases of the heart, lungs, kidneys, and blood
should be excluded by careful examination. A
satisfactory examination of the abdomen by palpa-
tion can be made only after the withdrawal of the
fluid. Palpation is then very easy on account of the
relaxed abdominal muscles. An enlarged liver or
spleen, or growths on the liver or in the neighborhood
of the portal vein can then be easily felt. At times
the nodules of tuberculous or carcinomatous peritoni-
tis can be made out. If primary cancer or tuber-
culosis is found in other parts, the problem is simpli-
fied. The great value of microscopical examination
of the fluid, as a material aid in differential diagnosis,
should be strongly emphasized. The fluid should
be centrifugated, the sediment spread on cover slips,
dried in the air, fixed in absolute alcohol and ether,
then stained with hematoxylin. Quincke, Rieder,
Dock, and Warthin have found in exudates cells
which seem peculiar to cancer and sarcoma of serous
membranes. Rieder found cells undergoing division,
their nuclei presenting numerous caryocinetic figures,
especially asymmetrical division forms, which are
found to a slight degree or not at all in endothelial
cells. Dock found in cancerous effusions more cells
showing mitoses than in simple or tuberculous
inflammations. Warthin concludes from his inves-
tigations that the presence of numerous cell-division
forms in the cells of the sediment of serous exudates
may be taken as strong, perhaps conclusive, evidence
that the effusion is due to the presence of a new growth,
inasmuch as mitoses are but rarely found in cells of
purely inflammatory exudates. Quincke claims that
carcinoma probably exists if a marked glycogen
reaction can be obtained in the endothelial cells.
Endothelial cells are sometimes mistaken for the
so-called cancer cells. Quincke states that the
diagnosis should be made only when large epithelial
cells of variable form, measuring 'at times 120 a in
diameter, are found in large numbers, especially
when arranged in groups, unless indeed cancerous
nodules presenting the characteristic alveolar struc-
ture are found. Hemorrhagic exudates are as a rule
tuberculous or cancerous. The fluid should be
centrifugated, spreads made and stained for tubercle
715
Ascites
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
bacilli, though those are rarely found even in un-
doubted cases of tuberculosis of the peritoneum. A
guinea-pig should be inoculated with the sediment,
since even when the bacilli are not found the pig
often develops tuberculosis. The diazo reaction is
occasionally present in the urine of tuberculous and
cancerous peritonitis, but does not help in differen-
tiating one from the other, as it has been found in
both. The quantity of fluid varies greatly with the
disease, but is usually largest in atrophic cirrhosis
of the liver and in perihepatitis chronica. AV. Hale
White reports the case of a patient with perihepatitis
who was tapped thirty-five times; the total amount
of fluid withdrawn was 790 pints; the largest quantity
taken out at one time was thirty-one and a half
pints. Piitz's case of atrophic cirrhosis of the liver
was tapped forty-seven times, with the removal of
1200 liters of fluid, during a sickness of four years'
duration.
Prognosis. — The majoritj' of the patients die
within two years. Some patients suffering from
uncompensated heart lesions recover under cardiac
treatment and live for many years. Occasionally a
patient with cirrhosis of the liver recovers, if a suffi-
cient collateral circulation is established. Numerous
recoveries have been reported in cases of tubercu-
lous peritonitis with ascites, treated by laparotomy.
Many theories have been advanced to explain the
cause of recovery in these cases. There are tuber-
culous diseases of the peritoneum which heal spon-
taneously. Hildebrandt believes that laparotomy
only increases the natural healing factors. This
author believes that the venous hyperemia which
ensues is the important factor in the healing of
tuberculous peritonitis. Following operation he has
observed an involution of the tuberculous process, and
in isolated cases a complete healing with disappear-
ance of the tubercles which he had seen in the first
laparotomy.
Treatment. — The ascites, if troublesome, should
be relieved immediately, and treatment directed to
the causative disease instituted if advisable. The first
is most successfully accomplished by the simple
surgical procedure of tapping. This operation is
strikingly free from the danger of infecting the
peritoneum. Flint refers to a patient who frequently
tapped himself with a jack-knife and used a clay pipe
stem for a cannula.
Aspiration, or the introduction of Southey's tubes,
may be resorted to.
If the diagnosis of tuberculous peritonitis seems
probable, then laparotomy should be performed.
The fluid may collect so rapidly that it is necessary
to tap every fortnight or oftener, but frequent tap-
pings do no harm. In ascites due to heart disease
and anemia, treatment appropriate to these diseases
should be given. The use of diuretics and hydra-
gogue cathartics is usually unsatisfactory. The value
of the dehydrating effect of dry diet should be
emphasized. Care should be taken, however, in
selecting appropriate cases, since a dry diet is well
borne in caidiac dropsy and poorly borne in renal
dropsy. James R. Arneill.
Edward Preble.
Bibliography.
Cohnheim: Allgem. Pathologie, 1SS2.
Cohnheim u. Lichtheim: Ueber Hydramie u. hydramisches
Ii in, Virchow's Archiv, Bd. 69, 1S77.
I luck: The Value of Cells in Effusions in the Diagnosis of Cancer
of the Serous Membranes. The American Journal of the Medical
Sciences, .Tune, 1897.
Halliburton: Allbutt and Rolleston's System of Medicine, iv., i,
521, 1908.
Heidenhain: Zur Lehre von dor Lymphbildung. Yerhandl. d.
X. [nternat. Med. Congr., ii. Berlin, 1S91, u. Arch. f. d. ges. Phys ,
Bd 19, 1891.
716
Herrick: Journal of Experimental Medicine, ix., 93, 1907.
Hildebrandt: Munchener med. Wochenschrift, 51 and .j_' ivi
Lazarus: The Pathol, of Edema. British Med. Jour., i., Igc
Lazarus Barlow: Manual of Pathology, 1904.
Quincke: Deutsches Archiv f. klin. Med., vol. xxx.
Reuss: Verhaltnissd. spec. Gew. z. Eiweissgehalt in seroscn Flu
sigkeiten. Deut. Arch. f. klin, Med., 28 Bd., u. Beurtheilung vn
Exudaten u. Transsudaten, ib., Bd. 24.
Rieder: Deutsch. Arch. f. klin. Med., vol. liv.
Simon: Clinical Diagnosis, Seventh Ed., 1911.
Starling: On Absorption from and Secretion into the Serot
Cavities. Journ. of Phys., xvi., 1S94; The Influence of Mechanic:
Factors on Lymph Production, ib., 1S94; Action of Lymphagogue
ib , xiv., 1896; Absorption of Fluids by Blood-vessels, ib., 189f
The Causation of Dropsy, Lancet, 1896.
Vierordt: Medical Diagnosis.
Warthin: The Diagnosis of Primary Sarcoma of the Pleura froi
the Cells found in the Pleuritic Exudate.
Ziegler: Text-book of Pathological Anatomy.
Ascites, Chylous and Adipose.
Vessels.
-See Lymphati
Asclepiadaceae. — Milkweed Family. This immens
family, of more than two hundred genera an,
fifteen hundred species, is an exceedingly difficult on
for botanists. There is probably no other famib
the relations of whose members are so poorly known
so that any present system of classification must l><
regarded as arbitrary. Nevertheless, the composi
tion and properties of its members are singularl;
uniform. Its plants, with few exceptions, abound
in a milky juice which possesses acrid and nauseating
properties, so that a great many of them have beci
used as nauseating expectorants, alteratives,
mild counterirritants. The glucoside asclepiw
occurs frequently in this juice, as do many othei
glucosides. The only plants which have been m
used in professional medicine are several specie
Asclepias (see Pleurisy Root) and Condurango. Man'.
are, however, used in native and domestic pra<
In India especially, a large number of species hav
been used, the principal of which are described bj
Dymock and Hooper in the "Pharmacograpld
Indica" as follows: Cryptostegia grnndiflora Br.,
which is poisonous and yields a rubber. Calotri
gigantea R. Br., and C. procera R. Br., which
irritant purgatives; Tylophorn asthmatica AY. and A.
which is a nauseating expectorant ; Dcemia ext
Br.; Dregea volubilis Benth.; Hemidcsmus Ind
Br., the root of which is a much-used and powi
diuretic; Cosmostigma racemosum Wight.; Gymm
sylvestre Br., and many others less well known.
II. H. Rusby.
Asclepiades. — Born about 124 B. C. in Prusa in
Bithynia. He studied medicine under Cleophantus,
a writer on pharmacology, but did not follow bis
teachings in practice, becoming a professional
therapeutic nihilist. He went to Rome as a teacher
of rhetoric, but soon abandoned that calling fur
medicine. His theory was that disease is caused I
over tension, strictum, or over relaxation, laxum, the
problem of the physician being to restore the equi-
librium. This he endeavored to do chiefly by did,
exercise, rubbing, and baths, his favorite maxim
being "nature convenienter vivere." He is said in
have been the first to advocate the operation of
tracheotomy to relieve asphyxia in severe angina,
Asclepiades was the type of the fashionable physii
he was an eloquent speaker, had an extensive acquaint-
ance with the Roman aristocracy, was filled with the
enthusiasm of a reformer or the man with a fixed
idea, had an engaging amenity and great tact,
favoring the whims of his patients yet usually
persuading them to follow his counsels. * He had an
enormous practice among the wealthy and acquired
a large fortune. Cicero said of him: " Asclepiadi
quo nos medico amicoque usi sumus, turn
eloquenlia vincebat omnes medicos, in eo ipso, quod
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Asepsis, Surgical
diet bat. medicince facilitate
■oittntia." ( De Oratore. ') The
a/' I'nlitr, non
collected frag-
in
M iiis nf his works were published ai Weimar ii
;mi. under the title: "Asclepiadis Bithyni frag'
lenta."
The name, \.sclepiades, strictly applied only to the
mi, of Asklepios, or JTisculapius (q.v.), came
10 be given to the priests who officiated at the
of the god of medicine. These men. who
to he the ministers of a beneficent god, the
pen 'is of life and health, ami the depositories
thi healing lore revealed by their ancestor, were
ir many centuries Hie only physicians that existed
Greece. Hippocrates was accounted to be one of
■ir number. A. H. B.
\sclepius. — See /Esculapius.
Vselli. — Born in Cremona, Italy, toward the end of
ixteenth century (about the year 1581). He
i< professor of anatomy and surgery in the Univer-
of l'avia, and surgeon-in-chief of the royal army
the cisalpine war. lie resided, the greater part of
i- life, in .Milan, and it was while living in that city
he discovered the lacteal vessels. On July 23,
J, as he himself relates, he was dissecting a dog, for
purpose of showing the distribution of the recur-
nerves. As it happened, the animal had been
, I just at the time when digestion was in active
peration. When the abdominal cavity was opened,
Iselli's attention was at once drawn to the presence.
he folds of the mesentery and in the walls of the
line, of numerous ramifying, delicate, whitish
His first impression was that these lines
sented nerve filaments; but, upon closer exami-
lation and after he had pierced some of them with
he point of a sharp scalpel, he became convinced
nit they were actually hollow vessels in which flowed
i creamy fluid. Many persons were present when
I lis discovery was made, and among the number
vere two physicians of considerable celebrity —
Uexander Tadino and Settala. Three days later
ic dissected another dog, under precisely the same
iitions, and again he found the same ramifying
■ hite vessels in the same abdominal organs. Aselli
lied in 1626, before he had been able to announce to
he scientific world the important discovery which
bad made. One year after Aselli's death, his
riends Tadino and Settala published a full account
if the facts. This book was printed in Milan in 1627.
A. H. B.
Asepsis, Surgical. — That wound infection and
suppuration are the result of the presence of vegetable
microorganisms is no longer a theory but a fact
proven by experimental research and clinical experi-
While no one will deny that wounds may,
under certain conditions, heal kindly without the
use of any precautions to prevent the entrance of
minute living organisms, such result obtains with
Creat rarity, and not in consequence of a lack of these
precautions but despite such negligence. The almost
complete disappearance of hospital gangrene, the
greatly diminished frequency of other forms of
ivound infection, the very low mortality rate, the
y with which the abdominal and cranial cavities
are invaded at the present time, render unassailable
evidence of the value of surgical asepsis. The term
asepsis now indicates an absence of germs in a wound.
Unfortunately, we are as yet unable to obtain a con-
dition of absolute asepsis. There is perhaps in every
wound some form of organism present, but by
proper application of the means now at hand, aided
by the resistance in the tissues, we are enabled, in a
large percentage of wound- btain healing without
inflammation or suppuration. In the development
of our pre out methods of asepsis, Listi i tand out
as I he pioneer, and although his idea thai air infection
was very dangerous has lien proven in pari fallacious
and the spray has fallen into disuse, the pre en(
technique is the direct outcome of his teaching, other
investigators having added to our knowledge during
the time thai has elapsed since his writings. The ob-
ject in wound t real me nt is to prevent anything coming
into contact with I he \\ ound surface which can convey
infection, and to limit the number and the virulence of
bacteria whose en I ranee cannot lie prevented. To ac-
complish this end requires unremitting care and atten-
tion to detail as well as a thorough appreciation of the
dangers resulting from the slightest oversight. The
more cleanly a surgeon is in his daily life, the more
easily can he form habits of surgical cleanliness.
Many surgeons obtain poor results because of an im-
perfect technique and fail to perceive such imperfec-
tion. Only by a careful investigation of poor results
can the evil be remedied. The young surgeon educated
to-day under the influence of the present teaching
more readily learns and practises aseptic surgery
than one who was taught and practised under the
old regime. The writer found some years ago a
marked improvement in wound healing when his
staff were trained to avoid at all times bringing their
hands into contact with pus. The infectious agents
are bacteria of different forms which exist in the air,
the soil, and the clothing, upon the skin and mucous
membranes of the healthy body, in the beard and
hair, and especially under the nails. The number
of bacteria in the air is inconsiderable compared to
the number found in the other places mentioned.
Virulent cultures of pyogenic bacteria have been
obtained by investigators from the crowded operating
theaters of some clinics. On this account and for
other reasons the seating capacity of operating rooms
recently constructed has been limited. If the air
becomes contaminated in this way vigorous steps
must be taken to remove this possible source of
infection. Air exhaled by the operator and his
assistants may carry bacteria, hence at present the
head, mouth, and nose of the operator and his staff
are covered by a mask, which has the additional
advantage of preventing any perspiration dropping
into the wound. The infection occurs as a rule by
contact with a broken surface. If the chances of
contact infection are excluded, air infection can be
almost entirely eliminated by care to prevent dust
being raised in a room. No sweeping, brushing,
taking down of curtains, opening windows or doors
on opposite sides of a room should be allowed just
before an operation. A moist cloth can remove
dust and dirt with the least possible disturbance.
Bacteria can scarcely leave a moist surface and pass
into the air.
The methods of handling dressings and wound
discharges will determine, to a large extent, the
number of bacteria which reach the air. It is im-
portant, therefore, to destroy all wound dressings
and not allow them to lie about in a dry condition.
That flies and other insects can be the medium of
transportation is well established, and while perhaps
not a frequent means of infection yet it is well to
exclude them from hospitals, for this reason as well
as for the comfort of the patients, by the use of
screens. The most frequent source of wound infec-
tion is the hands of the surgeon and his assistants.
This can be readily appreciated when we consider
the great frequency with which the surgeons and
their helpers are called upon to handle cases in which
bacteria are present in countless numbers, all possess-
ing some degree of virulence. In the language of
Keith, "It is the willing and tender though unclean
hand" which conveys the infection. Therefore the
fewer and better trained the assistants, the better the
717
Asepsis, Surgical
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
results obtained. If the chain of careful technique is
broken by any of these, the result will be infection
with its consequent inflammation, suppuration, and
sepsis.
The very greatest care cannot prevent the occur-
rence of an occasional contamination of the wound
surface. But in direct proportion to the care exer-
cised will the danger of infection be lessened. Every
surgeon should assume the right to inspect the hands
and nails of his assistants and accept or reject them,
for he alone is responsible for the outcome of the case.
No mere washing for one minute in this and for one
minute in the other solution will render the hands
sterile. Rubber gloves sterilized for each case will
prove very useful in handling septic cases with the
least" chance for contamination. Those working in
the deadhouse or in putrefying materials should not
perform or assist at surgical operations.
All who handle wounds should keep the idea of
asepsis always before them and should carefully avoid
needless contamination of their hands. In dressing
wounds which are suppurating or are infected, con-
tact should be avoided as much as possible. From
fifteen to thirty minutes' careful scrubbing with soap,
water, and freshly sterilized brush are necessary for
the mechanical cleansing of the hands. The water
either should be running or should be changed fre-
quently during this process. The soap should be
carefully selected and germ free. Ordinary green
soap is very frequently used for this purpose. A
cheap brush of vegetable fiber can be obtained which
has the advantage of not being injured by boiling.
Each person engaged in the operation should have
an individual brush for his final scrubbing. The
nails should be kept short and all visible dirt should
be removed by a sterilized scraper after a primary
washing and before the final scrubbing which should
extend above the elbows. Such mechanical cleans-
ing is the first step in all plans of sterilization of the
hands. In hospitals the final cleansing of the hands
is preceded by a complete change of the clothing,
the operator and assistants removing the outer
clothing and donning a white sterilized suit and cap.
Some operators go so far as to change the shoes as
well. In private practice such a change is not often
possible, therefore the coat, vest, collar, and tie are
removed and a large sterilized apron is used to cover
the clothing to within a few inches of the feet. In
such way the object desired can be accomplished. If
the apron and clothing beneath become saturated
with water, care must be used to prevent such spot
coining into contact with the wound, hands of sur-
geon, or anything which will touch the wound.
A number of investigators have made bacteriologi-
cal tests of the efficiency of different methods for the
preparations of the hands. In 1S85 Kiimmel made
a number of experiments to determine the value of
different antiseptic solutions, such as boric acid,
thymol, carbolic acid, and corrosive sublimate.
After rinsing the hands in soap and water, and im-
mersing in one of the above solutions, he drew his
finger tips over the surface of a sterile nutrient gela-
tin. He found the colonies least abundant when
five per cent, carbolic or 1 to 1,000 bichloride of
mercury was used. He concluded that primary im-
portance should be attached to the mechanical
cleansing, while chemical agents were of secondary
importance. Forster about the same time obtained
the same results. Furbringer in 1S88 showed that a
sterile culture resulting after such a test by no means
indicated that the fingers were sterile, for scrapings
from beneath the nails of such fingers would, when
thrown on gelatin, produce an excessive growth of
bacteria. This result was obtained even after the
utmost care in cleansing and scraping this part prior
to the disinfection. He was led to believe that the
grease adherent to the skin protected the germs
from the action of the chemicals. Acting on this
718
idea he used a strong solution of alkali, which provii
inadequate he abandoned for ether. This was ni
satisfactory owing to its rapid evaporation. A
cohol was found to have the solvent property of eth
without the rapid evaporation. His method was .
follows:
1. Thorough cleansing of subungual space.
2. Scrubbing the hands for one minute with wat
and soap.
3. Scrubbing the hands with sterile brush in eigb
or ninety-five per cent, alcohol for one minute.
4. Rinsing in three per cent, carbolic or tlin
tenths of one per cent, bichloride solution.
He did not claim germicidal action for the aleohc
The more recent investigations show that the tes
with alcohol give as good results without the fouri
step as when the germicides are used. The gre:
objection to bichloride of mercury is the cracking
the hands which follows its use. Some operate]
notably Kelly and others, use a solution of pota
sium permanganate and oxalic acid (Schatz' methoi
in addition to the mechanical cleansing mentiom
before; others "use turpentine, and still others u
sterilized ground mustard in their technique. Le
depends upon plans used than upon the thoroughne
with which the preparation is accomplished. Tl
method most in vogue is some modification of Fii
bringer's with the use of a longer time for the prepar; '
tion than his instructions would indicate. Fir.
scrub the hands and arms to the elbows with soa
and water, after cleansing the nails thoroughly unt
no dirt is visible. Then scrub thoroughly the hand
arms, and crevices about the nails in a basin of alec
hoi for at least five minutes. This, with or withoi
the use of bichloride of mercury, will give the he-
results and has the advantage of being very simp]
and easy of application. After this preparation El
been completed, the greatest care should be exercise
to keep from touching anything which is not sterili
That almost irresistible desire to scratch the nose c
to adjust spectacles must be controlled.
Mikulicz advised the use of sterile cotton gloves t
protect against infection from the hands. As migh
be expected, this was not successful owing to th
facility with which fluids passed to and from tli
hands carrying microbes through the gloves. Moi
recently thin rubber gloves and finger-cots hav
been introduced to provide a sterile finger and ham
These are not injured by boiling or by steam, there
fore can be made perfectly sterile, and will undoubted!;
have a large field of usefulness. The chief object i>
that can be offered to rubber gloves is that they in
terfere to a greater or lesser extent with the manipula
tions. Some surgeons, however, become quite
pert in their use and claim that the tactile sense is no
perceptibly lessened.
In the experience of the writer the use of rubbe
gloves has been a decided advance in asepsis and hi
believes that they should be employed in wounds whicl
do not require an exceeding delicacy of touch
They have been generally adopted by the profession
and when employed with the usual care in techniqui
wound infection has practically become an unknowi
quantity. Finger-cots are not to be employed ir
operations unless it is necessary to cover an injured
glove. The glove will prove of great service in thi
treatment of accidental or infected wounds. Sterili
glycerin or sterile talc will aid in putting the glo
on the hand. The cleansing process must be ju
thorough as when operating without the gloves.
Dr. A. C. Wiener of Chicago has suggested the u i
of celluloid dissolved in acetone as a substitute for
collodion. Enough celluloid is dissolved in the proper
amount of acetone to produce a thin syrupy liquid.
For holding small dressings in place, sealing wounds
and abrasions of the hands before operation, and
like purposes, it appears to be superior to collodion,
as it adheres much more tenaciously.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Asepsis, Surgical
Dr. James B. Bullitt, of Louisville, Ky., has pro-
ved the possibility of eliminating the finger nail and
, , ice as a factor in wound infection by sealing up the
nls by i lira lis of 1 1 lis preparation. Ho lias found that
a thin solution be first applied to the nail and the
uiis skin and thru, after this has dried, in a
. minutes a further coat, or coats, of a thicker solu-
the consistence of cream be applied, that the
:i l.i' completely sealed. If a half-hour's time be
.n given for drying and hardening it will be found
he hands can be thoroughly washed, scrubbed
ith a brush, and subjected to all of the usual prep-
ations for a surgical operation without the celluloid
ing its hold. In using this material forsuch pur-
it is recommended that the hands and nails be
ghly washed and prepared just as is usual for
ion, and that the celluloid be then applied, after
liich it is desirable to permit a half-hour to elapse
the hands are again placed in water. Sealing
■nails in this way leaves the tactile sense of the fin-
impaired, thus obviating an objection offered
many operators to the use of gloves, whether of
or of cotton fabric. Bacteriological investi-
upon this point will be of interest, and if the
. achieves the object desired it will prove quite
djuvant to our present technique.
The Patient. — It is undoubtedly a fact that the
ion of the patient is often responsible for a
infection. It has been proven that bacteria
d do exist in the blood of apparently healthy
lals, becoming localized only after a trauma,
nd in other cases the resistance of the tissues is
i:ir; therefore, when time is allowed, the patient
be placed on tonics and nutritious food. The
. skin, and intestines should be rendered
. live. In this way the bacteria present are elimi-
and the resistance of the tissues to infections
eased. A number of warm or Turkish baths
.mild, whenever practicable, be given prior to
ion. One warm bath should be insisted upon
i all cases in which it does not endanger the patient.
i bichloride of mercury bath will render the bacteria
surface less active, but is irritating to sensitive
kins. On the afternoon before an operation is to be
■erformed the field should be shaved and thoroughly
id with soap, water, and soft gauze. This
hould extend some distance away from the point of
in. The scrubbing should be done gently when
'Ver a suppurating lesion in the abdomen, to prevent
upture. After scrubbing with eighty to ninety-five
icr cent, alcohol and rinsing with plain sterilized
vater a sterile gauze dressing should be applied to
iroteet the field. Especial attention must be given to
he axilla, the umbilicus, the pubes, and also the scalp.
A'ithin recent years there has been an effort upon the
>art of some operators to revive the use of iodine for
terilization of the operative field. This drug in
ratery as well as alcoholic solutions was employed
ome years ago, according to Parkas early as 1876, but
i was not considered an efficient germicide. Grossich,
n 1908, published an article 1 advocating its use for
kin sterilization and claimed that a dry field was
ary to obtain success, since the iodine pene-
■ lies more deeply through the dry epidermis. Bovee"
ays that failure to heed this injunction may bring
nto disrepute this method of preparation of the field
jf operation. He has made a number of experiments
inline the efficiency of iodine in solutions of
i strengths for this purpose and concludes
thai "tincture of iodine diluted with an equal quan-
tity of absolute alcohol may be considered reliable
i a local application in preparation of the skin or
mucosa in any part of the body. Dilutions of less
strength are unreliable if hairs or large hair follicles
are in the field of operation. The fifty per cent, dilu-
tion of tincture of iodine, if not carelessly applied, is
not likely to injure the skin."
The writer has personally no experience with this
method of skin preparation, having found the one
previously described to be very satisfactory, and
believes thai if dependence is placed upon a chemical
method of skin sterilization sufficient attention will
not be given to the other methods of asepsis which
have been found so useful, and that its adoption will
be rather a step backward than an advance in prcpa-
ra( ion for operal ion.
The preparation of mucous surfaces w ill of necessity
be more or less i m perfect. The object is to promote the
highest degree of asepsis possible with the least injury to
the mucous membrane, for the intact membrane will
resist infections much better than one which has been
damaged. The eye cannot be scrubbed and cannot
-'and any strong germicides to promote asepsis.
Moreover, the normal secretions in this part seem to
have some antiseptic action. The integumentary
surfaces of the lids and brows should receive a
thorough scrubbing with soap and water. The con-
junctival sac should be irrigated thoroughly with a
saturated solution of boric acid or Thiersch's solution.
If the conjunctiva or the tear sac is infected, no opera-
tions upon the eye should be undertaken except those
of emergency. The results will certainly justify
waiting until the process subsides under proper
treatment. The nose can be cleansed only by the
use of the spray or douche and s e of the simpler
antiseptic solutions, of which an ordinary saline is one
of the best. Dobell's solution is also very popular.
Prior to operations about the mouth it is advisable to
have a dentist care for the teeth in order that the
chance of infection may be diminished. Before an
operation the teeth should be thoroughly scrubbed
with brush and tooth wash or powder. The mouth
should then be washed out with tincture of myrrh,
peroxide of hydrogen, or bichloride of mercury
solution, and subsequently rinsed with plain sterilized
water. The anus and rectum can be cleansed by
means of two or more scrubbings of external parts
followed by plain enemata prior to the operation.
And when the patient is anesthetized, the bowel can
be thoroughly scrubbed with soap and water and
flushed with a weak solution of corrosive sublimate
followed by one of plain boiled water. The same
plan can be followed with the vagina, using a small
nail brush, a jeweller's brush (Gerster), or a small
piece of gauze on forceps to reach the upper part.
The room should be light and well ventilated, devoid
of curtains or superfluous furniture. The tempera-
ture should be about 75° F. It should be so arranged
that cleaning can be easily accomplished by means of
a mop and wet cloths without impregnating the air
with dust. When one is operating in private houses
the furniture, carpets, and curtains must not be dis-
turbed at the time of the operation. The utensils
should be glass, porcelain-lined, or granite ware
which can readily be rendered clean and sterile by hot
water. Hard rubber makes the best portable trays,
owing to its light weight. The tables and other fur-
niture for the operating room should be of the simplest
kind, and those made of iron and enamelled, with or
without glass tops, are the best. Where these cannot
be obtained a plain table made of hard wood will an-
swer every purpose. They must be kept scrupulously
clean. All basins, pitchers, etc., which will be used
should be well scoured and boiled or scalded 'just
prior to use. Sheets and blankets should be sterilized
and the patient should be well covered except at the
site of operation. The towels must be sterilized and
kept tightly wrapped until ready for use. These
materials may be sterilized in the same way that
gauze and dressings are prepared.
Sponges. — The best silk sponges are expensive so
that resterilization would be necessary, and this is
more or less unreliable. Boiling unfortunately
hardens the sponges and destroys their usefulness.
This has rendered their thorough sterilization some-
what difficult. Very good sponges can be obtained
719
Asepsis, Surgical
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
for about two dollars and a half per pound, and these
can be thrown away after an operation. Many
methods of preparing sea sponges have been proposed.
The following (Schimmelbusch) is useful and very
simple: The sponges are beaten, washed, and kneaded
repeatedly in cold and warm water until the dirt, shells,
and other foreign matter are entirely removed.
They are then pressed together, surrounded by gauze,
and put into a one-per-cent. solution of soda, just
removed, while boiling, from the fire. They are kept
in this solution for half an hour. The soda is then
washed away with boiled water and the sponges are
stored in a tight jar and covered with a solution of
bichloride of mercury (1 to 2,000).
Still another method of sterilizing sea sponges is the
following: After the usual beating and rinsing to free
from dirt and lime, they should be immersed in a solu-
tion of hydrochloric acid, 2 drachms to the pint, for
twenty-four hours. They should next be soaked in a
saturated solution of permanganate of potassium, and
then decolorized in a hot saturated solution of oxalic
acid. The latter is removed by passing the sponges
through lime water. After being washed in plain steril-
ized water they are placed in a solution of bichloride of
mercury (1 to 1,000) for twenty-four hours and are kept
in threo-per-cent. solution of carbolic acid until neei led.
In the latter steps of preparation the sponges should
be handled by means of sterilized rubber gloves and
sterile forceps. The difficulty of sterilization and the
cost are objections to sea sponges, and while the
advantages of a good sponge are apparent, its place is
being largely taken by pads of absorbent gauze and
mops or wipers made of cotton covered by gauze
(Tupfers). These can easily be made by squares of
gauze with diagonal corners tied together and enclos-
ing a small pledget of cotton. 'When desired they
can be made of very small size for use in cavities.
They are easily sterilized by steam and are very
convenient and inexpensive. As far as possible the
edges should be turned in to prevent ravellings
being left in the wound. These mops and pads
should be wrapped in gauze, one dozen in a package,
and so sterilized. In this way they can readily be
counted so that none shall remain in the wound.
Large flat gauze pads with a string attached are now
often used in abdominal work in place of the large flat
sponges formerly so much in vogue.
The instruments should be made entirely of metal,
of very simple design and easily cleansed. They
should be kept perfectly clean by thorough scrubbing
with brush, soap, and water before and after each
operation. This should have the most careful at-
tention lest shreds of tissue and clots of blood re-
main. Proper cleansing having been obtained, the
instruments may be rendered sterile by boiling in
one-per-cent. solution of carbonate of sodium for
five minutes. The sodium salt seems to aid in the
destruction of microorganisms which may be present
(Schimmelbusch). It also prevents rusting of the
instruments which occurs in plain water. The ordi-
nary fish kettle is very useful for boiling instruments,
as the tray can be lifted and the instruments trans-
ferred to another tray or towel without being handled.
"Wiping them and placing in a towel exposes them to
a chance of contamination and is not as a rule ad-
visable. Cutting instruments unfortunately lose
their edge when boiled, hence other means are neces-
sary to render them germ free. Immersion in pure
carbolic acid for five or ten minutes, then in alcohol
which dissolves the carbolic acid, and finally in freshly
boiled water will lie the best plan for sterilization.
Germicidal drugs other than carbolic acid are seldom
used for the preparation of instruments. Bichloride
of mercury acts destructively upon metal. After
sterilization the instruments should be kept in basins
and covered with hot water or towels and should not
be handled again before the operation. One assist-
ant should have entire charge of the instruments, or,
720
perhaps better, the table containing them is ;
placed that the operator can get them himself,
an instrument falls upon the floor, is handled by set
tic hands, or is soiled by infectious material diirir
an operation, it should be discarded or resterilizei
When not in use instruments should be kept in a cleat
dust-proof case.
The Dressings. — Butter or cheese cloth is almo:
universally used at the present for a wound dressir
and is known to the profession as gauze. Surgeon
absorbent cotton is also very largely used as a woui.
dressing. Other materials, such as oakum, jute, etc
are used less frequently. The materials most suital
for bandages are butter cloth, unbleached curt,
flannel, and crinoline. The dressing, gauze, cotto
and bandages, also aprons, towels, gauze spongi
blankets, and sheets, can all be rendered aseptic 1
exposure to steam in a sterilizing apparatus for oi
hour on three successive days. The sterilizer <
Arnold, E. Boeckman, or a similar one may be t;
for this purpose. The chief object is to obtain
moving or live steam with sufficient pressure to 1
forced into all parts of the material undergoin
sterilization. Heat applied before closing the
zer will tend to prevent condensation of the steai
and saturation of the dressings. The same end ca
be reached by allowing the steam to pass through th
materials after opening the sterilizer. When tab
from the sterilizer they should be dry and should I
subsequently handled as little as possible and wit
the greatest precaution to prevent contamination. 1
folded in gauze before sterilization they should b
opened only when ready for use and in the meanwhil
confined in closed retainers.
Sutures and Ligatures. — The suture and ligature ma
terials now in use are catgut, silk, silkworm gut, liner
kangaroo tendon, silver wire, and horsehair, eacl
having its peculiar indications for use. Of these, cat
gut and kangaroo tendon are sterilized with mos
difficulty. The other materials are less readily affectn
by heat and are therefore the more easily renderei
sterile. The former have, however, the advantage o
being readily absorbed, and will be on this accoun
less likely to act as a foreign body and prove sub
sequently a source of irritation. Silkworm gut i
not absorbent, has no tendency to become softened bj
wound secretions, and is therefore not so likely ti
carry infection into the wound as catgut or silk. 1
is very useful when a firm, strong, and non-absorbablc
material is indicated. Silk sutures and ligature;
should be rolled on glass spools and sterilized will
the dressings by steam or by boiling in plain wat<"
just before use, or the method in use at the Jolir.r
Hopkins Hospital (Halsted) can be adopted. Thi
silk is cut in lengths of from nine to twelve inches, ami
ten of these strands are wound on a glass reel,
eral of these reels of desired sizes of silk are placed in a
glass tube, which is loosely plugged with cotton.
The tube is then placed in a steam sterilizer for an
hour on the first day and on the two following days for
half an hour each time. When the tubes are removed
from the sterilizer the cotton is pushed tightly into
them, and they are kept in aseptic glass jars until
wanted. Frequent boiling of silk appears to lessen its
strength to some extent. Boiling silk or silkworm gut
in soda solution will soften it and cause deterioration.
The sterilization of catgut is a more difficult task, and
most methods have been far from satisfactory. The
prepared gut offered for sale is as a rule most satis-
factory. Catgut kept in alcohol in a sealed glass tube
can be sterilized by boiling for two hours. Kelly for
some years used catgut that had been soaked in ether
and then boiled in absolute alcohol under pressure,
but he abandoned the method after several cases of
infection, which were thought to be due to imperfect
sterilization of the gut, had occurred. He has recently
used Kronig's cumol method modified by Clark and
Miller. This he describes as follows: 1. Cut the
HKFF.RENCE HANDBOOK OF THE MEDICAL SCIENCES
Asepsis, Surgical
feut into desired lengths and wind twelve si rands
,7 a figure-of-eight form so that it may be slipped
,, g large test tube. 2. Bring the catgut gradually
i temperature of 80° C. and hold it at this point
, hour. 3. Place the catgut in cumol, which must
I be above a temperature of 100° ('.; raise it to
(J, ami hold il at this point for one hour. 1.
nr oil the cumol and cither allow the heat of the
H | bath to dry the catgut or transfer it to a hot-air
! a temperature of 100° C. for two hours.
rransfer the rings with sterile forceps to test
previously sterilized as in the laboratory.
n, I is not explosive but very inflammable; care must
e be used to keep it from the flame. Kanga-
. tendon is not generally used, but is useful when
bsorption is not desired. It can be prepared
inner similar to that employed for the sterili-
ion of catgut. The irregularity of the tendon
ikes it .somewhat difficult to handle. Silkworm
be readily sterilized by steam or by boiling
I can then be kept immersed in alcohol. It can,
, be boiled with the instruments at the time
operation and thus rendered perfectly- sterile.
cutting oil' the two irregular ends of the required
of strands and making the first turn of a
f knot, they can easily be handled and one strand
1 a I a time by holding at the knot and pulling
fmm the convexity of the loop.. Another good
to place the strands in test tubes in which they
n be sterilized and kept aseptic until ready for use.
ver wire is easily sterilized by boiling with the in-
uments. It is a favorite suture with many opera-
, vially when a considerable thickness of tissue
to be approximated. Some abdominal operators
3 it in suturing the abdominal wall in tiers. It is,
r, not so frequently used as some of the other
terials and often causes irritation when embedded
the tissues. Horsehair makes a very valuable
I I rial for suturing the skin where tension will be
slit. Black hairs are best as they are larger and
r. The hairs are readily prepared as follows:
Ice a small bunch of hair from the horse's tail and
ush it in a direction opposite to its growth to re-
1 !• the short hairs. Then wash it thoroughly,
-I in soap and water to remove grit and dirt, and
I'U in ether to remove fats. Finally, boil and
ep in alcohol until needed for use. Or the small
ndles can be put into a test tube and sterilized by
"am as is done in the case of silkworm gut. The
ir suture is best inserted as a buttonhole suture or
the chain stitch of Billroth. In order to do this,
■ the first stitch as in simple continuous sutures,
en pass the needle through both lips of the wound
d hook the emerging end of the suture under the
lirr to lock the stitch.
Fluid for Irrigation. — Water as generally seen is not
rm free. The best and simplest method to render
sterile is by boiling with or without previous filtra-
m. The latter is to be preferred, because there
II be less sediment and the vessels will the more
idily be kept clean. These vessels should be pro-
led with covers which are put in place after the
•rilization. It is well to supplement the cover by
few folds of sterile gauze or a towel. Some of the
liould be sterilized long enough before the
'(ration to allow time for cooling. The dipper for
nveying the water from one vessel to another can
sterilized with the water. In fresh and clean
iunds germicidal solutions are to be used only in
(•paring the field and the hands prior to operation,
id only plain sterile water or physiological salt solu-
>n, 6 to 1,000, used during the operation. In acci-
ntal wounds and septic conditions an effort is to
■ made to destroy the organisms by the use of
emicals such as 1 to 1,000 bichloride of mercury
ration, or from one to five per cent, solution of
rbolic acid, or one-per-cent. solution of acetate of
uminum. In fresh aseptic wounds many surgeons
Vol. I. — 46
use the dry method of operating and obtain excellent
results. No fluids of any kind come into contact
with the wound, and dry gauze sponges remove the
blood. In this way one of I he thine- necessary for
bacterial growth, moisture, is markedly 1' i oi d
The Drainage. — Material for drainage is used to
remove from wound spaces the serum which would
form a pabulum for bacterial growth, and in accidental
or infected wounds to remove pus and incidental
colonies of bacteria, but in many cases some addi-
tional drainage material is necessary. This object
may be accomplished by a simple counteropening at
:i dependent part. Strands of sterilized silk, horse-
hair, catgut, and silkworm gut are frequently used
for this purpose. The other materials which are
employed for drainage an 1 gauze and tubes made of
decalcified bone (Neuber), of glass, or of pure rubber,
fenestrated as desired. The latter is one of the best
and most universally Used. Glass tubes an 1 used
almost exclusively in abdominal and pelvic work, and
are less useful in other parts of the body. Tubes of
glass and rubber can be made perfectly sterile by
boiling, and they produce as little irritation :i- any of
the other forms of drain. Owing to the tendency tin'
tissues have to become adherent to the meshes of the
gauze, it has been proposed to surround the gauze
drain by gutta-percha tissue. This tissue cannot be
boiled as it is destroyed by heat, and dependence
must be placed on alcohol, bichloride of mercury, or
other chemical disinfectant which is washed away
before the drain is inserted.
Drainage should be employed only when there i^ a
distinct reason for so doing, as where there is excessive
wound secretion, where contamination of the wound
has occurred, where dead spaces are unavoidable, and
where the wound is connected with mucous surfaces.
The danger of contamination of the wound through
drainage must not be overlooked. When the object
for which the drain has been inserted has been
accomplished, or when its presence produces irritation,
its use should be discontinued. The size of the drain
must be suited to the. amount of fluid to be removed.
If rubber tubing is used, it should just emerge from
the skin to prevent flexion and obstruction, which
may occur if it projects too far out, and it must not
be choked by the pressure of the nearest suture.
A sterilized safety pin passed through the margin
will prevent the tube slipping into the depths of the
wound.
The Wound. — In making a wound the surgeon
should endeavor to injure the tissues as little as
possible, using sharp knives and making a clean-cut
incision. The tissues should be torn asunder as little
as possible so that the amount of dead tissue will be
small, thus lessening the favorable soil for bacterial
growth. For the same reason rough sponging and
injurious chemicals are to be avoided. Hemostasis
must be complete, and suitable drainage arrangements
should be made for the removal of the wound secre-
tions in the larger wounds and in those in which
infection is likely to take place. The dead spaces
must be as nearly as possible effaced by position,
suturing, and bandaging; in fact, everything should
be excluded from the wound which will lessen the
vitality of the part or form a nidus for the growth of
bacteria. It is a well-known fact that too much
tension upon a suture will favor the formation of a
stitch abscess; therefore the stitches are to be drawn
only tight enough to approximate the edges without
tension. When the suturing is complete, the wound
and adjoining field should be freed from blood by a
piece of moist gauze and dried thoroughly. The
dressing is then to be applied, the character of which
will depend largely upon the situation and size of the
wound. The small and superficial wounds can be
-ealed by the use of collodion or celluloid, and if a
drain is needed its point of emergence can be left open.
In the latter case it is wise to apply a sufficient quan-
721
Asepsis, Surgical
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
tity of gauze over the wound to take up the secretion,
and then to cover this with cotton and a bandage. In
the larger wounds plain sterilized gauze in voluminous
folds should, after being shaken up, be applied and
covered with cotton and a bandage. The part is
then to be placed at rest, and if an extremity, in an
elevated position. The application of chemical
dusting powders to the wound will depend largely
upon the experience of the operator. The substances
most used for this purpose are iodoform and boric
acid, neither of which is germicidal or sterile as
usually seen. Iodoform can be made sterile by plac-
ing it in a gauze bag and immersing in a strong solu-
tion of mercuric chloride.
For some years the writer has adopted the practice
of dressing aseptic wounds -without any dusting
powder, and has found that they remain dry and
heal as kindly as with the use of such substances.
When an inspection of the wound is demanded there
is no crust covering the wound to prevent the dis-
covery of a small focus of suppuration, and there is
no obstruction to the free removal of wound products
by the dressing. When it is found necessary to use
adhesive plaster for coaptation or to prevent separa-
tion of wound surfaces, several folds of sterilized
gauze should be placed between the wound and the
adhesive.
Subsequent Dressings. — The same degree of care
in the preparation of the hands should be observed
for the dressing of wounds as at the time of the
operation. Rubber gloves and finger-cots will find a
very useful field where many wounds are to be dressed
in succession. If drainage has been used, the wound
should be dressed at the end of twenty-four or forty-
eight hours, and the gauze or tube removed. After
this time there should be some distinct indication for
such interference before the wound is again disturbed.
Repair will not be hastened by needless inspection.
Fever, pain, odor, and saturation of dressings will
indicate the necessity for an examination. The
sutures should be removed when they have fulfilled
the indication of their insertion or when they are
producing irritation and thus are failing in this
purpose.
Accidental Wounds. — A large percentage of such
wounds are infected before they reach the surgeon
and therefore require especial efforts at sterilization.
The wound and surrounding skin must be thor-
oughly cleansed with soap and water, and washed
with an antiseptic solution, either of corrosive
sublimate (1 to 2,000) or of carbolic acid (1 to 100).
The solution is removed by flushing with sterile
water. Complete approximation is not often advis-
able and drainage is the rule rather than the exception.
Van Arsdale has recommended the use of a five-per-
cent, solution of balsam of Peru in castor oil as a
wound dressing. This can be sterilized by heat and
will be found useful especially in accidental and
suppurating wounds. It prevents the dressings from
adhering to the wound and permits of their easy and
almost painless removal. The appearance of infec-
tion in a wound demands the establishment of free
drainage and the use of antiseptic irrigation. The
application of a hot, moist antiseptic dressing will
often prove beneficial.
Asepsis of Special Operations. — In abdominal
operations, in which contamination of the cavity by
pus, feces, bile, or urine may be feared, it is essential
that the general peritoneum be protected by the
interposition of gauze pacts or sponges to taKe up
such material. These sponges or pads are removed
after the field has been cleansed and the danger of
further contamination is passed. Following this, the
general cavity is to be sponged carefully and a
complete toilet made. Similar steps are necessary
in opening a cerebral abscess w r hich is likely to be
followed by a general inflammation of the meninges.
Minor surgical procedures demand aseptic precau-
tions, such as aspiration and injection of caviti(
saline infusion — hypodermic injections — and the u
of catheters and sounds for urethra, bladder, at
ureters. Aspirators and syringes should be so co
structed as to be easily sterilized. A hypodern
syringe is now on the market which is made entire
of metal and can be boiled. Overlach's syringe wi
rubber piston, glass barrel, and metal mountings c:
also be sterilized by boiling. The needles should
boiled in soda solution before they are used. T
fluid to be injected into the tissues should be boile
unless it is itself germicidal. Fountain syring
made of rubber or glass can be boiled and are ft
quently used for making saline injections into t
blood and tissues. They must be freshly sterilizi
before they are used. It is essential that the sk
should also be sterilized in such procedures.
It is claimed by Cazeneuve and others that the uri
from healthy kidneys in a healthy bladder is ahva
sterile. Decomposition of the urine and inflammatii
of the bladder occur only as the result of the presen
of microorganisms, which as a rule enter from withot
The entrance of septic germs does not always produ
an inflammation of the bladder, as they are rapid
expelled with the urine. Any obstruction to outfk
will favor their retention and growth, and the develu
ment of inflammation in the ureters and kidneys
well. Every effort must be made, therefore,
prevent infection of this tract. Catheters are mai
of soft rubber, metal, silk, or linen sealed by gin
The metal and soft rubber are best. They should 1
sterilized by boiling for five minutes, and tin
anointed with sterilized glycerin or oil before they a
introduced. Sounds and other instruments shou
be treated in the same w-ay. If such procedu
would injure the instrument, dependence must t
placed on a strong carbolic solution. Brisk frit-tic
for one minute with a wet towel followed by simili
treatment with a dry cloth will make the soli
instruments sterile (Schimmelbusch). A viruk-i
urethritis contraindicates catheterization, and befoi
any instrument is passed, the urethra should I
cleansed by the evacuation of the urine or by flusliii
the canal with water or plysiological salt solutioi
Constant watchfulness in all surgical procedures, hot
large and small, is absolutely essential for tl e pn
vention of septic contamination. This watchfulnes
can be cultivated to a very high degree so that
becomes more or less a matter of habit. When th
occurs, however, there enters the danger of careless
ness. Therefore it is well to remember that on
technique is always open to improvement and that tli
danger lies in indifference and a lack of care.
J. Garland Shereili.
1. Grossich: Centralblatt fur Chirurgie. Oct. 31, 1908.
2. Bovee: Am. Journal of Obstetrics, January, 1911.
Aseptol is the trade name of a solution of sozoli
acid, of the strength of thirty-three per cent. S02
olic acid, C 8 H 1 (HS0 3 )OH, is, chemically, ortho-phenol
sulphonic acid. It is formed when carbolic acid i
dissolved in concentrated sulphuric acid. It is :
syrupy, reddish-brown fluid, miscible in ail proper
tions in water, alcohol, and glycerin. It is les
poisonous and less irritating than carbolic acid am
has a more agreeable odor, but it is not so powerfu
an antiseptic. A ten per cent, solution may bi
employed as an antiseptic wash, and as a local ajjpli
cation to the throat in diphtheria. It may be givei
internally, but the official salt, sodium sulphocarbi
kite is to be preferred. Dose, gr. xx. (1.3).
W. A. B.VSTEDO.
Ash Bark. — See Fraxinus.
Ash, Prickly. — See Xanthoxylum.
722
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Asheville, N. C.
vshcville, N. C. — Asheville is situated in Western
,ih Carolina upon a hilly table-land, at an elevation
,n feet, in the culmination of the Alleghany
]l.u'ntains, between the diverging ranges of the
i :ii Smoky Mountains and the Blue Ridge.
Jompletely surrounding this plateau of some thirty
i les in width, with the Blue Ridge to the south, ea t,
northeast, and the Smoky Mountains to the wesl
: I northwest, are the projecting spurs and peaks
e ranges with an elevation double and almost
diat of Asheville. The meteorological con-
of the plateau — the temperature, the purity
. the air, and the amount of precipitation — are
v influenced by these high mountain chains.
e rain clouds, especially those approaching from a
li.rly direction, are saturated at a higher tem-
ature than they meet on approaching and pa sing
ise mountain ranges, and on that account they
cipitate their moisture before reaching the plateau.
equence there is a difference of from fifteen to
inches of annual rainfall, and from ten to
■Ive degrees in relative humidity, between places
i immediately in the surrounding mountains
Lsheville plateau.
i ille is practically an all-year resort, having,
the parlance of climatologists, a medium elevation,
ring favorable conditions for out-of-door life
-casons of the year.
The Winter Months. — January and February
, however, periods of cold weather, lasting
w days, and exceptionally for a week, and
i.cral of such "cold spells" are observed during
r mi 11 ths. Such a spell is as a rule initiated with
onsiderable wind movement from the north, during
■ h the temperature falls rapidly to 10° F. or to
o, and temperatures below zero have been observed
everal of the twelve winters during which the
iter has had charge of the local weather bureau.
already stated, these cold spells do not last, the
nd subsides after from twenty-four to thirty-six
lire, and then the temperature rises. The days are
ight, and during the hours of sunshine invalids can
oul of doors, when properly clothed, without
tiering from cold.
The humidity averages between fifty and fifty-five
r cent, in the two winter months, and the dry
mosjphere and large amount of sunshine have a
ululating and exhilarating effect upon all cases
lich are otherwise in a condition to profit from
inatic treatment. The amount of ozone in the air
aches its greatest proportion in these months, and
Miity per cent., of a scale from to 100, has fre-
icntly been recorded.
In some years the winters have been very mild, but
ists occur in the spring months as late as the latter
ii of April. Snow rarely falls, and when it does, it
I's away under the sun upon the same day or
thin a day or two thereafter. The average snow-
II is less than two inches.
The spring season, has its beginning between Febru-
y 20 and March 10, during which the vegetation
gins to spring up, and the trees to leaf out. The
e comfortable, and while not hot, temperatures
> to 75° F., during the hours from 10 a.m. to 3 p.m.,
e quite common.
Thunder storms occur with the advent of such
armer weather, and are attended with brisk showers,
pecially upon the environing high mountain
where one can often see such storms in pro-
esa while the plateau enjoys bright sunshine. The
lative humidity during the spring months averages
itween sixty and sixty-five per cent.
< >ne of the features of the spring is the beautiful
id varied flora of this region, and the azalea, laurel,
id rhododendron, as well as the smaller flowers of
te mountains, are the delight of all visitors.
The Summer. — In some years past June has been as
arm as any of the summer months, and the highest
maximum temperature may fall in this month or in
July or August. The highest temperature recorded
in the past twelve years was 91. 3°- F., but 90° 1'. is
frequently reached during the summer of every
year.
I'sually there are c 1 breezes during the day, and
Unless one is exposed to the direct rays of the sun,
there is no discomfort on account of heat. When tin-
sun goes down the air cools rapidly, and the nights are
always comfortable and bed covers are necessary, at
least after midnight.
The rainfall (hiring the summer months is, as a
rule, greater than in the winter, and heavy rains of
short duration occur more frequently. I have
known an inch of rain to fall in tin' course of an hour
or two, but the excellent natural drainage carries the
water off quite rapidly and tic- streets become dry
in a few hours. The average rainfall for the summer
is four inches per month, and the average humidity
varies between seventy and seventy-five per cent.
The Autumn. — With but few exceptions in the
twelve years of my experience, the fall weather has
I u continuously pleasant and enjoyable until
January, when, as stated above, colder weather
usually sets in. With frosts in October the foliage
of the great variety of trees and shrubs begins to turn,
assuming every possible shade and hue from the
green of the pine, to yellow, crimson, red, purple, and
brown, and this change goes on until December or
even later, when the leaves begin to fall. Visitors
never tire in their admiration of this ever-varied play
of colors in the closely adjacent forests, and thousands
of boxes of leaves and branches of myrtle, mistletoe,
holly, and galax are mailed from Asheville during
the fall and winter months to distant friends and
relatives. The fall months are always delightful,
the temperature declining in average and maxima
gradually; and after October 1 artificial heat is
frequently required in houses in the early morning
and evening.
The total annual rainfall is forty inches, and is
nearly equally distributed over all the months, with
a slight increase in summer. There is no distinctly
rainy season or month, and no distinctly dry season
for any part of the year.
The city has a permanent population of eighteen
thousand and a floating population of several thou-
sand more, the latter consisting of people who are in
search of health and pleasure. The railway station
is situated in the valley near the confluence of the
French Broad and the Swanannoa Rivers, at a
distance of a mile from the center of the city, which is
located on a bluff about three hundred and fifty feet
above the river valley. The streets are well paved
with bitulytic or brick, there are good sidewalks
mostly of concrete or cement, and a brick pavement
and macadam extend to Biltmore, a distance of two
miles, to the Vanderbilt estate. Electric trolley lines
connect the different parts of the city with the de-
pot and with Biltmore, and also extend to other
suburbs, giving ample facilities and good service for
all purposes. The business part of the city is well
and substantially built, and the business establish-
ments compare favorably with those of even larger
cities either North or South.
Apart from its mercantile business, Asheville is
practically a town of hotels and boarding-houses, and
the available accommodations are ample in kind and
good in quality according to the rates charged. As
to the latter it must not be forgotten that provisions
and fuel are more expensive than in thickly populated
centers, which are nearer to their sources of supply
and have low rates of transportation.
The rates in the cheaper boarding-houses vary from
$4 to $8 per week, but most of these do not offer
accommodations suitable for invalids. The better
houses charge from $10 to $15 per week and give
good accommodations. A few of them refuse in-
723
Asheville, N. C.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
valids altogether, catering to well people and pleasure-
seekers only.
There are several good commercial hotels in the
center of the city, with daily rates of from $2 to S3.
These are suitable for a brief stay when one first
arrives; but invalids should be advised to avoid
such hotels for permanent quarters on account of the
want of facilities for out-of-door life. The more
fashionable hotel at the present time is the Battery
Park, open all the year, and, though centrally located,
it has large grounds and abundant piazza room, and is
otherwise first class in all its appointments. "The
Manor," also a first class hotel, is situated in the
Albemarle Park and is often preferred by those
desiring more seclusion; having a number of separate
cottages it offers the best facilities for a prolonged
sojourn. The cottages are rented furnished and have
a complete equipment for housekeeping, but are
near enough to the main building for those who
desire to take their meals there. Two new hotels
are in process of building, one in the center of the
city; the other in the outskirts is located in Grove
Park, and is planned especially for visitors.
A special institution for tuberculous patients was
established over thirty years ago by Dr. J. W.
Gleitsman, now of New York. After it had been
conducted for several, years and had shown excellent
clinical results, it was closed in 1SS3. The Winyah
Sanatorium for tuberculous patients was established in
18S8 and has been in successful operation since.
New, modern, and perfectly appointed buildings and
cottages were erected during 1S99, and were opened
for patients in 1900. This institution is situated in
a small wooded park of seventeen acres, in the out-
skirts of the city, and the electric car line passes
through its grounds. The admissions are limited
to such patients only as have a reasonable prospect
for improvement and recovery, and, as far as there is
room, accompanying friends can also obtain accom-
modations.
While there is no city hospital receiving all patients
free, the Mission hospital has facilities for caring for
the city poor, as well as for those who can afford to pay
for private rooms. It admits no contagious diseases.
The water supply of the city is from the headwaters
of the Swanannoah, reaching the city by a gravity
line extending to the intake, a distance of about
twenty miles, which latter is within the water shed
of Black Mountain, fenced in, and owned and con-
trolled by the city of Asheville under the care of
special watchmen. The supply is ample and the water
system is the pride of the city.
The city is well sewered and under the diligent
labors of a competent board of health, the general
sanitary conditions of Asheville have been much
improved, and are now as good as those of other
progressive cities. The city has a hygienic labora-
tory in charge of the Board of Health. Meat and
milk inspection is obligatory and thoroughly en-
forced, and the dairies supplying milk are supervised
and controlled in regard to the health of animals,
cleanliness and care of the milk until it reaches the
consumer. The expectoration ordinance is strictly
enforced in the streets, sidewalks, street cars, and
other public places, and the streets are regularly
flushed by the Sanitary Department. Notification
of infectious diseases including tuberculosis is ob-
ligatory, and rooms and houses in which such diseases
occur are disinfected by the Health Department of
the city, which was one of the first to inaugurate a war
against the house fly, with evident success. The
mortality of the city is very low, especially among
the white population; malaria is unknown, and
phthisis among the natives is rare.
Asheville has a system of good graded schools, a
military academy for boys, and several colleges for
girls, and these private institutions are of a high
standard and well conducted. Students from locali-
ties in which the climate is unfavorable to delica
and rapidly growing youths, and invalided paren
who come to Asheville for permanent homes wit
their children, are offered excellent educational ai
vantages. The principal religious denominations a
all represented and their church edifices would 1
creditable to a larger city.
Opportunities for amusement and recreation a
chiefly limited to driving, horseback riding, and wal'
ing amid the beautiful scenery of this region. Gc
links, said to be among the finest in the countr
baseball grounds, two opera houses, and the gayetii
of the fashionable hotels furnish their part in
Carriage hire and riding horses may be obtained
Asheville at very reasonable rates.
Asheville is on the Southern Railway, about ha
way between Salisbury, N. O, and Knoxville, Ten
Through sleepers leave New York City over tl
Pennsylvania Railway via Washington at 4:1
p. m. and arrive at Asheville at 3:30 p. m. the ne:
day.
Through sleeping car accommodations exist all
from Jacksonville, Fla., New Orleans, La., Loui.-vil!
Ky., Nashville, Tenn., and Cincinnati, Ohio.
Karl von Ruck.
Ashhurst, John. — Born in Philadelphia, Pa., Ai
gust 23, 1839. He studied medicine in the medic;
department of the University of Pennsylvania, an
received from that institution the degree of Doctor c
Medicine in 1860. He afterward, during the Civ
War, served three years as Acting Assistant Surgeoi
United States Army. In 1877 he was elected Pre
fessor of Clinical Surgery in the University of Peni
sylvania, and a few years later he received froi
the same institution the appointment of Professi
of Surgery. His death occurred January 7, 1900.
Ashhurst was widely known as a surgeon of gri
skill in the planning and performance of an operatic
and of unusually sound judgment. The two wort
which will hand down his reputation to posterity ai
his "Principles and Practice of Surgery," Phflade
phia, 1871 and 1885; and the great "Internation:
Encyclopedia of Surgery" (six volumes, New Yorl
1881 to 1886) which he edited and to which a lar<>
number of the leading surgeons of the countr
contributed. A. H. B.
Asiatic Cholera. — See Cholera, Asiatic.
Asparagus. — The common garden asparagus, A
officinalis Linn. (Fam. Liliaceo?), will hardly be mad'
more familiar by description. It is a native i
Europe, and cultivated everywhere. Both tli
underground portion and stems are official in Franc
"Asparagus root" contains resin, glucose, dextr
bitter extractive and other simple constituents, but n
asparagin. The fresh sprouts have, in addition, th
interesting compound asparagin, discovered in 180
by Vauquelin and Robiques.
As a medicine asparagus is of little use. Its prop
erty of modifying the odor of the urine is known i
every one, and is caused by methyl mercaptan,
decomposition product of protein. It may incrcas
the quantity of urine excreted, but does not do si
always. It appears to make it slightly irritating, ani
to prompt to more frequent micturition. At man;
European watering-places it occupies an importan
position in the articles of diet in lithiasis and in tin
treatment of gouty patients. It may cause vesica
irritation, and should be used with caution wb
renal tissue is diseased. In cardiac dropsy it i
recommended, as its action is said to resemble tlia
of convallaria.
Asparagin is regarded as the active constituen
of asparagus shoots. It is also widely distribute!
in nature, having been found in almonds, liconw
724
liKl'I'.RENCE HANDBOOK OF THE MEDICAL SCIENCES
Asphyxia
t belladonna leaves, potatoes, lily of the valley.
arshmallow, and many other plants. It occurs
i. brilliant, colorless crystal-, with a Faintly
line, cooling taste, soluble in water, one pari in
■"Ivc.
Ii may be administered in doses of one grain and
half three times a Jay. II. II. I!i shy.
Aspergillosis, Aural; — See liar: Diseases of ti
\ ory < 'anal.
Aspergillosis, Pulmonary.
-See Lungs, Aspergillosis
Aspermia. — See Sterility in the Male.
Asphwia. — This term which really signifies absence
pulse (a- privative and es in
token of air hunger, reaching its maximum at the
convulsive period, 'rim air hunger a.l-,, soon makes
ii ill lilt on the vasomotor center, «ith resulting
slowing of the heart. The inhibition may In- com-
plete for a few moments, but eventually ceases, the
heart pulsating anew and gradually failing. The
Organ may In' found contracting after the asphyxia
cycle is completed. This cardiac survival may also be
seen in mankind.
In mankind and even in animal experiment
asphyxia may lie atypical, and cases may show
gnat individuality. Sometimes one or more stages
may be absent, and death may occur with such
rapidity that tin- stages cannot be distinguished.
Much depends on the constitutional vigor of the sub-
ject. In some instances of supposed asphyxia death
nally occurs from sudden cardiac paraly-is.
Postmortem Appearances. — The vast number of
data recorded as postmortem asphyxia finds, shows
such a volume of conflicting evidence that Ziemke
is forced to conclude that not a single find is path-
ognomonic of death by suffocation when considered
alone. This conclusion, however, has chiefly a
forensic import to be considered elsewhere. The
death agony with its effects in the individual, is
evidently not so much modified by sudden suffocation
as to result in any special or distinctive anatomical
changes. We are not concerned here with the finds
in particular types of suffocative death, but entirely
with suffocation per se. It will be noted under
asphyxia due to special causes, that the pathological
finds depend essentially on the particular causes of
asphyxia.
Special Causes of Asphyxia. — These comprise
constriction of the air passages by hanging or choking
(with apparatus or the fingers); arrest of respiration
by thoracic compression; occlusion of the external
orifices; obstruction from foreign bodies, and drown-
ing. Other causes might be enumerated, such as
confinement in a narrow space, and inhalation of
smoke and irrespirable gases, but the further we get
away from immediate direct arrest of respiration
the more the situation becomes complicated with
other factors. Instead of asphyxia we have to deal
with a complex conition.
Constriction of heAir Passages. — In asphyxia from
this cause not only the windpipe but the great
els and nerves in the neck are compressed.
Hence the brain is largely cut out of the circulation,
as is also to some extent the spinal cord. Com-
pression of the vagus also in itself tends to disturb
further the circulation and respiration. It is there-
fore apparent that we are somewhat removed here
from the picture of pure asphyxia, so that it is not
advisable to discuss further these deaths which will
be considered under their proper titles.
Compression of the Thorax. — Asphyxia from this
cause occurs in connection with falling masonry, etc.,
but most of the victims of compression are young
infants overlain in bed by parents or others, or
compressed by heavy material which they cannot
remove.
Occlusion of the Nostrils and Mouth. — Asphyxia
from smothering represents a pure type, and from
the absence of collateral lesions and evidences of
violence is of great forensic interest. Bedding is
chiefly employed and the victims are nearly always
young children.
Occlusion of the Windpipe. — Suffocation from
foreign bodies in the air passages or compressing the
latter from the esophagus represents, when the
occlusion is complete, a pure type of asphyxia.
725
Asphyxia
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Suicide or homicide is hardly involved in this mode
of death; and since in very many cases occlusion is
not complete, the condition of the patient is often
one of dyspnea only. Its proper consideration,
therefore, is under Air passages, Foreign Bodies in the.
Submersion or Drowning. — This is a well-recognized
individual subject in which asphyxia is largely
involved. If there is simple occlusion of the nostrils
and mouth, as when a subject is rendered helpless
while in a bath, the mode of death is ordinary smoth-
ering. When a subject is submerged while in the
water, the stages of asphyxia tend to succeed one
another in typical fashion, and this occurs when for
any reason he is relatively helpless, as during a fit.
Ordinarily, however, the efforts of self preservation,
and the fact that the body is in reality light enough
to float so modify the act that it demands and receives
separate consideration (See Drowning). Further-
more, the postmortem appearances of a submerged
body have a special literature.
It is still customary to speak of asphyxia as one of
the common causes of death in general. All deaths
of this type would naturally be preceded by progress-
ive dyspnea and cyanosis, and in certain affections
the various stages of asphyxia, as already related
would be in evidence — for example in edema of the
glottis, or tetanus causing arrest of respiration
through the muscles. Other forms of mechanical
impediment are seen in clogging of the bronchi in
bronchopneumonia and compression of the lungs by
double hydrothorax, etc., etc. Death, when not
violent, is a very complicated process, and unless the
stages of asphyxia are recognizable, and the direct
relationship between causes and effects is in evidence,
it would be difficult to show that death was due to
such cause. The mere presence of antemortem
dyspnea and cyanosis is not enough. And as already
emphasized postmortem appearences cannot decide
the case.
Treatment. — In many instances of apparent death
from asphyxia, resuscitation may be effected by means
of artificial respiration, early resorted to and per-
severed in for a sufficient length of time. For a con-
sideration of the various methods of artificial respi-
ration see the article Resuscitation.
Medicolegal Relations.* — In .its medicolegal
sense, asphyxia is the cessation of the heart's action
which arises from interrupted respiration, caused
either by expelling the air from the body or by pre-
venting the entrance of pure air into the body.
When air is eliminated from the body, or pure air pre-
vented from entering the body, the action of the lungs
is paralyzed, and the blood, no longer aerated, loses
its vital qualities and circulating powers. The com-
bination of these conditions causes death. Death so
resulting is called death from asphyxia, and the con-
dition produced by this combination is asphyxia.
There are four divisions of asphyxia which it is the
province of this paper to treat, namely: (1) As-
phyxia from the want of respirable air and the inhala-
tion of noxious gases; (2) asphyxia from suffocation;
(3) asphyxia from strangulaion other than from
hanging; (4) asphyxia from hanging. Asphyxia
from drowning is considered under that head.
Asphyxia from the Want of Respirable Air and the
Inhalation of Noxious Gases. — The older authorities,
and the laity fall into the error of calling by the name
of asphyxia, certain conditions which are actually
gas poisoning. Indeed, if an intelligent layman were
asked to give an example of asphyxia, he would prob-
ably cite poisoning by illuminating gas, or fumes of
burning charcoal. The more recent standard writers
have placed these cases where they belong — under
toxicology.
* In this section the writer has drawn largely from the article
on the same subject, by the late Professor John Bell Keeble, in the
second edition of the Handbook.
726
A theoretical form of suffocation from exhausti
of atmospheric oxygen in a confined space does i
appear to occur in forensic medicine. Such ca
should not differ materially from those produced
smothering, etc.
Suffocation. — Following the definition in Whart
and Stille's work on " Medical Jurisprudent
suffocation may be said to ensue when, " by a
means air is excluded from the larynx or chest, or t
chest is prevented from receiving it."
Suffocation is most commonly accomplished in t
ways:
(a) By expelling the air from the lungs, by press)
upon the abdomen and chest, and by such contim
pressure preventing the physical action necessary
respiration. Cases of this kind are more usually foi
where small children have been overlaid by older j
sons during sleep, and occasionally where a person ]
been caught in a jam of heavy material, or pre?,
excessively in a great crowd. Death in such case!
attributed to the fact that pressure upon the abdom
and chest compresses the vital organs, expels the
from the lungs, and so closes the lungs and windpipe
to prevent other air from entering. Death of tl
character usually results from accident. Br
reports the case of a child who died from bei
wrapped up too closely by the parents, when it n
being taken to a nurse.
(b) By covering the mouth and nostrils so as
prevent the ingress and egress of air, most frequent
accomplished by the use of bedclothes. In tl
division should also be included those cases in whi
the victim has been covered by dirt, ashes, sno
or the like, as by being buried alive or caught undo
slide of snow. And in the same connection should
mentioned those cases in which feeble or intoxicat
persons have fallen face downward in snow or sa
or other similar substance, and, being unable to ri
have been suffocated.
Suffocation is not often adopted as a method
suicide, and it is infrequently resorted to for the pi
pose of homicide. Perhaps it more frequently occi,
by accident.
Unless some facts are proven which point to t
cause of the death, the expert is at a great disadva
tage in attempting to determine whether or net dea
was due to external cause, or was the result of ap
plexy, faucial disease, or pulmonary congestii
Some of the most common physical indications
death by suffocation are lividity of the face and sa
guineous engorgement of the viscera of the thorax ai
abdomen. There are frequently bloody infiltratii
of the eyes and eyelids, and very small ecchyi
the neck and chest; a partial engorgement of the Inn
little, if any, blood in the left ventricle of the beat
while the right ventricle of the heart is general
engorged. Sometimes a reddish froth is found in tl
trachea and bronchi. As a rule, the body is slight
if at all discolored, and the vascular system of tl
brain shows rarely any evidence of disorder. Ol
of the most common indications is congestion of tl
kidneys. When a dead body is found in earth, ashc
or snow, or the like, the question presents itself ;
once whether the death preceded the fall or the burin
Perhaps the best-recognized test is to examine tl
stomach, gullet, and air passages. If the foreiti
matter is found in the stomach or in the gullet, this
regarded as very positive evidence that death followr
the fall or burial, as only by the action of a bod
instinct with life could the foreign matter be so draw
in. On the contrary, if the foreign matter is foun
only in the nostrils and mouth, this is positive < >
dence that death was not caused by suffocatioi
Suffocation frequently is caused by foreign sut
stances becoming lodged in the windpipe or in th
esophagus. Children and infirm people more fr<
quently suffer in this way. This often makes
necessary, in order to determine the cause of death, t
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Asphyxia
j,ke an examination of the windpipe and gullet,
MMontly by incision.
[svhyxia from Strang ultil ion Other Hunt hi/ Hanging.
first question to be determined in this division
i of course: Was death caused by si rangulat ion, and
,,, by what means? Under this head we shall con-
r ill.' indications of strangulation other than that
unplished by hanging.
\> in all eases of asphyxia, the trouble in strangula-
ii is the lark of air in the body. Hut the means
>d to create this lack is, in strangulation, different
:, the means employed in either of the two preced-
divisions.
la strangulation, the access of air into the lungs is
pted by a pressure upon the windpipe at the
This method provides a double means of
and in the majority of instances death is the
suit of combined causes, namely, the lack of breath
by the pressure upon the windpipe and the
of the larynx, and congestion of the brain
bo by pressure upon the veins of the neck.
ther of these might be, in itself, sufficient to cause
according to the violence of the attack, bid it
irely the case 'that the expert can definitely
.•portion the responsibility.
In the majority of eases, there are many apparent
lysical signs that point with great clearness to the
a of death, and give great aid in arriving at a
iper conclusion.
Some of the physical indications that tend to lead to
elusion that death has resulted from strangula-
m may be enumerated here. One of the most com-
on indications is the presence of ecchymoses upon
e face, neck, and chest caused by extravasated
ood. The presence of these ecchymoses points
rongly to death by strangulation, although it is
uaUy conceded that the absence thereof will not be
ive proof to the contrary. Frequently these
chymoses are so minute as to fail to attract the
tention of the lay observer, and for this reason a
refnl examination by the medical expert is often
valuable.
An examination of the brain will disclose more or
ss congestion and disarrangement of the vascular
generally; and congestion of the kidneys and
irer is very common.
iside from these indications, the swollen face,
ten the protruding tongue and eyes, and the distortion
the features generally throw much light upon the
ibject.
is strangulation other than by hanging is usually
imicidal, great attention should be paid to noting
ly mark of violence upon the body, any evidence of
niggle either upon the body itself or upon the sur-
mndings. The condition of the clothing may be
rongly indicative of attack and resistance.
Death from manual strangulation may be aecom-
lished by means of the hands, cord, or other ligature.
i'hen the hands are used, it is very easy, as a gen-
ral thing, to determine that the strangulation was
lanual; but when a cord or ligature was used, the
inclusion cannot be so safely or easily arrived at.
n such cases, the mark of the cord or ligature
ill give aid. Where the strangulation was manual,
- distinguished from strangulation from hanging,
I'.' mark of the cord will be very nearly horizontal,
'hereas in strangulation from hanging, the mark will
« higher on one side than on the other, and will at the
■chit of the knot approach near the head. The mark
f the cord or ligature in manual strangulation is also,
s a rule, much lower on the neck than when the
trangulation results from hanging, as the weight of
lie body invariably causes the cord to slip as high as
ible, it being stopped, as a rule, only by the head.
There are seldom (in manual strangulation) any
n juries to the vertebra?, and the ligaments of the neck
ire rarely torn; while, on the contrary, such results
ire frequent when strangulation is caused by hanging.
And, finally, it may lie observed that in manual
Strangulation the throat is rarely so perfect l\ clo ed
in strangulation from hanging, for the suddenness of
the fall, combined with the weight ol I he body, tends
thoroughly to shut all tin- an pa sages. While the
position of i he body u iiaiiv throws some light upon
the question, yet this is by no means decisive, for it is
an easy matter for the assassin, after accomplishing
murder by manual strangulation, to suspend the body
by a cord in order to east about, the death the appear-
ance Of suicide. The foregoing signs are merely help-
ful, and rarely unconnected with collateral evidence
entirely satisfactory to the conscientious administra-
tors Of the law.
Human experience has demonstrated that few signs
of l his nature are to be absolutely relied upon, for
oftentimes incidental and accidental physical facts
tend to incriminate an innocent man, and frequently
the guilty deliberately make evidence of this character
in a skilful manner for the purpose of creating the
impression of self-murder.
The importance of a careful investigation and physi-
cal examination is very apparent, when it is considered
that, while the law takes great care to punish the de-
struction of human life, it also takes greater care that
no innocent man shall suffer. To such a degree is
this carried that if from the evidence the jury should
have a reasonable doubt as to the fact that the death
was homicidal, under the instructions of the court an
acquittal is necessary.
Asphyxia from Hanging. — In determining whether
or not death was caused by hanging, either when the
dead body is found suspended or when it shows certain
external evidences of such a death, although no longer
suspended, many of the evidences found in death
from manual strangulation should be considered and
sought for.
The congestion of the brain and the derangement of
the organ in other respects are largely alike in the two
forms of asphyxia, although more pronounced in
death from hanging; the ecchymoses are also in evi-
dence again, usually in a more pronounced manner,
and the same physical distortions and swellings of the
face and neck will be found, save, as in the congestion
and ecchymoses, to an accentuated degree. But to
the unskilled observer these indications may be said
to be similar in death from hanging and in death
from manual strangulation. After having observed
these indications, which are largely alike, as just set
forth, it is probably best to look carefully for those
marks which are common in both cases, but different
in form or degree. The first should be the mark of
the cord. In hanging it vul\ be found to be not
horizontal, one side usually being much higher and
terminating in something like a point; the mark,
furthermore, is invariably higher than in manual
strangulation, the weight of the body drawing
downward and forcing the cord to the base of the head,
while the air passages are closely shut by virtue of the
weight of the body or the sudden force of the fall.
The marks of the cord are usually deeper and more
distinct, and there will rarely be the same evidence of
finger marks upon the face and throat. There are
more pronounced excoriations in connection with
the marks of the cord. The great majority of deaths
from hanging are due to the combined causes of as-
phyxia and apoplexy; while in manual strangulation,
perhaps a majority of deaths ensue from asphyxia
alone.
One of the most common physical evidences found
upon a body when death is attributable to hanging
consists of injuries to the ligaments of the spinal
column and the tearing of the carotid arteries in the
neck.
The lens of the eye is said to be often cracked by
the sharp shock of descent, and this sometimes gives
help to the expert in his examination.
The effect upon the genital organs of both the male
727
Asphyxia
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
and the female victim often throws great light upon
the question. It is mentioned by the authorities that
hanging causes congestion and erection of these
organs both in the male and female, but usually
more pronounced in the male. However, evidences of
this are not always present, and in view of the fact
that this condition may be found after death from
other forms of violence, it alone will not suffice to
prove that death was caused by hanging. The usual
effect upon the male genitals is a state of tumefac-
tion; spermatozoa are found in the urine and in the
urethra, and frequently there is an emission of semen.
In the female, there is often found a dilated and in-
flamed condition of the genitals, and sometimes a
bloody discharge.
Another indication commonly observed is a dis-
charge from the bowels.
As many deaths resulting from hanging are suicidal,
it is often a question of grave importance to deter-
mine whether the hanging was in fact suicidal or
homicidal. It is the unanimous opinion of those
who have made profound study of this subject that in
the absence of collateral evidence the presumption is
that the death was suicidal.
Hanging is such an easy and convenient method of
exit from the world that the wretched and despond-
ent frequently adopt it, in ridding themselves of those
"ills they have." This is probably due in a certain
measure to the fact that unlike many other methods
of suicide, hanging, when once begun, can rarely be
stopped by the would-be suicide. The first com-
pression of the air passages tends to benumb all
sensibilities, to stupefy the will, and to paralyze those
other members of the body which, upon a change of
mind, would be necessary to effect a self-rescue.
Therefore, doubtless, in many instances in which the
resolution to destroy one's self is only partially fixed,
when the first step has been taken there is rarely an
opportunity to go back.
Hanging can be accomplished in so many ways, and
with such simple appliances, as also to present a royal
road to death to the melancholy and desponding.
The main things to consider in this connection are:
the position of the body, whether it swings clear or
barely touches the ground; whether the hands and
feet are bound; whether or not the cord or other
device gives evidence of being prepared by another;
and sometimes the manner in which the knot is tied.
There is no doubt also, as a rule, that in suicide there
are no marks of violence upon the body, and rarely
any evidence that would tend to show struggle.
But, in the end, evidence purely expert and
ln-pothetical, in this as in all methods of determining
the cause of injury and death, is to be received with
caution, and is most valuable when considered to-
gether with proven facts that point to a cause of the
death. Edward Preble.
Aspidium. — Male Fern, Filix-mas. The dried
rhizome and stipes of Dryopteris filix-mas (L.) Schott.
(Fam. Polijpodiacew.) This is a large, robust, and
handsome fern. It is one of the commonest in the
cooler parts of Europe, and abundant also in the
temperate parts of Asia, in the northern and southern
extremes of Africa, and in both North and South
America. It is not found in the Eastern United
States, but occurs in British America and in the
Western States. Its employment as a teniacidal
agent is of great antiquity, as it is mentioned by
some of the earliest writers upon medicine. The in-
troduction of the "oleoresin" (ethereal extract) dates
from the recommendation of an apothecary of Geneva
named Peschier, in 1825 (Fliickiger). The horizontal or
decumbent rhizome is collected and either dried and
marketed in its natural state, or (as now usual) after
stripping it of its dense coat of leaf bases and chaffy
scales, then constituting the "peeled fingers."
Description. — Before being peeled, ten to fifi. i
centimeters (4 to 6 in.) long by five to seven cei
timeters (2 to 5 in.) thick, including the dense
imbricated, dark brown, cylindraceous, slight
curved stipe-bases and the dense mass of brow
glossy, transparent, soft, chaffy scales; when peelr
one to two or three centimeters (f to about 1 n,
thick, slightly curved or claw-shaped, somewli:
narrowed toward one end, bearing several coari
longitudinal ridges and grooves, pale-green when fir
peeled, becoming pale-brown, or when too long kei.
rusty-brown, smoothish (or somewhat roughly scan
with remains of the stipe-bases); texture rati.
spongy, pale-green, with age becoming gradual
brown from the outside inward, showing, on cross-si
lion, about ten steles in a loose and interrupted c
cle. The marginal hairs of the stipe-scales of A.fih.
mas consist each of two parallel, slender cells, neitln
of them glandular; those of A. marginalis are almo
identical in appearance, being directed slightly moi
toward the apex of the scale, and their lowet ci
often a little narrower. Upon the older scales the
are nearly wanting. Male fern has a disa.L'i
odor and a bittersweet, acrid, astringent, and nat
seous taste.
The chaff, together with the dead portions of tli
rhizome and stipes, should be removed, and en!
such portions used as have retained their green
The powder should be freshly prepared and brigl
green.
Several, perhaps many, adulterants and subsl
tutes have been and are sold. Some of these can 1
distinguished by their different numbers of steli
while the distinctions of others are microscopic!
and obscure. It is not indeed practicable, without
very elaborate description, to exclude all the possibl
adulterants. Some, not readily detected in the peele
drug, are so when the covering of stipes is present,
condition which is, for other important reasons, al-
to be preferred.
Of late years, the market has afforded very
more male fern only an inch and a half in Ieng
quarter or a third of an inch thick, than of the large
sort. The size, however, does not appear to aflVr
the quality greatly, except that the larger form re
tains its freshness longer.
Few drugs are more certain to prove effective thai
male fern of good quality and properly prepared, ye
there are few whose preparations, as found in phar
macies, are more uncertain. The quality of tin
genuine drug appears to depend wholly upon it
freshness and correct and careful preparation. Tin
freshness is at once determinable by the color, and m
pharmacist is excusable for accepting or using
inferior article. The outer surface at first lose-
green, and assumes a very pale-brown, then a dn i
rusty-brown color. At the same time a similai
change of color is occurring internally, beginning a:
the exterior and gradually working inward. Tin
quality is in a general way proportional to the re-
tention of the green color.
The composition of male fern is very complex and
variable with the length of time that the drug
retained. Many compounds have been from time
time described and, being found to act more or less
like the drug, have been credited as the active con-
stituents. We are unable, however, to state positii
to what the action is due. There appears to be little
doubt that several of the constituents are aeti\>',
upon both the system and the parasite. Filicic acid,
which is certainly somewhat active, was long re-
garded as the chief teniacidal agent, but since it in-
creases upon keeping the drug, while the latter
becomes less effective, this view has become modifi
Aspidin is more abundant in the fresh drug and bas
been proven to be active, as has aspidinin. With
these substances occur six or seven per cent, of fixed
oil, a variable amount of volatile oil and tannin, and
728
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Aspiration
■irious less known bodies. The twenty per cent.
. thirty per cent, of filicic anhydride or JUicin is not
■live.
In medicinal doses of 7> ] to i. (1.0 to I I
„■ oleoresin, the preparation almost entirely em-
loved, mule fern ordinarily has a purely extraneous
affecting only the parasite, lint, when very
rge doses are taken, or when absorption occurs, this
ling favored by the use of fats while the oleoresin is
ill in the intestine, for which reason castor oil is an
ii adjuvant, poisonous symptoms may occur,
id the results may be fatal. '1 he symptoms of
lisoning are those of great intestinal irritation and
nation, purging and vomiting, convulsive
lents ami powerful depressi ending in coma.
irablc result from the use of male fern depends
mea mi re upon the method of ad m in is (rat ion.
ie of the most important points in its administration
the dietetic preparation of the patient. F'or ten or
elve hours before the first dose he should eat no
• iiil food whatever, and the bowels if full should be
nptied by a cathartic. Milk may be taken freely,
■ thin soup; then about four grams (5i) of the
in should be given at one dose; after several
i second dose may be given, to be followed by
cathartic, if needed. The discharges should always
I nlly examined for the head and upper portions
i lie worm. Unless these are passed the cure cannot
■ considered certain, and it may be found necessary
i repeat the treatment. H. H. Rusby
\spidocotylea. — An order of trematodes or flukes,
he adhesive apparatus occupies nearly the whole
entral surface of the body, from which it is usually
istinctly constricted off. The order contains but
single family, and none of the representatives is
mud in warm-blooded vertebrates. See Trematoda.
A. S. P.
Aspidosperma. — Quebracho. White Quebracho. The
ried bark of Aspidosperma quebraeho-blanco Schlech-
■ndahl (fain. Apocynacea:).
This plant is not to be confused with the Quebracho
ilorado (red quebracho), the wood and bark of which
re very largely employed for the preparation of an ex-
•act used in tanning, and pertaining to the Quebra-
'■iia morongii Britton .(fam. Anacardiacece). The
.tie "quebracho" means axe-breaker, and is, for
bvious reasons, applied to various trees. In the last-
amed species it is the ironlike wood which has given
.ie name. In that under consideration, it is the great
bundance of stone cells in the bark which, occurring
i masses, chip out the edge of the axe. The tree is of
tedium size, widely spreading, evergreen and hand-
sale, and inhabits the northwestern portion of the
,rgentine Republic and adjacent countries. The
apply of bark is irregular, and it is usually scarce and
ear. It occurs in irregular chiplike or blocklike
ieees, and is about the thickest and roughest medicinal
ark of commerce, resembling only dita bark in this
articular. The gray outer surface is most coarsely
ad deeply fissured, while the texture is so compact
ad tough that there is little tendency for it to scale
ff. Half the thickness or more consists of cork and
ortex, the latter filled with large groups of stone cells,
"he color of this layer may be either of a yellowish-
,'hite or pale yellow, or more or less rusty or brick
ed. The inner bark consists of several thick layers
f very coarse bast fibers and varies from nearly
vhite to a rather dark brown. It is very compact,
ough, hard and woody, and of splintery fracture.
Ul parts of the bark have an intensely bitter taste.
The variation in the color of the bark cannot be ex-
ilained in the present state of our knowledge. It is
iot the darkening of age, as the writer has bark
vhieh has been kept for many years, but which is
ilmost white throughout. It is not improbable that
two or more closely related species arc in use. [I o
the matter is in much need of investigation, a the
composition and properties may differ with the
phj lical characterisl ics of the bark.
Composition. U though aspidosperma contains,
along with a small amount of tannin, no less than six
alkaloid-, its action is remarkably simple, owing to
the fact thai the alkaloids agree rather clo ely in their
general action. Aspidospermine, quebrachine, que-
brachamine, and aspidospermatine are crystalline,
aspidosamine and hydroquebrachine arc not.
Properties. — Their combined action is first to
stimulate, then to depress the respiratory centers and
to produce a nauseating expectorant effect, followed
by muscular depression or weakness, including
moderate cardiac depression. Abnormal temperature
may be reduced. The drug, used in moderate doses,
thus becomes capable of increasing both the number
and the depth of the respirations, and of relieving
spasmodic Conditions, while in large doses it induces
convulsive breathing and may end in fatal respira-
tory paralysis. Vomiting very rarely accompanies
the nausea. It is said thai aspidosamine, used alone,
acts as an emetic. Little has been done therapeutic-
ally with the individual alkaloids, that usually sold
as aspidospermine being an alkaloidal mixture.
Neither has the therapeutical use of quebracho in any
form been greatly developed. It is said to be used in
its native home partly as an antiperiodic, and partly,
like coca, to overcome the dyspnea of mountain
travel. Its chief use in professional medicine is to
relieve the dyspnea of asthma and other spasmodic
conditions, as well as of emphysema. Owing to its
weakening effect upon the heart, it is contraindicated
in case of organic disease of that organ. The results of
its continual use have not been found satisfactory,
being those of continued depression of the nerve
centers, with salivation and nausea. A peculiar
effect has been reported, in some cases, of promptly
curing erysipelas by the hypodermic injection into the
affected part of a half-grain of commercial aspido-
spermine. The dose of aspidosperma is 5 i to i.
(1.0-4.0). The extract, in five-grain (0.3) doses, is
commonly employed. H. H. Rusby.
Aspiration. — Dr. George Dieulafoy, in a paper
presented to the French Academy of Medicine in
1869, described the first perfected aspirating appara-
tus, to replace the hollow needles and trocars then in
use. The process he termed pneumatic aspiration.
This instrument was shortly followed by the larger
and more useful one suggested by Potain. These two
instruments remain in use to the present day, and,
although many modifications have been proposed,
the originals have not been replaced by any more mod-
ern invention. The only improvement of decided
value has been the introduction of trocars in the place
of hollow needles in Potain's aspirator. The advan-
tage being that the withdrawal of the trocar leaves a
blunt-pointed canula which may be freely moved
about without endangering the soft tissues, also
any obstruction in its lumen is readily removed by
reintroducing the trocar.
The Dieulafoy aspirator (Fig. 509) consists of a
glass syringe holding three or four ounces, and having
two outlets at its lower end, each of which has a stop-
cock, B,B; a rubber tube, into which is let a glass
index, E; and four needles of various sizes. The
apparatus is used as follows: The needle having been
connected with the syringe by means of the tube, and
the outlets closed, the piston is withdrawn to its full
extent, and secured by a quarter turn. The needle is
now to be introduced at the proper place, and as soon
as its point is buried in the tissues the corresponding
cock is to be opened, thereby extending the vacuum
to the extremity of the instrument. The needle is
carefully pushed forward as far as is desirable, or
729
Aspiration
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
until fluid is found, which will be indicated by its
appearance in the index, if not in the syringe. The
latter may be emptied by closing its outlet leading to
the tube, opening the other, and unlocking and driv-
ing the piston home. Another vacuum is to be made
as before, and the process may be repeated indefinitely
without removing the needle or disconnecting the
syringe.
Should the needle become stopped up during the
operation efforts may be made to clear it by reversing
the action of the syringe, and forcing a little fluid
back, or it may be partially withdrawn, or carried a
«.$^K>
Fig. 509. — The Uieulafoy Aspirator.
little deeper, or its direction may be changed. These
maneuvers failing, it must be taken out, cleared, and
introduced in another place.
With this instrument, liquids may be injected into
a cavity by filling the syringe with the fluid, instead
of exhausting the air.
Potain's aspirator (Fig. 510) comprises an air pump,
A, having two openings, C, D, each of which is supplied
with a metallic valve, working in opposite directions,
the former allowing an exit, and the latter an entrance,
of air to the pump; a bottle, with a capacity of a pint
or more, fitted with a rubber stopper, B, which is per-
forated by a double metallic tube, whose outer portion
terminates in two branches, each having a stop-
cock, K, L; two rubber tubes, with the necessary
needles, complete the apparatus.
It is made ready for use by connecting the bottle
with the needle by the indexed tube, E, and with the
pump by the tube, G. The cock, K, nearest the pump,
is opened; the other is closed. The air is exhausted
from the bottle by a few sharp strokes of the piston,
and the cock, K, is closed. The puncture is now
made, and as soon as the point of the needle is under
the skin the corresponding cock, L, is to be opened,
and the exploration carried to completion. Another
vacuum is readily established without disturbing
the needle or its connections.
By attaching a rubber tube to the inner end of tl
metallic one, long enough to reach to the bottom of tl
bottle, and by changing the tube G from D to (
so as to force air into the bottle, instead of exhaustii
it, the apparatus may be used for injection or irrigatio;
or the bottle may be emptied of its contents by simp]
working the pump. This action is due to the fa*
that the inner orifice of the tube K is on the side ju:
below the stopper, and hence independent of the till
in the bottle.
As a more perfect vacuum can be obtained wit
Dieulafoy's instrument, it is the best one for diagnost;
purposes. It is also well suited for evacuating or ii
jecting small quantities of fluid, especially when it
desirable to be exact as to the amount. But fr
drawing off large effusions, or for irrigating larp
cavities, Potain's apparatus saves time and labo
And it may be said that for general use the latt ■
instrument is the more serviceable of the two, as i
can be made to do the work satisfactorily in most c
the cases requiring this operation.
The peculiar feature of the aspirator, which di.<
tinguishes it from the trocar, and which makes i
so much more valuable, lies in what Dieulafoy call
the "previous vacuum." As this extends to tli
point of the needle the operator is notified of th
presence of fluid the instant it is reached, and there
fore there is little danger of passing through a sma!
collection of fluid without knowing it, or of wound
ing deeper structures unnecessarily, a matter of mud
importance in tapping joints and other cavities. Tb
strong suction power of this instrument enables on<
to use smaller needles, as well as to evacuate fluid
which are too thick to be withdrawn with an ordinar;
trocar.
The aspirator should always be tested just before i
is used upon a patient, because, from its peculiar con
struction, it is very liable to get out of order. Tin
piston gets loose, the needles are easily plugged witl
rust or dirt, the tubes crack and break, the coeb
stick, the stopper may not fit the bottle. All of thest
points require attention in order to avoid embarrass
ment and delay.
Fig. 510. — Potain's Aspirator.
After having been used, the needles should be
thoroughly cleansed with hot water (carbolized),
dried, and threaded with a wire to keep them patent.
Pleuritic Effusions.- — Potain's aspirator is almost
universally employed, its early and repeated use being
generally accepted. With proper care and as-
precautions it has become a harmless procedure.
General anesthesia has been replaced by the local use
of ethyl chloride or cocaine, which should always be
employed. Asepsis is of the utmost importance,
equally in the preparation of the site of puncture, in
the instrument and needles, and particularly in the
hands of the operator.
The patient is usually placed in the semi-recumbent
position, but, in suitable cases, he may sit upright
with the body bent forward, the arms raised and rost-
730
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Aspirin
ie on some firm object. Some operators prefer to
lair t lie hand of the affected side upon the opposite
loulder, as this tends to widen the intercostal spaces
n the affected side.
In selecting the site for puncture, the anatomy of
ie oavity and its contained organs must be kepi in
lind. The arch of the normal diaphragm in t he nipple
no rises to the fourth interspace, in the mid-axillary
ne from this to the sixth, and in the line of the angle
i the scapula it is on a line of the eighth interspace.
\ hen there is much fluid the diaphragm is displaced
I th.re is not much danger of its being injured,
it in chronic cases where there is not much fluid, or
here adhesions have formed, the relation of these
arts is important. Usually one of the posterior sites
selected, the sixth interspace at the axillary line
ng most desirable, as the walls are less thick and
lie interspaces most marked. When the chest-wall
thin it may be more satisfactory to select the more
isterior and lower site. Whichever site is selected.
lid be carefully selected and precisely marked
ire puncturing. The fluid should be withdrawn
Iv with intervals of rest, and the conditions of
he patient's respiration and pulse being closely
itoned. If the removal of pressure is too rapid
heart and vessels may be suddenly engorged
ausing distressing and even fatal consequences.
rapid distention of the lung tissue may also give
ise to an acute edema. The amount of fluid that
hould be withdrawn has been much discussed. This
s best determined by the extent of the effusion.
Alien it is very extensive more may be withdrawn
i when the quantity is less, but it must not be
orgotten that in such cases the structures have been
rreatly compressed and there is correspondingly a
treater reaction and strain upon the heart and
■insulation. It is advisable to stop the withdrawal
if fluid after the earliest signs of trouble and if neces-
ary repeat the operations in a few days. In other
ises, where the amount of effusion is not great, a
omplete emptying of the cavity may be effected
without any but beneficial result.
There is not much danger in inserting the needle
thesia. These are the true agnosias. The asyn
bolias consist of psychic deafness, psychic blindnes-
or psychic anesthesia. All of these some author
have called astereognoses.
True tactile agnosia may depend upon at
three factors: (a) loss of motor power of the palpatin
hand which is seen frequently in hemiplegia, to
instance, (b) loss of sensibility, and (c) loss of sen
sibility without any recognizable loss of motion.
In the first instance, the importance of contrac
tures is often extremely important, for even witl
some loss of sensibility unimpaired motion has quii.
independent gnostic perceiving qualities. Loss o
touch sensibility may be due to impairment am
where in the touch sensibility pathway to the thai
amus and thence to the cortex. The peripheral
spinal, and thalamic type of touch sensibility ha
been elaborated most carefully by Head and need no
be entered into here. (See Anesthesia and Analgesi
Cortical touch differs greatly in its disturbance
from other forms in spite of the fact that Dgjerim
has maintained that thalamic tactile loss and cor-
tical tactile loss could not be separated. The wori
of Head and Holmes points in an entirely different
direction.
Head, in particular, has shown that the ordinary,
sensation of touch is by no means a unit. Tour
resolvable into several entities or groups. Tin-
groups have special receptors and probably spe
pathways. These pathways occupy certain relative
positions in the peripheral nerves, the spinal cot
the mid-brain, the thalamus, and the cortex. These
relations undergo certain definite regroupings in
different parts of the nervous system so that certain
pathways common to two or more modes of sensi-
bility in one place shift their position, dissociations
occur, and hence one is able to pick out at differi
levels certain variations in touch sensibility due to
these altered or rearranged pathway groupings.
Thus in the analysis of tactile agnosias a distinct
step in advance has been made, and on the strength
of Head's findings an exact topographical localiza-
tion is possible in the successive levels to the cortex.
Within the peripheral neurone all of the set
bility fibers are gathered in one bundle. A se
peripheral lesion therefore should, other things being
equal, annihilate all the modalities of sensation,
epicritic touch, protopathic touch, epicritic and pro
topathic heat and cold, pain, and deep sensibility,
When such a program occurs, the peripheral nature
of a tactile agnosia is certain, and no other localiza-
tion is possible to explain the tactile agnosia.
Within the cord a rearrangement takes place. All
pain pathways are collected; heat and cold path-
ways separate and may be independently involved.
The familiar dissociation of pain, heat, and eold
from the epicritic touch is seen in intramedull
lesions — syringomyelia, hematomyelia, cysts, tu-
mors, etc.; these are well known clinical syndromes
in which this dissociation takes place. Tactile agno-
sia from spinal cord lesions, therefore, has its special
accompanying differentials of certain value.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Asthenia
On passing into the thalamus, a regrouping of the
. tsory pathways again takes place and those under-
jng tactile recognition of object qualities again
■liny new relations. A thalamic syndrome arises
,m lesions here with its well recognized association.
;i> briefly consists of a persistent loss of superficial
isation in one-half of the body and face. This loss
touch, pain, and temperature is more or less defi-
quI the loss of deep sensibility, postural sense,
,v sensibility is always more pronounced. There
slight hemiataxia and tactile gnostic loss with ac-
;,,, . on the affected side. There may be slight
,i,,r iietniplegie weakness and choreoid or atheto-
ivements in the limb on the affected side.
Ive ei ional response to stimulation of the
esthetic side is a special feature brought out by
ad Holmes.
finally, in cortical sensory loss, the whole picture
Primary sensibility becomes related. The
cortex is the organ by which attention may
focussed on any part of the body that is stimulated.
nies of response to sensory stimuli unknown
r levels are found in cortical lesions. The
BT the area affected between the precentral fissure
occipital lobe, the more certainly will sensi-
bow these characteristic changes.
iccuracy of response to measured tactile stim-
gradually reduced. The answers become
jrular and uncertain. Contact sensibility is not
it. Tactile sensations tend to persist, and almost
hallucinate." Fatigue comes on readily. Estima-
oti of warmth and cold suffers, if the thermal sen-
bility has suffered. Tests for recognition of pos-
e, of passive movement, and spatial discrimina-
bow profound loss.
Further detail of these important researches must
consulted in the original studies (see also Anes-
■nd Analgesia). Enough has been said to show
e main outlines of differentiation of localization
lesions causing tactile agnosia.
\-ymbolia is due to a purely cortical lesion in
Inch the angular gyrus is very often involved.
Smith Ely Jelliffe.
Asterol. — Para-sulpho-phenol mercurv and ammo-
ium tartrate— C 1 ,H I0 O s S 2 Hg.4C 4 H 1 O 8 (NH 4 ) 2 +8H ! O.
his is a preparation claimed by its manufacturers
i contain fifteen per cent, of mercury, to have
iss action on metals than other mercury com-
ounds, and to precipitate albumin to only a small
egree. Steinmann's investigations have sustained
claims, and he states that 1 to 10 per cent,
ilutions of albumin are precipitated by 0.1 per cent,
ilution of mercuric chloride, while they are made
nly slightly opalescent by a solution of asterol of the
ame strength. Vertun has questioned the claims
f the manufacturers, stating that he found only
leven per cent, of mercury, and that it would attack
urgical instruments and precipitate albumin. As-
erol is a brown powder, slowly soluble in cold water,
nd rapidly soluble in hot water with the formation
f a permanent solution. It is used as an antiseptic
ubstitute for mercuric chloride in 0.1 to 4 per
cnt. aqueous solution. Such a solution of 0.7 per
cut. strength is equivalent in antiseptic power to a
1.1 per cent, solution of mercuric chloride.
W. A. Bastedo.
Asthenia. — This term (meaning without strength,
lebility, weakness, loss of power) was used by Brown
n 1780 for general weakness or prostration, and
inployed by him in his theory of disease. He sought
he cause of all disease in a departure from a mean
>r medium degree of excitability or irritability, either
n an increase above the normal mean (sthenic or
lyperslhenic disease), or in a decrease (asthenic dis-
ease). Asthenology is, therefore, the theory of asthenia
diseases according to Brown's conceptions; astheno-
macrobiotic, the art of prolonging an asthenic life.
Some survival of these views is found at the pre
in our use of sthenic and asl henic as applied to levers.
Asthenic fiver (adynamic or torpid fever) is one
characterized by extreme weakness and prostration,
dulled sensorium, small, weak and frequent pulse,
weak heart, and low blood pressure. In sthenic fever,
on the other hand, these characteristics are absent,
the pulse is full and bounding, arterial pressure high,
and the patient excited and active. In modern
medicine these terms have bul little significance
beyond describing the patient's condition, or the
degree of toxemia (asthenic fever in septicemia,
pyemia, typhoid fever, severe variola, diphtheria,
pneumonia, scarlatina, meningitis, acute tubercu-
losis, etc.); they are not in any sense diagnostic or
used with reference to the nature of the disease.
The present generation uses these terms more and
more seldom, and they arc employed almost wholly
by older medical men.
Still more nearly obsolete is Yirchow's classifica-
tion of inflammations as sthenic and asthenic. His
idea of a sthenic inflammation as a pure form under
favorable circumstances and conditions, and of an
asthenic inflammation as one occurring in weakened
parts or bodies, is entirely out of harmony with our
present conceptions of inflammation, and has no
longer any practical value, so that these designations
are now rarely employed.
In the sense of weakness or impaired strength, asthe-
nia has gained a wide use as a general term; and in
combinations, such as myasthenia, neurasthi raid, ■psych-
asthenia, etc., is used to designate certain special forms
of weakness. By some neurologists motor asthenia is
used as a synonym for paralysis. Internists apply
asthenia to any marked weakness, but particularly
to the loss of energy and extreme weakness seen in
Addison's disease. In the majority of cases of this
condition the first symptom is an unusual tendency
to fatigue from either physical or mental exertion.
So marked is this symptom, even before any other
sign of the disease develops, that any severe
asthenia should always excite a suspicion of Addison's
disease. Asthenia, in the sense of a motor insuffi-
ciency characterized by difficulty or impossibility of
prolonged muscular effort, is a symptom found in
the beginning, course, or decline of a number of
diseases, particularly in affections of the abdominal
organs, certain nervous diseases, disorders of the
cerebello-sympathetic system, etc. In these condi-
tions the asthenia is symptomatic and secondary.
A primary constitutional asthenia dependent upon
a congenital weakness of the cerebello-sympathetic
system has within recent years been described by a
number of writers (Londe, etc.). This condition mani-
fest itself at different ages as a difficulty or impossi-
bility for prolonged or repeated muscular effort. In
infants the crying is feeble, sucking movements slow
and weak, the stomach empties itself slowly, and
constipation is the rule. Such infants show a lowered
resistance to colds and infections, and especially to
gastrointestinal intoxications. Dentition is slow,
and accompanied by gastrointestinal disturbances.
All muscular movements are slow and learned with
difficulty. Walking is not acquired until in the
second year. The child is feeble ; its motor apparatus
is capable of only a small amount of work.
During adolescence the asthenic shows his constitu-
tional weakness in many ways (amyosthenia, diges-
tive disturbances, familial, orthostatic or cyclic
albuminuria, cardiac weakness, various functional
disorders, cerebral dullness, apathy, etc., inconti-
nence of urine, chorea, scoliosis, etc.). In the female
disorders of menstruation, migraine, membranous
enteritis, vomiting of pregnancy', etc., are to be
regarded as signs of a weaker organism. Gastro-
735
Asthenia
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
enteroptosis is an especial feature of constitutional
asthenia. The adult asthenic knows his weakness,
and is either pessimistic or attempts to conceal it.
The abuse of coffee, alcohol, and other stimulants is
common to these asthenic individuals. Drug habits
often result from the attempt to mask the condition.
The adult asthenic is also especially susceptible to
intoxications, autointoxications, and infections. Ac-
cording to the conditions of existence and predis-
position the effects of constitutional asthenia are
shown at certain times in one or another organ.
Periodical attacks of migraine, dyspepsia, jaundice,
grippe, bradycardia, uremia, etc., are the results of
a digestive or nervous insufficiency. Chronic inter-
stitial nephritis is of frequent occurrence in the
asthenic. Slowness characterizes all vital move-
ments, mental as well as physical. The asthenic
does not care for active sports, and is incapable of
planning far ahead. His faculty of adaptation is
limited. Not all asthenics may be recognized by
their slow reactions or apathy, since their asthenia
may be wholly relative. The asthenic who recog-
nizes his weakness may defy it. and with a strong
will-power compensate for it. This compensation by
means of the will may, however, be suddenly broken
by some shock, and the asthenia increased. From
neurasthenia the condition is differentiated by the
ability of the asthenic to compensate for his inferior
organism by means of his will-power. In the as-
thenic, failure of memory or attention, or of judgment
is the result of fatigue. Hypochondria does not
characterize the asthenic. Sexual power is not lost
in asthenia as it so often is in neurasthenia; it requires
only conservation, excess is impossible. The diag-
nosis of primary constitutional asthenia rests upon
the history of a delicate infancy and signs of asthenia
in adolescence, the necessity for rest, the inability to
commit excess, and the frequent attacks of illness
during adult life and old age.
Stiller's publication in 1907 of his monograph on
" Die asthenische Konstitutionskrankheit" gave to
asthenia a much more specific significance, inasmuch
as he makes Glenard's disease (enteroptosis) one of
the most prominent features of constitutional asthenia.
Tuffier (Scmainc Medicate, 1894) had previously
expressed the view that enteroptosis was a feature
of a general disease characterized by an alteration
of all tissues, "a congenital insufficiency of the
tissues"; and in 1899, Strauss (Berliner klinische
Wochenschr., 1S99) also spoke of constitutional forms
of ptoses. Stiller's especial service has been in giving
a broader view to the conception of enteroptosis,
considering this condition, not as the result of local
mechanical factors, but as a feature in a constitu-
tional peculiarity characterized by a definite type of
body, the habitus asthenicus. The chief features of
this are a slender skeleton, slight panniculus, slight
musculature, pale skin, flat and narrow thorax,
narrow thoracic aperture, narrow epigastric angle,
floating tenth ribs, prominent abdomen, ptosis of
stomach and colon, low or floating kidney, small
heart, perpendicular position of heart, and tendency
to hemorrhoids and varices. Hausmann ( Wiener
klin. Wochenschr., 1909, Bd. 22, 109S) considers the
following anatomical peculiarities to be constitutional
signs of morbus asthenicus:
1. Pylorus palpabilis — pylorus mobilis.
2. Deep-lying greater curvature.
3. Deep-lying transverse colon.
4. Cecum mobile.
5. Flexus mobilis.
6. Low umbilicus.
7. Floating tenth rib.
With the anatomical peculiarities of asthenia
universalis congenita go hyperesthesias and lability
of the nervous system, muscular weakness, gastric
disorders (atony, nervous dyspepsia, hyperacidity,
736
spastic obstipation, gastric ulcer, etc.). Stiller
views of the constitutional nature of enteroptos
have been opposed by some gynecologists, an
accepted by others. It remains to be seen, howeve
whether his asthenia universalis congenita can \
given a distinct nosological position. The relatic
to rachitis and infantilism is not yet worked ou
Strauss (Berl. klin. Woch., 1910, Bd. 47, S. 20'
regards the habitus asthenicus as a result of disturbe
development related to infantilism (habitus infm
tilis). The condition is not found in infants, he i>
lieves, but develops during adolescence, and is moi
frequent in females. As to the treatment he coi
siders preventive measures the only ones likely to I
of value. Both operative and orthopedic procedun
often fail. If the enteroptosis and floating kidnc
are but single features of a constitutional anomah
operations are not likely to offer much relief, and tl
experience of many operators bears this out. Nep]
ropexy is considered useless by some writers. ]
should be borne in mind that some of these ea
habitus asthenicus have been operated upon U
chronic appendicitis without relief. Gynecologist
are divided in their views as to the value of operation
As etiological factors there have been suggeste
too frequent and too close pregnancies on the par
of the mother, rachitis, thyroid insufficiency, an
other forms of autointoxication; but no causal nlj
tionship has yet been demonstrated. Further stud
is needed to clear up the matter of eonstitutiona
asthenia and its nosological position can hardly bi
regarded as a settled one.
The prognosis in constitutional asthenia depend
largely upon the will-power of the asthenic. Hi
cannot change his constitutional anomaly, but recog
nizing it, he may rise above it, and by conservatii
of his powers live as long and accomplish as much ai
the average normal individual who does not have i
concern himself with conservation of his functions
Some asthenics show a high plane of moral elevati..,
General hygiene, and especially mental and mora
hygiene, are the chief factors by which congenital oi
acquired constitutional asthenia may be foughl
The education of the asthenic child should be eon
ducted along especial lines, and in this respect shouk
be begun as early as possible.
Aldred Scott Warthi.v
Asthenopia (from cuiQivb-:, weak, and &p, eye). This affection
stands in close relation to parametritis, and is rebel-
lious to all therapeutic measures directed to the eyes;
its course is extremely tedious, but recovery generally
Vol. I.— 17
737
Asthenopia
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
takes place when the pelvic disease has been arrested
or has run its course.
Muscular Asthenopia. — As in hypermetropia, with
accurate covergence, the accommodation is forced
to perform its work at a disadvantage, so in myopia
the habitual relaxation of the accommodation in near
vision may be attended with disabling inhibition of
convergence.
Fatigue of the recti interni muscles was recognized
by Scarpa (1807) in some cases of asthenopic vision,
but the recognition of muscular asthenopia as a
distinct type was possible only after the demonstra-
tion of the interrelation of accommodation and con-
vergence as affected by errors of refraction.
The name "asthenopia muscularis" was given by
von Graefe to the complex of asthenopic symptoms
in which muscular fatigue gives way to crossed
double vision, in near work. Myopia was recognized
as an important etiological factor; but equal or greater
stress was laid on contributory insufficiency of the
recti interni muscles and the indications for prescrib-
ing prismatic-concave glasses, or for neutralizing the
relative preponderance of the recti externi muscles
by tenotomy.
The clinical observations of von Graefe, and the
study of myopia from the anatomical and physio-
logical stand-point, by Donders, proved that as over-
loading of the accommodation in hypermetropia is
the predominating cause of accommodative astheno-
pia, and of convergent strabismus, so relaxation of the
accommodation in myopia is a principal cause of
muscular asthenopia, and of divergent strabismus.
As accommodative asthenopia is the expression of
relative insufficiency of accommodation under normal
convergence, so muscular asthenopia is the expression
of relative insufficiency of convergence under relaxed
accommodation.
Treatment. — As regards the curability of astheno-
pia opposite opinions have prevailed at different
times. So long as it was supposed to be a form of
amblyopia, the prognosis was unfavorable. When
it had come to be regarded as the expression of "morbid
sensibility of the retina," so-called derivative med-
ication, local abstraction of blood by cupping or
leeching, counterirritation above the eyebrows,
blisters or setons in front of or behind the ears or at
the back of the neck, and protection from strong
light by green or blue glasses were thought to be
curative. Reading or other near work was forbidden,
and out-door life enjoined. In obstinate cases the
sufferer was advised to "live on a farm," or to "go
to sea," in the hope of benefit from prolonged rest of
the eyes.
The fact that many asthenopes discover for them-
selves that convex glasses are helpful in reading was
known to physicians long before they ventured to
prescribe them for young persons. Later, when
asthenopia was explained as a special form of presby-
opia occurring in childhood or youth, it was thought
that the guarded use of convex glasses might be per-
mitted in near work, but the very idea of a young
person wearing glasses "strong enough for his grand-
father" was regarded with horror, as fraught with
untold danger. Hence convex glasses were pre-
scribed of the least power compatible with fairly easy
use of the eyes, with a view to changing them for
progressively weaker glasses and ultimately to doing
without them. That this plan of treatment was not
altogether irrational is evident from the experience
of the very large number of young hypermetropes
who are able to use their eyes freely in prolonged
near work; a fact entirely in accordance with the
observation of Donders, that, with parallel visual
axes and also under moderate convergence, a hyper-
metrope ordinarily brings into use much more of
his accommodation than does an emmetrope under
like conditions. Moreover, it is not uncommon for
asthenopic symptoms, occurring in connection wit]
hypermetropia of moderate grade, to disappear aftc
a few weeks or months of relief from strain affordei
by the use of weak convex glasses in reading am
study. In these cases the glasses give great relic
when first worn, but after a time the need of then
comes to be less urgently felt, so that the child be
gins to do without them and at last forgets to us
them at all. But these cures, however satisfactor
they may be for the time being, are apt to be foi
lowed by relapses, which, again, may yield to a ne\
course of treatment by glasses, until, with increasin
age and the physiological limitation of the rang
of accommodation, the habitual use of con\c.
glasses becomes imperative.
Asthenopia may be treated with some measure o
success by the methodical use of myotics. In hi
original study of the action of Calabar bean
Donders observed that the range of accommodatioi
is positively increased, and that this incret
which is greatest after about two hours, dimin
ishes rather slowly. He observed, also, a materia
increase in accommodation as related to con
vergence, amounting to rather more than ().;
dioptrie eleven hours after the instillation; and In
makes the very significant remark that "hyperme
tropes, under the double advantage of smaller circle
of diffusion and of easier tension of accommodation
lose for a time their asthenopia." 3 The introductioi
of pilocarpine in ophthalmic therapeutics has made i
practicable to maintain a condition of mild stimula
tion of the accommodation for an almost indofiniti
period. In cases of asthenopia in young perso
with hypermetropia of low grade, pilocarpine may bi
employed in a weak solution, instilling any desirec
fraction of a minim measured by means of a slendei
glass pipette. The treatment may be begun with i
two per cent, solution, used night and morning, am
the observed effect regulated by varying the quantity
used or the strength of the solution. In this way it
is sometimes possible to tide over an intercurrent
asthenopia in a young hypermetrope, and in some
cases to postpone recourse to glasses perhaps foi
years.
In asthenopia dependent on hypermetropia of high
grade, the only effective resource is in the use of oo
vex glasses, and these should be, as a rule, of the highest
power compatible with distinct vision at a distance
Owing to the fact that a part of the hypermetropia
is almost always latent (see Hypermetropia), fully
correcting (neutralizing) glasses often prove less
acceptable in the beginning than those of less power,
but in every case the selection of glasses should be
made with distinct reference to the total hyperme-
tropia, and in the expectation of ultimately applying
the full correction. In a few cases of asthenopia, in
which any exercise of the accommodation is attended
with pain or fatigue, a bifocal combination of a
neutralizing convex glass for distance with a stronger
correction for reading may be indicated. In still
rarer cases, in which the attempt to read indu
accommodative spasm, it may be necessary to ha
recourse to atropine, to assure complete physiolog-
ical rest. During the maintenance of the mydriasis
reading may be permitted with the aid of strong ci
vex glasses, which must be exchanged for neutraliz-
ing glasses when the accommodation is allowed to
resume its function. A young hypermetrope who
requires convex glasses for reading sees perfectly at a
distance with the same glasses, and, as a rule, finds it
convenient and agreeable to wear them constantly;
but in this he may generally be permitted to follow
his own pleasure. If for any reason he is disinclined
to wear glasses constantly, a compromise may often
be effected by prescribing spectacles for reading or
study, and a pince-nez for occasional use.
In muscular asthenopia the treatment consists
primarily in the correction of the myopia, together
738
REFERENCE HANDBOOK OF Till". MEDICAL SCIENCES
Asthma
itli any astigmatism that may be present, by means
■ neutralizing concave spherical, spherico-cylindrical,
• toric glasses. The glasses should, as a rule, be
iounted in a spectacle frame rather than as a pince-
and they should be worn continuously. The
lief afforded by neutralizing glasses is generally
imediate and complete, but in a few cases it may
>sary to prescribe stronger concave glasses
hich, by over-correcting the myopia, compel some
of the accommodation in distant vision and
immensurately increased accommodation in near
ork. This over-correction, which may be carried
. high as three or even four dioptries in children or in
nine adults with ample range of accommodation, is
, |, •fully accepted, and appears not to be attended
ith the' danger commonly attributed to the wearing
irons concave glasses by myopes.
lei ■.■Titration of concave glasses outward, or,
amounts to the same thing, the grinding of
spherical or spherical and cylindrical surfaces
1 convergent prisms, is often of advantage by cor-
■ctlng the refractive error and at the same time
vine some measure of direct relief to the recti interni
In the higher grades of relative muscular
[sufficiency, division of the tendon of the rectus
cternus muscle in one eye or in both eyes may be
i id, but operative interference should be
insidered only after an exhaustive investigation of
ich particular case, and a full trial of other methods.
In the treatment of asthenopia, whether accommo-
utive or muscular, the principal, and oftenest the
ngle indication is to correst the underlying error of
■fraction (hypermetropia, myopia, astigmatism,
lisometropia) by giving neutralizing glasses (convex,
mcave, cylindrical, or of different power for the
vo eyes). A practically normal relation of accommo-
ition to convergence is thus established, and, except
i progressive myopia, the same optical connection
iffices until, with beginning presbyopia, other glasses
■ required in reading, (see Accommodation and
fraction, Astigmatism, Hypermetropia, Myopia,
esbyopia). John Green.
1. E. Dyer: Transactions of the American Ophthalmological
■ ii-ty, 1S65.
_ \. E. Ewing and G. Sluder: Transactions of the American
phthalmological Society, 1900.
3. F. C. Donders: On the Anomalies of Accommodation and
efraction of the Eye, 1864.
Asthma. — This disease well illustrates the harm
hich may follow- upon interference with normal
■ivsiological habits. The most uniform habit in the
nly is that of the succession of expiration upon the
id of inspiration without a pause between the two
ts. Xow all coughing interferes with the act of
tpiration. Prolonged coughing, therefore, is one
the commonest causes of asthma, as it is shown by
te frequent supervention of asthma upon measles
id whooping cough in childhood, the formative
■riod in life of physiological habits. These habits
re organized in the respiratory centers of the medulla
ilongata, so as to produce a perfectly rhythmical
ving of the pendulum, so to speak, in the act of
reathing. But anything which interferes with the
ivthinical succession of expiration upon the end of
ispiration will itself sooner or later become a morbid
ahit of checked or prolonged expiration. Now
nighing does this because it is exclusively an expira-
)ry act.
This derangement of the rhythm in the function of
le medullary centers may sooner or later originate
titer morbid habits excited by afferent stimuli, which
ould not have any such effect in previously healthy
ersons; hence those curiously varied excitants of
le asthmatic paroxysm in chronic asthmatics,
ometimes a simple mental impression in such
atients may induce an attack. At other times
afferent impressions starting from the nose as the
mosl sensitive part of the breathing apparatus will
bring on fits of dyspnea from certain odor mch B
the smell of violets, or of animal I iiianat ions, like
those from cats or horses, or bj avi it to a menagerie.
As might be expected, therefore, di ea e conditions
in the nose itself, such as nasal polypi, may be the
cause, and will be relieved only by suitable attention
to conditions of the nose. But this morbid excitabil-
ity to afferent impressions may become widely
spread, so as to be induced through those branches
of the pneumogastrie nerve which supply the organs
of digest ion, thus giving origin to w hat is called peptic
asthma. Afferent excitations from other parts of the
body rarely have anything to do with asthma,
because those parts have no connection with breath-
ing. Asthma, therefore, may be properly termed a
pure neurosis involving the respiratory centers, while
all changes of an anatomical kind in the bronchi or
in the air vesicles are simply secondary in their
nature. Asthma-like paroxysms may be caused by
blood poisons, such as in gout and in uremia, but
these can be readily distinguished and treated apart
from the functional nervous symptoms which accom-
pany them. There is one normal change, however,
which occurs in breathing during sleep, which may
affect the respiratory rhythm in asthma. In sleep,
particularly if it is profound, the breathing is much
slower than in the waking state, with a prolonged
inspiration and a shortened expiration, the opposite
of the breathing in asthma. But as this itself is
unnatural, so it is a frequent cause of asthmatic
attacks at that time, the patients often beginning to
breathe asthmatically even before they wake.
The dyspnea in a developed attack of asthma is
so great that if it happened in any other disease
would denote actual peril to life. In asthma, how-
ever, though the distress be great, alarm is signifi-
cantly absent from the patient, which it is not in
asthma-like paroxysms due to such blood poisoning
as in uremia.
Symptoms. — The leading symptom of asthma is a
marked difficulty limited to the act of expiration.
Unlike croup, asthma allows the air to enter readily
with inspiration, but the expiration is labored
throughout, rendering this act two to four times the
length of the inspiration. This disproportionate
expiration is characteristic, for though the expiration
is prolonged in emphysema, yet it never equals the
delay of asthma. The patients dread, therefore, the
most ordinary acts which entail a prolongation of
expiration, such as coughing, or even speaking, though
in some, laughing of itself is sufficient to induce an
attack, while on the other hand a deep inspiration
may serve to break the paroxysm.
No consideration of this subject would be complete
without alluding to the supervention of asthma in
chronic bronchitis. Many cases of chronic bronchitis
end in time in the condition which differs but little
from true asthma, but the practical point is that if
you cure the bronchitis, you cure the asthma. These
cases from their long standing are apt to cause enlarge-
ment of the right side of the heart, with regurgitation
into the great venous vessels to such a degree as to
cause general dropsy, beginning like other forms of
cardiac dropsy in the feet. Like other asthmatics
they can scarcely undergo any muscular exertion,
such as rising from bed, without bringing on severe
coughing along with asthmatic breathing. These
cases, therefore, ought to be called examples of
asthmatic bronchitis, the bronchitis being the chief
factor in the general derangement. They ought,
therefore, to be treated as cases of bronchitis and not
of asthma.
Owing to this impeded exit the residual air increases
in the lungs to such an extent that the intercostal
spaces become much widened and the girth of the
739
Asthma
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
chest so expanded that the ordinarily worn clothes
of the patient will not come together by from one to
three inches. The upper abdomen also becomes
similarly distended by the forced descent of the
diaphragm pushing down the liver, stomach, and
spleen. The walls of the chest finally seem too fixed
to allow of any but the slightest expansion and
retraction in breathing, and this condition gives to the
patient a sense of suffocative tightness, as if caused by
some external compression. Salter notes also, as a
frequent symptom, a persistent itching of the chin,
and often between the shoulder blades and sternum
as well, supervening with the first symptoms of
asthmatic breathing and passing off with the full
development of the paroxysm.
Diagnosis. — Physical exploration of the chest now
affords a group of characteristic symptoms which
render the diagnosis of asthma a matter of no great
difficulty. The lung distention exaggerates the
pulmonary resonance on percussion and extends its
area in every direction, behind the clavicles, over the
heart, and downward over the regions of normal
splenic and hepatic dulness. From the same cause
the vocal fremitus either disappears or is much
diminished in those localities where it is well marked
in health. Auscultation, however, is the most decisive
in its indications, for the normal vesicular murmur is
quite displaced by high-pitched sibilant rales, which
often attract the attention of bystanders, as they
become audible to some distance from the patient.
On applying the ear to the chest, however, one
distinguishes very fine rales, mingled with others
larger and graver in tone, which, moreover, seem
to shift in location as if sometimes near to the ear,
and then farther off, like a wavy passage of air over
various musical tubes. In simple asthma these rales
are purely sibilant, but in prolonged attacks, or when
bronchitis is also present, they become more or less
crackling.
As the disordered respiration continues, the suffer-
ings of the patient for breath become extreme.
His whole frame partakes in the struggle for air,
which leads him involuntarily to try to expand the
chest yet more and more. He strives to make
immovable his back, shoulders, and head, so that
from them the accessory muscles of respiration may
pull upon the already tense walls of the thorax.
Hence he fixes his arms or plants his elbows on a
table or other support, while his head is thrown back,
his mouth panting, his eyes widely opened and fixed,
and his face pale and bedewed with perspiration. He
speaks only in monosyllables, and resents everything
which calls him off, even for a moment, from his
efforts to breathe. The pulse grows small and feeble,
and the patient becomes so cyanotic and cold that his
wet, clammy skin and ghastly expression are apt to
inspire strangers with fear of his near dissolution.
The duration of an attack varies greatly, not only
in different patients, but in the same patient at differ-
ent times. The attack may come on in the night and
pass off soon after daylight, or it may be prolonged
into a series of exacerbations and incomplete remis-
sions for several successive days and nights, until the
sufferer becomes almost fatally exhausted. In like
manner the subsidence bears little relation to the
severity or duration of the attack. Either as the
effect of remedies or spontaneously, the breathing
may become suddenly easier, the rigidity of the chest
walls pass off, the inspirations grow fuller and the
expirations shorter, and the patient, who but a few
moments before seemed about to perish in his distress,
will soon return, after a moderate expectoration of a
clear frothy mucus, to regular and natural breathing,
with no other indication of his recent sufferings than
an expression of fatigue. At other times, especially
if bronchitis supervenes, the attack passes off in a
series of irregular paroxysms of difficult breathing,
alternating with coughing and free expectoration.
In many fully developed attacks, however, the
patient has carefully to watch for its decline by avoid-
ing all causes of exacerbation or relapse, especially
from eating, so that some asthmatics are obliged to
go to bed fasting if they are to pass that night free
from dyspnea.
Etiology. — In asthma, as in other markedly spas-
modic diseases, the afferent impression which induces
the attacks varies indefinitely, both in kind and in
seat. The sensory nerves, however, which are
distributed to the mucous membrane of the respira-
tory tract, including the olfactories, afford the most
frequent instances of the curious impressibility which
excites refiexly the asthmatic spasm. On this
account bronchitis itself takes the lead, for asthmatic
breathing occurs in so large a proportion of both
acute and chronic forms of this affection that some
writers have gone the length of ascribing all asthmas
to bronchitis. It is easy to show, however, that
asthma lacks no element of a true neurosis, and that
in many typical cases there is no bronchitis whatever.
In the initial or "dry" stage of acute bronchitis,
along with the sense of soreness and tightness across
the chest, auscultation reveals the presence of true
asthmatic wheezing, while in chronic bronchitis
asthmatic attacks often occur upon very slight
provocations, such as by rising too suddenly, or from
attempting too long a sentence in talking.
After the irritation of bronchitis, the list of excitants
of asthma which take their start from the sensory
nerves of the respiratory mucous membrane varies in
a most extraordinary degree. Nearly every asthmatic
has his specialty of the kind, so to speak, often with
a most unaccountable caprice of choice. The writer
has known of a gentleman who, while in his room on
an upper floor, yet could tell at once by his breathing
that buckwheat flour had just been brought into the
house. The smell of powdered ipecacuanha is often
mentioned as a similar excitant, but although this
may be ascribed to irritation by minute particles of
ipecac inhaled — and the like may be said of asthma
from the inhalation of mustard or of the fumes of a
sulphur match — yet such an explanation cannot
hold good in asthma caused by the smell of violets or
of other fragrant flowers. In fact nothing can be
more whimsical than the behavior of asthma as
regards either what may be resented as an ingredi-
ent of the air inspired, or simply the general char-
acter of the outer atmosphere. One asthmatic may
find comfort in the air of a particular locality which
another asthmatic can enter only at his peril. Salter
mentions the instance of two friends who could not
exchange visits at their country houses, which were on
opposite sides of a ridge, though both were suited
with the air of London. The air of large cities, in
fact, despite its smoke and dust, agrees oftener with
asthmatics than does the pure air of the country.
Next to the respiratory tract, the most frequent
excitants of asthmatic attacks proceed from the
alimentary canal, especially from its gastroduodenal
portion. Most asthmatics, indeed, are also dyspep-
tics, and are thus doubly obliged to be particular in
their dietary. The list of forbidden articles is
singularly varied, as we might expect from the range
in this respect among dyspeptics as a class. Some
will have asthma if they take cheese, others almonds,
others apples or wine or tea or tobacco, etc.; the
peculiarity being that the particular idiosyncrasy is
generally consistently adhered to, perhaps for many
years, or at least as long as natural tastes or likings
are apt to last. With many patients, however, it is
not so much a particular article which brings on a
paroxysm, but a too hearty meal for them of any
kind. On the other hand, constipation is the sure
provocative with some who are also often promptly
relieved by a cathartic. In women, uterine derange-
740
REFERENCE HANDBOOK ( )!•' THE MEDICAL SCIENCES
Asthma
merits have their share in 1 1 1 « ■ causation of asthma,
though not as frequently as they serve t<> excite ot her
spasmodic diseases ; while a certain proportion remains
whose attacks seem to be induced solely by mental
excitement, particularly of a depressing kind.
Among the special predisposing causes of asthmatic
seizures is the stale of sleep, for the majority of
distinct attacks set in after the patient lias been
asleep for some time, and oftenest during the hours of
profound slumber, after midnight, tin that account
the majority of attacks occur after the patient has
been asleep for some time. Most asthmatics, there-
fore, have to take their heartiest meal about noon,
and not dine in the evening. Some asthmatics are
obliged to keep awake after noting certain of their
usual premonitory signs', or the attack will surely
develop if they happen to sleep at all. The relation
of sleep to the attacks is also well illustrated in peptic
asthma, for though the offending article of diet be
taken in the morning, yet it will not be until its
customary hour in the night that the asthma which
it induces will come on. This chronometry of asthma
exemplifies the real but unperceived continuousness
of the spasmodic nervous diseases, in all of which the
outbreaks are sudden only in the manifestation of
certain symptoms, and which mere symptoms, like
spasm, etc., are therefore too often mistaken for the
whole disease. The reasons which have been adduced
by various writers for this nocturnal feature of
asthma, as in the analogous instance of nocturnal
epilepsy, are too hypothetical to call for extended
discussion. It is interesting, however, to note that
the mere fact of darkness seems to dispose to the
attacks. Not a few patients can prevent them by
keeping a light burning brightly in their rooms,
while if the light be put out they will soon wake up
with difficult breathing.
Asthmatic dyspnea is also occasionally secondary
to other diseases or morbid states, in which case it
ranks only as a symptom of them. Thus, in heart
disease, particularly in mitral stenosis, the widespread
congestion of the bronchial mucous membrane may
excite real asthmatic symptoms, which, moreover,
should not be confounded with true cardiac dyspnea.
In the latter, the patient resembles one who is out of
breath from muscular exercise, as after running, but
cardiac asthma, properly speaking, shows the same
derangement of expiration as ordinary asthma, and is
evidently due to the bronchial hyperemia acting as a
reflex excitant. Toxemia also sometimes produces
asthmatic attacks, especially in gout and in uremia.
In the gouty cases the attacks are sudden, nocturnal,
and quickly accompanied by a great bronchial flux,
which may be pinkish from capillar} 7 hemorrhage.
A patient of mine once expectorated two large basinfuls
of such mucus between midnight and morning, but
after three such attacks they ceased and never recurred
afterward. In gouty asthma alarm is wholly absent,
but not so in uremic asthma. Here again, as in the
cardiac cases, the dyspnea should not be mistaken
for asthma, if it be due, as it commonly is, to pul-
monary edema or to pleuritic effusion. True uremic
asthma is characterized by sudden attacks of difficult
breathing with great terror, and often also with severe
palpitation of the heart, which is usually much hyper-
trophied from the arterial obstruction of chronic
renal disease. After a few attacks, if not after the
first one, the breathing remains permanently short-
ened, and the patient dreads the slightest cause of car-
diac excitement. In most cases uremic asthma is a
late, and not a favorable symptom of chronic Bright's
disease, particularly of interstitial nephritis, and it is
commonly associated with abundant light-colored
urine of low specific gravity, with or without albumin,
and with evidence of general endarteritis as illustrated
by the tortuous and rigid temporal and radial arteries.
In one case, however, seen by me in consultation, the
kidney affection seemed to follow the asthma rather
than to precede it. The patient, a gentleman about
fifty years of age, was suddenly seized, while appar-
ently in perfect health, with extreme dyspnea. His
physician on arrival tested his urine and found it
heavily loaded with albumin. This albumin, how-
ever, wholly disappeared in a few days, until after a
fortnight, when he had another exactly similar
seizure, also in the daytime. The interesting circum-
stance connected with the second seizure was that he
had sent a specimen of urine, passed only an hour
before the attack, to be examined, and it was found
to be wholly free from albumin and of normal specific
gravity; but some tested immediately after the
seizure set in became nearly solid on boiling. This
observation of the reappearance of albumin only at.
the attacks, with its gradual but ultimately final
disappearance until another fit of dyspnea arrived,
was repeated a number of times, once by myself, as
daily examinations of his water were kept up. He
finally succumbed, some months later, to extensive
effusions in both pleura?.
Asthmatic attacks are also sometimes plainly
associated with the disappearance of chronic skin
eruptions. A patient of mine always became asth-
matic whenever an old eczema of the chest began to
subside, until he found that he could rid himself of
the infliction by an artificially induced eczema with
croton oil.
Age. — Asthma may begin at any age. An intelli-
gent patient of mine, seventy years old, stated that
the disease was observed in him on the first day of his
life. There is, however, a special proclivity to it in
the first decennial, owing to the predisposition of
children to bronchitis. Of 225 cases, Salter had
seventy-one under ten, and in eleven of them it began
in the first year. The prognosis of asthma is better in
childhood than later on, as it is frequently outgrown
after puberty, particularly if the causes of bronchitis
be carefully avoided. The cases which begin in
adolescence are relatively few, and are then gen-
erally of the purely spasmodic form. But in middle
life the proclivity to asthma again increases with the
greater exposure from outdoor occupations, but, un-
like bronchitis, asthma as a new disease begins to fall
off, and progressively decreases in its ratio till seventy.
The common impression that asthma is a disease of
old age is a mistake, arising rather naturally from
the frequency of chronic bronchitis with asthmatic
wheezing among elderly persons.
Sex. — The influence of sex is considerable, the
preponderance of males being about double that of
females. That this, however, is due to the greater
exposure of men to causes of bronchitis, is shown by
the fact that the cases of the pure spasmodic variety
are about equally divided between the sexes.
Heredity. — Asthma belongs also to the markedly
hereditary diseases, as might be expected from the
characters of its common accompaniments. An
inherited proclivity to bronchitis is observable as
often as a family tendency to phthisis, while neuroses,
on the other hand, are more frequently of constitu-
tional origin than any other class of affections.
About thirty-five per cent, of all asthmatics, there-
fore, will show some sign of heredity, and oftener
from the paternal than from the maternal side — a
fact, moreover, in keeping with the greater frequency
of the disease among men.
Pathology. — Asthma has no characteristic ana-
tomical lesions. That extensive pathological altera-
tions are often found postmortem is quite true, but
in most cases they are caused by intercurrent affec-
tions, particularly by bronchitis. Under this head
come hypertrophy of the circular muscular fibers,
with consequent narrowing of the bronchioles, it may
be even to occlusion, collapse of lobules, emphysema,
and dilatation of the right side of the heart, with the
various sequela; of these conditions. But there are
(41
Asthma
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
some organic alterations which may be ascribed to
the labored respiration of asthma alone, when severe
and prolonged attacks come so often that the parts
have no opportunity to return to their normal state
during the intervals. That this is the occasion of such
changes appears from their complete absence in those
patients who have perfect intermissions between the
attacks. The first of these effects is dilatation of the
right heart, caused by long labor in the difficult
propulsion of blood through the lungs so soon as
apnea occurs in any form. During a paroxysm of
asthma, the left heart and the systemic arteries are
relatively empty and the pulse is small, while the
systemic venous system from the right auricle back-
ward is everywhere overloaded. The heart beat is
then found, not under the nipple, but in the scrobicu-
lus cordis; partly, it is true, from the displacement
caused by the dilated left lung, but equally also from
the distention of the right ventricle. Another con-
stant result is emphysema, or permanent overdisten-
tion of the air vesicles, caused by the progressive
accumulation of the residual air from the imperfect
expiration. Emphysema may thus be found in old
asthmatics, whether they have had chronic bronchitis
or not. Lastly, from the combined derangement of
the pulmonary circulation caused by the intermittent
apnea and the permanent emphysema, we have
a tendency to bronchial flux to relieve the congested
vessels, which finally adds chronic inflammation to
chronic hyperemia, and thus establishes the vicious
circle of impeded circulation causing bronchitis, and
bronchitis in turn causing progressive circulatory
impediment.
These slowly induced effects finally produce those
changes of personal appearance which mark old
asthmatics. As the general nutrition suffers from
the persistent congestion of the liver caused by the
impeded outflow of the right heart, these patients are
usually thin, pale, or cyanotic, and with deficient
muscular power. The eyes are prominent and
watery, the voice is weak, the gait slow and measured,
and the back rounded, often to great deformity. The
head, however, is always thrown back between the
elevated shoulders, and the trunk of the body is kept
so rigid that the arms hang passively, swmng by the
movements of walking.
Leyden endeavored to demonstrate that the cause
of asthma lies in the presence of sharply tipped
octahedral crystals, found abundantly in the expecto-
ration which terminates a paroxysm of asthma, and
which, he supposed, by their numerous fine points
set up a reflex irritation of the terminal branches of
the vagus in the bronchial mucous membrane.
This theory, however, is sufficiently negatived by the
discovery of the same crystals in the secretions of
other bronchial affections in which there is no asthma.
That asthma, instead, is essentially a functional
neurosis is readily apparent when the disease is
studied in uncomplicated cases, for in them, though
there be neither bronchitis, heart disease, nor toxemia,
we have typical attacks developing in association
with phenomena which belong to nervous diseases
alone. Of such phenomena we would cite: 1.
Extreme suddenness of onset, as the immediate
a-thma caused in some by certain odors. No loss
sudden also in many cases is its departure, as upon
the inhalation of certain fumes. This feature mili-
tates also against the theory of Weber, who ascribes
asthma to turgescence of the mucous membrane,
narrowing the caliber of the bronchi as an acute coryza
impedes breathing through the nose. Storck lent
support to this view by laryngoscopic observation of
tumefaction of the tracheal mucous membrane as far
as the right bronchus in an asthmatic during an
attack. Bristowe, moreover, cites the rapid sub-
sidence of cutaneous turgescence in some cases of
urticaria evanida as affording some support to con-
gestive swelling of the bronchial mucous membrane
being a factor in the etiology of asthma. But thoue
it be freely granted that the agonizing struggles of a
asthmatic for air may have considerable effect upo
the circulation of the bronchial walls, yet the fa<
remains that no known swelling, however evanescen
vanishes so quickly as some true asthmatic dyspnes
vanish, the patients becoming natural often mot
speedily than is common after either epileptic r
neuralgic attacks. 2. Like other spasmodic ne
whether sensory or motor, asthma often has chara-
teristic prodromes of the attacks. One of the mo-
common is a feeling of almost irresistible drov
giving way to which, the patient well knows, will j
followed by the old dread awakening. With so
on the other hand, unusual wakefulness is a sur
precursor. As in epilepsy and in migraine some ar
warned by the temper becoming very irritable, or I
spirits causelessly depressed, while others experi'
unwonted buoyancy of spirits. Moreover, as in tl
neuroses, the attacks are sometimes preceded,
oftener followed, by an abundant flow of pale, limpii
urine. 3. Mental influences alone are known bot
excite and to suspend the attacks with some. I
certain patients a fit of anger may induce an attac;
immediately, in others, more significantly still, i
invariably insures the attack during the succeedini
night, long after the angry emotion is gone or forg
ten. 4. It is only in functional neuroses that we fin
many and widely differing exciting causes. Thu
epilepsy has been wholly relieved by the expui
of a tapeworm, or of a renal calculus, or by trepanni
But in this respect asthma surpasses ail other com
plaints, and the bearing of this fact upon the nervou.
character of the disease appears when contra -
with bronchitis, which involves, moreover, just th(
same parts which asthma affects. Bronchitis cer
tainly, as well as any other disease with palp;
lesions, cannot be excited by such a motley arrat
influences as the smell of cats or of violets, the ea r
of raisins or nuts, by constipation, by depre--
emotions, or by the extinguishment of a light. 5
decisive consideration is to be noted also in th<
intermediate condition between the paroxysms. In
typical asthmatics in whom no organic changes have
yet been induced, such as emphysema or the effect -
of chronic bronchitis, the existence of asthma cat
be even guessed. The patient shows to inspect
and to physical exploration of the chest no more
signs of being subject to violent and prolonged attacks
of dyspnea than an epileptic's muscles tell of his
convulsions.
Mechanism. — Asthma, therefore, may be regar
as essentially a derangement of the innervation of the
respiratory apparatus, disturbing the rhythmical
succession of contraction and relaxation by a muscular
cramp, W'hich interferes chiefly with the act of expi-
ration. But the mechanism, so to speak, of the
asthmatic paroxysm itself is by no means agreed upon.
The majority of authorities ascribe it to narrowing of
the bronchioles by spasm of their muscular coat,
while others maintain that it consists in spasm of the
diaphragm and costal muscles. Each of ti
theories may be said to explain what the other lea
unexplained, and hence it is doubtful if either of them
alone can be regarded as adequate. The argument-
in favor of the latter theory are:
1. During the attacks the whole aspect of the
patient is that of extreme external muscular rigidity.
Both the thorax and abdomen appear fixed and
immovable, and show none of those strong heavin;
and expansive efforts which are visible in other
forms of dyspnea. Thus, in asthma, the diaphragm
remains depressed, as if arrested in inspiration, and
the muscles of the distended abdomen grow hard and
tense as they labor in vain to overcome the resisting
diaphragm and thus assist expiration. From the
powerful contraction of the abdominal muscles it
742
REFERENCE HANDBOOK ( >F Till: MEDICAL SCIENCES
Asthma
, 'ii happens that the lower ribs often bulge during
■ efforl al expiration. On the other hand, when
, K is obstruction in the respiratory Iran, as in
,1 croup, edema glottidis, etc., the phenomena
! all different. The difficulty is then plainly in the
Ipiration, and not in the expirati and the ribs
■ which tin- diaphragm is attached actually sink in.
,11 (luring inspiration. Why obstruction in the
i mohi should reverse all these effects is not explained.
■ II- theory of bronchial spasm fails to account
the difficulty of expiration in asthma. If con-
! occurs in the tubes, it must interfere with
ih inspiration and expiration equally, unless it
i be shown thai the circular libers have a valvular
lion at the points of contraction, admitting the
g, hut interfering with the outgoing, current,
nomenon, however, has never been induced
animals experimentally, and is even difficult to
Moreover, that nothing of the kind occurs
d by auscultation, for a valvular obstruction
the expiration would totally alter both the quality
! the pitch of the expiratory sibilus, which is not
a the other hand, the theory of diaphragmatic
ism explains why inspiration is easier than expira-
n in asthma, because it is well known that partially
imped voluntary muscles, like the diaphragm, can
be stimulated to further contraction, though
inclined to yield to relaxation. This appears
ikingly in tetanus, in which disease the tonic
liility of the muscles never wholly gives way,
hough every few moments fresh and powerful
ntractions occur in response to the slightest
iinal impressions. Meantime, the statement that
depressed state of the diaphragm is a passive
ndition due to the overdistention of the lungs with
-idual air, is negatived by the active muscular
u traction of the abdomen above referred to, which
quite different from the passive distention of the
.luminal walls when the diaphragm is depressed
emphysema.
1. The asthmatic paroxysm is always aggravated
certain movements which confessedly occur only
the diaphragm itself. Patients, on this account,
pecially dread to laugh or to do anything which
.s or checks the relaxation of the diaphragm.
i h as loud talking. But how these actions could
any way affect bronchial constriction is difficult to
mceive.
On the other hand, there is one incontestable proof
lat constriction of the bronchi does take place in
ery case of real asthma, and that is the invariable
esence of general sibilant rales of every variety of
/.e, from fine whistling to large cooing sounds. In
■ asthma these sounds are purely tubular, and
om their shifting character, above alluded to, it is
ain that they are produced by progressive waves of
infraction in the bronchial walls, and not by a
lifortn diminution of their caliber, such as general
tion (Weber) would occasion. Those rales,
oreover, are simultaneous with the onset of the
tack, as they are audible sometimes in the breathing
an asthmatic, even before he is awakened by a fit,
id so constant are they that no dyspnea can be
Tined asthmatic if there be no wheezing. Now, the
icory of diaphragm spasm wholly fails to account
ir these characteristic bronchial rales. If we had
iaphragm spasm alone, the symptoms then would
itner resemble burking, or, more properly, the
yspnea which is often the fatal complication of
in which disease death results from tonic
lasm of the respiratory muscles. Here, as I have
ad personal occasion to note, there is no wheezing
hatever.
From these considerations the view of Lebert seems
i us preferable, namely, that the asthmatic paroxysm
egins with spasm of the bronchial muscles, much as
lie first discharge of epilepsy often begins with a
special group of muscles, and then pread to ether
and wider muscular association . Con idering hoi
intimately and constantly the muscular actions of
re piration are associated, it is easy to conceive how
disordered innervation of the bronchial muscles may
become quickly accompanied by disordered innerva-
tion Of the diaphragm, and thus click the return of
in-piled air. Some ten such re pirations would
suffice to inflate the lungs to the extremes! degree
observable in asthma, until the whole muscular appa-
ratus of expiration would join in the spasm and
'■ plete the picture of this dyspnea, in which con-
dition almost the only movements which remain in
the distres ful breathing are the Lifting actions of the
in el. and shoulder muscles. Lebert justly insists on
the contrast between the pulmonary dilatation in
asthma and its absence in fibrinous bronchitis, in
which disea.se, 1 hough I he obstruction is great and the
constriction of the bronchioles a tubular narrowing,
yet there is but slight, if any, dilatation; which
proves, therefore, that something more than bronchial
constriction is needed to explain all the clinical
features of asthma.
Treatment. — The treatment of asthma may be by
remedies which relieve its symptoms but do not cure
the disease. Thus the symptom of bronchial spasm
may be relieved at once by such agents as stramon-
ium, compound spirit of sulphuric ether, niter, and
lobelia. Of these the most noted is the inhalation of
the fumes of burning stramonium leaves. Individual
asthmatics, therefore, usually have their own reme-
dies of this sort, but though the paroxysms may for
years be relieved each time by the use of these reme-
dies, yet the action is no different from the effect of the
first dose, and the disease itself remains as settled as
ever. This is all due to the important distinction
between functional remedies and constitutional or
disease remedies. Constitutional remedies are given
not for the symptoms, but for the morbid condition
itself, and they never produce their effects by one
dose, but only by prolonged and repeated doses.
Thus iron cannot cure anemia until it has been
administered for several weeks, nor mercury cure
syphilis until it has been given in small, repeated
doses for prolonged periods. With such remedies
the symptoms of the disease, therefore, disappear-
only with the disappearance of the disease itself.
Practically, asthma can be cured only by two reme-
dies, namely, arsenic and potassium iodide.
Much the greater number of reputed remedies
for asthma are little else than palliative, because
their operation merely relieves a paroxysm or attack
of the complaint, just as opium may relieve the pain
of a syphilitic node without producing the least
effect on the cause of the symptom itself. The
peculiar motor spasm of asthma is not the disease,
but only a symptom of it, the same in nature with
pain, and hence, like other mere symptoms in nervous
diseases, it can be affected by a great variety of in-
fluences. Thus, such unlike agents as caffeine,
chloral, ether, and tobacco, or the inhalation of
stramonium or of niter fumes, are each spoken of as
marvellously relieving certain confirmed asthmatics.
No sooner does the patient begin to experience the
special effects which these drugs produce in a healthy
man than the agony of his breathing subsides, and
a restful calm succeeds as by magic. But the great
disappointment with these seemingly effective reme-
dies is that the longest use of them brings the patient
no nearer getting rid of his enemy than when he
began. He may break up his attacks for years with
his special prescription, but the asthmatic fit is as
ready to return, and as severely, as if no remedy for
it ever had been tried.
The reason for this failure is fundamental. These
so-called remedies for asthma are all nervines, and no
agent like opium, or aconite, or stramonium, or
743
Asthma
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
ether, whose whole medicinal action is obtained by
one dose, can do anything more than that one dose
does. However often repeated, no cumulative pro-
gressive effect follows upon the administration of
nervines, and hence they can affect only the functional
manifestations of a constitutional disease. All that
such medicines can do is to produce some immediate
but temporary change in some symptom of the
complaint, but no more. There is hence a parallel
between the curious variety of the exciting causes of
asthma in different persons and the like variety both
in the nervines themselves and in their disproportion-
ate efficacy in different patients. For while the
exciting causes show by their incongruity that they
are not true but only accidental elements in the case,
so the diverse nervines recommended for asthma
show that they affect only some accessory but not
essential factor in the disease. When a nasal polypus
makes one patient an asthmatic and a loaded rectum
another, neither of these cases throws the least light
on the true cause of asthma. Likewise when a
nauseant emetic and a glass of hot spirits and water
are each said to "work like a charm" in some asth-
matics, we can scarcely say of such remedies that
they bring us nearer the true therapeutics of the
malady, for it is plain that they modify only some
chance association of perverted function.
In this class of palliative remedies we would assign
the first place to the mydriatics, belladonna, hyoscy-
amus, stramonium, and duboisine. The wide range of
disorders in which these medicines have been found
beneficial is due to a general principle in their opera-
tion, which also suggests the explanation of their use
in asthma — viz., that they relieve disordered innerva-
tion of involuntary muscular fiber by a motor stimu-
lant action which restores its rhythmical contraction
when it has been arrested by spasm from any cause.
Spasm and paralysis are associated phenomena in
unstriped muscle, tetanic contraction of one portion
and relaxation of the remainder taking the place of the
normal wave movement throughout the whole.
Hence the use of belladonna and its allies in spasmodic
action of the bladder in cystitis, in nocturnal in-
continence of urine, in the constipation of women
from reflex pelvic irritation, in spasmodic gastrodynia,
in cardiac pains when due to left hypertrophy derang-
ing the rhythm of the two sides of the heart, etc.
As with other nervines, the earlier they are given in
the attack the more pronounced and speedy is the
effect. A full dose of the tincture or of the fluid ex-
tract of belladonna should be given, enough to produce
well-marked constitutional effects, and then the dose
should be repeated in two hours if there be only im-
perfect relief. If the second dose fails to affect the
breathing, a very effective method is to give a hypo-
dermic of atropine injected deeply into the nape of the
neck, a locality which is the seat of a sensation of
great weariness in severe attacks of asthma, and
which this measure often mitigates at once, after
other employment of the remedy has failed. Hyoscy-
amine sometimes affords more relief than atropine,
but in most cases is not superior to it. Other patients
are best relieved by the inhalation of the smoke of
stramonium leaves, for which purpose they may be
lit at the bottom of a cup, or used like tobacco in a
pipe, or made into cigarettes; the effort being to
inhale the fumes as deeply as possible, when the dysp-
nea sometimes is found to vanish with surprising
rapidity.
Coffee should be reckoned also among the nervines
which are effective in asthma by a stimulant action.
It should be made very strong, taken always on an
empty stomach and taken hot, for the sipping of the
potion is not without its own effect, as it has been
shown by Kronecker that the act of swallowing
itself powerfully stimulates the cardiac and pul-
monary branches of the vagus. Coffee taken after
eating aggravates asthma by interfering with diges-
744
tion. In some cases I have found the alkalo
caffeine of temporary benefit, but on the whole
regard it as inferior to the freshly made and strong i
fusion. Hot coffee is particularly good in asthmat
bronchitis, as it facilitates the expectoration while
relieves the spasmodic condition. It is in the sari
class of cases, also, that the muscle stimulant, ni
vomica, is sometimes beneficial. Here again t]
tincture or the fluid extract of the drug is preferab
to its alkaloid, strychnine.
Next in order come the nervines which probab
relieve the asthmatic paroxysm by a sedative aetii
on the initial irritant impression. Among these v
would enumerate alcohol, the ethers, chloral, ai
opium. It should be noted that while alcohol is
stimulant to the heart and to some cerebral function
it is an immediate sedative to the sensory nem
and this sedation steadily increases in proportion
the dose. Sulphuric ether, when taken internal!
resembles alcohol in these respects, though its sed
tive effects are much more pronounced. Hence tl
use of both alcohol and ether in the muscle cramp
intestinal colic and in spasmodic affections of due
generally. Full doses of spirits, therefore, taken ho
will relieve some asthmatics to the exclusion of n
other remedies; but the relief does not occur general
until enough is taken to intoxicate a well perso
though it rarely does so with an asthmatic. Sulphur
ether, however, is much more generally effectiv
especially in the preparation of the spirit us con
positus, or Hoffman's anodyne, owing to the oil i
wine which it contains. As this latter ingredient
expensive, it is sometimes fraudulently omitto
with a plain falling off in remedial power over tl
attacks. The dose for the paroxysm should be nc
less than two drams. As the latter acts in a diffe
ent way from the belladonna (being more conneete
with the sensory element of the spasmodic conditioi
while the belladonna affects the motor), an unqur
tionable gain is secured by administering these tv.
remedies together.
As might be expected, there is much contradictor
testimony about the value of opium in asthm:
This need not be wondered at in view of the widel
different effects of opium, e.g. as a soporific, in diffei
ent individuals. The mode of administration. ho«
ever, counts more with this remedy than with an
other, for the speedy effect of a hypodermic of moi
phine is much oftener successful than morphine <
opium taken by the mouth. This, however, is i
accordance with the general rule that the mor
quickly a nervine is felt, the more effective it i
against any spasmodic affection — e.g. arresting a
epileptic fit by a sudden irritant impression, bu
which it fails to do if applied gradually. Chloral i
large doses, thirty to sixty grains, is claimed as a
excellent remedy for asthma; but the patient'
tolerance of this drug, sometimes fatal in onl;
fifteen-grain doses, should be well established beion
this treatment is tried. Inhalations of nitrite o
amyl often arrest a commencing attack, but are no
of much use in a fully developed paroxysm. Thi
fumes of the nitrate of potassium, however, inhale*
by burning cigarettes made of rice paper dipped in:
saturated solution of the salt and then dried, an
much more generally effective. This remedy un
doubtedly acts by virtue of the well-known locall}
sedative properties of potash itself, and hence ma;
well cooperate with the different action of the funic;
of stramonium leaves rolled up with the niter paper
Lastly, we have the pure sedatives whose actio'
cannot be secured until nausea has been occasioned
by them. Asthmatic spasm, like every other cramp
rarely holds out against the sickening effect of tobacco.
lobelia, or even of ipecacuanha. Tobacco, therefore.
is effective only with those who are not used to it.
Lobelia has the disadvantage of producing too much
prostration, and the same may be said of tartar
REFERENCE HANDBOOK or THE MEDICAL SCIENCES
\ -Ihni.i
ictic. This class of remedies works much better
' bronchitis than in peptic asthma.
Besides these there arc but few nervines left in the
tcopeia which are not recommended by some
asthma, although no one is ever permanently
nefited by any of them.
Better results, however, may be hoped for from
directed to other aims than simply to relieve
i| of the dyspnea when present. Asthma is at no
ibsent from the asthmatic any more than
ilepsy from the epileptic, though the manifestations
rare only occasional, 1'rophylaxis, therefore.
es an exceptional importance, because, as in
spasmodic neuroses, the malady becomes
ate in proportion to the frequency of the
As in the case of epilepsy also, the slightest
- of asthma are as much to be avoided as the
ones, if there is to be any hope of the patient
coming ultimately free from "them, and hence the
g causes in each instance should be carefully
and jealously provided against. In those
i which the susceptibility to odors indicates
e upper respiratory tract as the seat of the irritabil-
.. the inhalation of carbolized steam should be
The steam should be made to surround the
•ad by the simple device of directing it under an
i'lrelia, held low by the patient himself, so that he
ty inhale without more effort than in ordinary
piration, because breathing by will is too fatiguing
be kept up for long by any one, and it is this
which accounts for the uniform failure of the
inhalers and atomizers which have been
ed during the past century. This treatment
iould be kept up twice a day for months, the object
■ing to produce a permanent change in the suscep-
bility of the sensory nerves distributed to the nasal
laryngeal mucous membranes. Occasionally
e vapor of turpentine may be substituted for that
carbolic acid. It is in these cases also that much
lay be expected from the French procedure, origi-
by Ducros, of painting the posterior wall of the
liarynx with aqua ammonia?, although, to prevent
irae being made worse by the irritant fumes,
• ousseau recommends inhalations of ammonia first
•om a vial and then touching the pharynx with a
eak solution, to be made stronger as the patient
ecomes accustomed to it. Trousseau refers the
amunity of many patients from visits of asthma so
ing as they reside in the vicinity of gas-works to the
ce of ammonia in the air of the locality; but
bile this possibly may be operative, yet we would
scribe it more to the unmistakable sedative effect
pon the bronchial nerves of air charged with creosote,
arbolic acid, and other allied products of wood
i-t illation. It is in this class of patients also that
lie bromides are useful, owing to their paralyzing
be reflex excitability of the pharyngeal nerves. A
lose of thirty grains of potassium bromide, with a
Iram of Hoffman's anodyne at bed-time, will often
vard off a nocturnal visit of the enemy.
It is, however, in bronchitic asthma that prophy-
ixis is particularly imperative. As comparatively
ew cases of bronchitis originate from direct irritation
if the bronchial mucous membrane, but much more
■nmmonly from some partial exposure of the skin
o unequal degrees of temperature, so the partic-
llar susceptibility of different cutaneous regions
Oinuld be tested and preventive measures adopted
iccordingly. As a general rule, in bronchitis which
legins usually with a coryza it is the nape of the neck,
•vhile in phthisical cases it is the anterior surface of
the chest, and in pharyngeal or tonsillar cases the
eet, which are the most susceptible to those impres-
sions of passing cold that set up their special tracks
3f inflammation or hyperemia in mucous membranes.
After a few days' continuance of the catarrhal state,
however, the skin of the whole surface partakes in
this specific irritability, so that the patients may
bee e aware of a draught from a distant open door
which others do not feel. Many cs es of bronchitic
asthma, therefore, are promptly relieved by putting
on a whole suit of buckskin over a ligh< under-flannel,
and wearing the same until settled summer weather.
These patients also should guard against nocturnal
perspiration about the neck and shoulders, by the
of light flannel instead of cotton or linen night-shirt s.
Daily inunctions with oil also, applied especially to
the feet, and preferably done on rising, do much to
lessen the tendency to catching cold. The bronchitis
itself, of course, should be treated according to its
indications, with especial benefit to be hoped for in
asthmatics from the emulsion of linseed oil. We
need also only allude here to the importance of making
the utmost of the intermediate summer period of
mitigation of bronchitis with many patients before
the malady has become too chronic.
Peptic asthma is so much influenced by the Btate
of the alimentary canal that some have spoken of the
treatment of asthma in general as if it were mainly a
matter of regimen and diet. Indigestible food, even
a single meal of such, is to be scrupulously avoided
in every form of spasmodic disease. The patient,
must not endeavor to reconcile his digestive apparatus
to any second trial with an offender. Whether the
proneness to spasmodic or convulsive disorder be due
here to the greater susceptibility of the nerve centers
to reflex excitation from the alimentary canal than
from any other nerve distribution, or whether the
susceptibility is caused by the absorption of nerve
poisons generated in some intestinal fermentation,
it is unquestionable that any departure from good
digestion is to be dreaded in treating such complaints,
and in none more so than in asthma. Experience
will best teach each one all the particulars as regards
what he can and what he cannot eat, and its verdict
must be accepted. Moreover, with all asthmatics,
the digestive power decreases as the day wears on, as
previously stated.
But as the prevention of peptic asthma wellnigh
involves the treatment of all the varied forms of
dyspepsia, we can direct attention here only in a
general way to the subject, for each case is to be
managed according to its own indications. Wo
may remark, however, that bismuth appears to be
one of the most effective preventives of peptic asthma,
probably owing to its antiseptic properties. A good
form of administration is in capsules of five grains
each of bismuth carbonate and of pulvis calumbse, two
such to be taken an hour after meals and at night.
Ten grains of sodium benzoate and ten grains of
bismuth salicylate, administered in two capsules, will
also often be found effective in preventing intestinal
fermentation.
In conclusion, we would recommend, besides pro-
phylactic measures, the recourse to certain remedies
whose benefit, when secured, can properly^ be termed
lasting or curative, instead of merely palliative.
Want of success with them may be due often to a
failure to recognize the fact that to be truly curative
in such a deepseated and lifelong malady as asthma a
remedy must be given continuously without reference
to the attacks, and long enough to produce a decided
modification in the system itself. Such a result
never can be obtained from agents which merely
affect nerve functions, however steadily or largely
they be taken, as is proved by the absence of any
recognizable sign, either during life or after death,
of the years spent by many in consuming tobacco
or opium. In arsenic and potassium iodide, how-
ever, we possess truly constitutional medicines, whose
value in asthma has been repeatedly demonstrated.
If these medicines, however, have any effect on
asthma, that effect is wholly different in kind from
the immediate relief produced by a transient-acting
nervine, for it must be by causing a more or less
organic alteration in the lesion itself. Their proper
745
Asthma
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
administration in asthma, therefore, should be like
the administration of iron for anemia, or mercury for
syphilis, or the bromides for epilepsy, the effect being
obtained not by one, or by the first dose, but only
after months of steady use. I feel assured that if a
combined or alternate arsenical and iodide treatment
were as systematically adopted in the treatment of
asthma as fhe above-named constitutional remedies
are used in other maladies, many a case of this
disease would be finally got rid of which now, under
the deceptive recourse to mere functional agents,
becomes at last an incurable habit of the nervous
respiratory mechanism.
To obtain the best results with constitutional
remedies, two therapeutical rules should be steadily
followed. The first is to administer along with them
one or more of the restoratives, in order to prevent
the injurious effects of the continued taking of such
unnatural substances into the system as arsenic or
iodine. No symptoms of iodism or of arsenic should
be allowed, because the remedial effects of these
medicines cease at once upon the appearance of any
signs of their poisonous operation. If diminishing
the dose is not followed by a cessation of the symp-
toms, these drugs must be omitted for a time, and
then resumed in small doses, to be increased again
only as the patient can tolerate them. The best
restoratives with arsenic are quinine and codliver oil,
while phosphorus and the muriated tincture of iron
best prevent the injurious effects of iodine.
The second rule is to secure the cooperation of
functional medicines, for though these latter cannot
be curative in themselves, yet experience proves that
they unquestionably promote the action of constitu-
tional remedies when they relieve some of the symp-
toms of the disease. Thus I have repeatedly noted
potassium iodide fail adequately to cure a syphilitic
node until opium and conium were added to the
prescription. And on the same principle I have been
accustomed in asthma to prescribe a combination
somewhat as follows: Py Potass, iodic!., o iss.; Liq.
pot. arsen., o i.; Spts. eth. sulph. co., § iiss.; Tr.
belladonna, o ij.; Syr. aurant. cort. ad 5 vi. M.
S.: Two teaspoonfuls in water an hour after meals.
Belladonna is introduced because it is in the same
botanical family as stramonium. The active prin-
ciple of belladonna or atropine is often effective when
given hypodermically at the nape of the neck in a
dose of 1/100 to 1/75 of a grain.
In a certain proportion of cases a curative effect
is secured by counterirritation applied along the
cervical and upper dorsal vertebrae. The actual
cautery is to be preferred, and one form of this
irritation is both effective and readily applied without
expensive apparatus, namely, by the not glass rod.
Spots of ink, half an inch or so apart, made along the
spinous processes, are to be lightly touched by the
tip of a glass rod raised to a white heat in the flame
of an alcohol lamp. This simple procedure causes but
little pain, and immediately after the application
shows a continuous red line as if made by the passage
of a hot iron. The application should be repeated
about every fourth day.
If there is any history of the alternation of asthma
with the disappearance of a cutaneous eruption, an
artificial eczema by croton oil on the chest, as already
mentioned, is often positively remedial if persevered
in on the first sign of a return of the dyspnea. Asth-
ma secondary to other diseases must be treated with
them. In the cardiac cases, and in gouty patients as
well, a continued use of saline waters, like the Congress
or Hathorn of Saratoga, will afford the best prospect
of relief.
In all cases of asthma, however, a careful examina-
tion of the nasal passages should be made at the
beginning and repeated throughout the treatment.
The innervation of the outlets of all long tubular
tracts is closely associated with the nervous mechan-
ism controlling the muscular movements of the who]
tract, examples of which are seen in the heighten?
irritability of the whole genito-urinary apparatus b
a narrowed meatus, or orifice of the prepuce; by tli
pylorus remaining patent so that the stomach is to
quickly emptied in dysentery, etc. We need n<
wonder, therefore, if the normal rhythm of respiratio
is readily deranged by a polypus or other obstructio
in the nose, and all such conditions should be full
remedied when found. But aside from such lesion,
many asthmatic-attacks may be prevented or aborte
early by a spray of carbolized oil — one part of carboli
acid to forty of sweet almond oil — used especially o
retiring at night. William H. Thomson.
Astigmata.— A subdivision of the Acarina, or mite>
in which the body contains no tracheal respirator
tubes and in which the legs bear small appendage
or epimeres. This group contains the itch am
cheese mites. See Arachnida. A. S. P
Astigmatism,* As (from a, privative, and 0-7(7^0
a point) is the name proposed by Whewell (1846) ti
designate the visual anomaly which results fron
unequal refraction in the planes of the several ocula
meridians.f Accurate measurements of the cornel
reveal some degree of asymmetry in nearly ever
eye, and not infrequently the difference in curvatun
in different meridians is so great as to give rise t<
serious imperfection of vision. As a rule, the merid
ian of greatest curvature is vertical or approxi
mately vertical, and the meridian of least curvature
at right angles to the former, is horizontal or approxi-
mately horizontal. To this rule there are, however
many and conspicuous exceptions.
The crystalline lens, also, is the seat of asym-
metrical refraction, either from inequality of curva-
ture in different meridians or from imperfect cen
t rat ion of its two surfaces, together with the cornea,
in a common axial line. Astigmatism of the crystal-
line lens is generally of comparatively low grade,
and the meridian of greatest lenticular refraction i
oftenest approximately horizontal. Hence lenticular
astigmatism tends oftener to correct than to increase
the astigmatism due to asymmetry of the cornea
the total astigmatism falling short of rather than
exceeding that which would result from the corneal
asymmetry alone.
From the fact that, as a rule, neither the cornea nor
the anterior or posterior lens surface is a perfect
surface of revolution, and that not one of these sur-
faces is quite accurately centered with reference .11
the visual axis, it follows that the ocular refraction,
whether symmetrical or asymmetrical, is the resultant
of three more or less asymmetrical refractions. In
practice, however, these complications are disre-
garded; and the investigation of any case of astig-
matism is limited to the measurement of the asym-
metry of the cornea and the determination of the
refractive error as a whole.
The characteristic property of a pencil of light after
a single astigmatic refraction (or reflection) is that it
has no focus, properly so called, but that all its rays
pass through two nearly straight lines at right angles
to the axis of the pencil (focal lines). The construc-
tion of such a pencil is shown in Fig. 511, in which I.
represents a luminous point; M N, OP lines intersecting
* Asligmia, astigmie, of French writers.
t For convenience, the system of lines and circles used in ?<
raphy is extended to the topography of the eyeball. Designs
ing the center of the cornea and the central fovea of the retina
the anterior and posterior poles, the line connecting them is the
axis; all great circles passing through the poles are meridians; tli"
great circle which cuts all the meridians at right angles is tho
equator; and the surface included between any two parallels ia a
zone.
746
REFERENCE HANDBOOK OF THE MEDICAL SCIEN< ES
Astigmatism
Ltrighl angles at L and parallel, respectively, to
[i and A C, B D bounding an asymmetrically
ng surface of which the meridian of greatest
ll( iii.u is assumed to be vertical; .V .M', parallel to
\V the first focal line (/,); and P" O", parallel to
i • the second focal line (/.). Cross-sections of the
ted pencil, elsewhere than in the two focal
re indicated by the three rectangles, a,c,b, one
ii (c) falling between the two focal lines but
to/, than to f 2 , is of the same form as the
lion of the pencil before refraction (shown
| he diagram as a square). The other cross-sections
I all rectangles having their longer sides parallel to
nearer focal line. The distance separating the
ocal lines i /, and/.) is called the focal interval*
rem the construction it follows that if the pencil is
v the retina at/,, the luminous point at L will
seen as a horizontal bright line, and that if it is
at f . the point L will be seen as a vertical line.
lencil is cut by the retina at c, the point will
as a small illuminated area having the form
drical lens rendering an emmetropic eye myopic in all
i ne iid ia ns other than that of the axis of the cylinder —
simple myopic astigmati m I \xo)\ and a concave
cylindrical lens rendering an emmetropic eye hyper-
metropic in all meridian- Other than that of I he a ■•. i of
the cylinder — simple hypermi i gmati m < \h).
A convex spherico-cylindrical lens renders an emme-
tropic eye myopic in all meridians, but the myopia
is greatest in its meridian of greatest refraction and
[east in its meridian of least refraction compound
myopic asliymatixm i M + Am I ; ami a concave spherico-
cylindrical len renders an emmetropic eye hyperme-
tropic in all meridians, but the hypermetropia is
■i' a i est in its meridian of greatest (negati\e) retrac-
tion and least in its meridian of least (negative)
refraction — en m pi> n 11 d hypermetropic astiymtilixm
til + Ah). A tilth typi — mixed astigmatism (Anih
or Ahm) is reproduced by looking through a convex
spherical lens combined with a concave cylindrical
lens of greater power, or through a concave spherical
lens combined with a convex cylindrical lens of greater
Fio. 511.
i the refracting surface, which, in the eye, is deter-
l ned by the form of the pupil and is therefore ap-
I 'xiniately circular. If the pencil is cut at any
i ier part of its course the point will be seen as an
id, approximating an ellipse. The section* of the
I at c is called the circle of least confusion.
If, instead of a single luminous point at L, we
I nine an indefinite number of points arranged
jmg the horizontal line M N, these points will be
ed at /,, each as a horizontal line, and these
es, overlapping each other in the greater part of
i 'ir length, will appear fused in a longer horizontal
Ie. So also a series of points arranged along the
it ical line O P, or the vertical line P itself, will
projected as a vertical line at /,. Lines lying in
ie or the other of these two directions (parallel to
X or to O P) are, in fact, the only objects projected
the astigmatically refracting surface without
Dspicuous alteration.
^s, by construction, the first focal line (/,) is par-
M N, and the second focal line (/,) is parallel
P (drawn perpendicular to M N), planes passed
rough M N, N' M' and through O P, P" (_)" intersect
■ asymmetrical refracting surface in its meridians
least and of greatest curvature. These two planes
erpendicular to each other) and the two meridians
which they intersect the refracting surface (also
rpendicular to each other) are called, respectively,
6 principal planes and the principal meridians.
ie principal meridian of greatest corneal curvature
designated by the symbol M c , and that of greatest
ular refraction by M .
V normally seeing (emmetropic) eye may be ren-
ired astigmatic by wearing a piano- or spherico-
lindrical lensf in a spectacle frame; a convex cylin-
*The form of the refracted pencil may be shown in three di-
visions by projecting it on the fine particles of dust in the air,
a 't:irkened room.
■ \ piano-cylindrical lens has one surface plane and the other
mind to a cylindrical curvature, which may be either convex or
'leave. Lenses are also ground with a convex or concave spher-
il surface on one side and a convex or concave cylindrical sur-
ue on the other side, and may be imitated by cementing to-
power. These five types include all forms of regular
astigmatism.
Astigmatic vision is best studied in the case of
simple myopic astigmatism (Am), in which a distant
bright point is seen elongated in the direction of the
ocular meridian of greatest refraction. Figs. 512
and 513 show arrangements of dots and lines as seen
by an emmetropic eye and by a myopically astigmatic
eye when the meridian of greatest refraction is vertical.
It will be observed that in Fig. 512, b, the dots appear
elongated vertically, and that in Fig. 513, 6, the hori-
zontal and oblique lines appear blurred in the same
direction — the vertical lines appearing sharply defined,
but somewhat elongated.
For the detection and measurement of astigmatism,
as of ametropia generally, both objective and sub-
jective methods are employed. In the examination
of the eyes of very young children objective methods
are alone available; and in nearly all cases they afford
important data, to be utilized in further tests.
For convenience and general applicability the
ophthalmometer of Javal and Schiotz (see Ophthal-
mometer) holds a foremost place. By means of this
instrument the smallest deviations from symmetrical
curvature of the cornea are detected; and both the
direction of the meridians of greatest and of least
curvature and the difference in the corneal refraction
in these meridians are measured with great accuracy,
and at minimum cost of time and effort. Working
from these corneal measurements as a starting point,
the way to the determination of the refraction of the
eye as a whole is shortened and made clearer, and in
the end a more comprehensive diagnosis is reached
than is otherwise possible.
The presence or the absence of astigmatism of high
or of medium grade is generally discovered at a first
glance on looking into an eye with the ophthalmo-
scope. Viewed in the erect image, the fundus of an
astigmatic eye appears to the observer as an enlarged
gether, by their plane surfaces, an ordinary plano-convex or
plano-concave lens and a piano-cylindrical lens. Such a com-
bined lens is called a spherico-cylindrical lens.
r47
Astigmatism
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
reproduction of its details would appear if viewed by
the same eye at long range. In the higher grades of
astigmatism the fundus presents the strikingly char-
acteristic picture of a diffuse red ground marked by
conspicuous parallel streaks of a deeper red in which
the double contour of a retinal artery or vein is here
and _ there recognizable, and by a lighter oval area
(optic disk) blurred in the direction of its longer axis.
The examination is best made with the ophthalmo-
scope specially adapted to this use by Loring 1 in which
any one of a series of selected convex and concave
lenses, mounted in a revolving disk, may be rotated
at_ will into a position behind the sight-hole in the
mirror. By means of this instrument the refraction
is measured in each of the principal meridians; the
difference of the two measurements representing the
grade of astigmatism within a margin of error of less
than one dioptrie. The diagnosis of astigmatism may
also be made in the inverted image, but with less ac-
curacy than in the erect image. (See Ophthalmoscope.)
Another application of the ophthalmoscope to the
investigation of the refraction is by the method
known as retinoscopy, shadow test, etc., which con-
sists essentially in the observation of the direction
in which the dark border of the image of a flame,
reflected into the eye by the mirror, moves across the
Fig. 512.
Fig. 513.
strongly illuminated pupil. (See Shadow Test.)
By this method measurements of the ocular refrac-
tion in the two principal meridians and an estimate
of the direction of one or of both meridians may be
made within a narrow margin of error. Preliminary
dilatation of the pupil is helpful, and often indispen-
sable. It is not necessary or desirable to paralyze
the accommodation.
Subjective tests for astigmatism turn, on the visual
analysis of the confused retinal image as exemplified,
for a case of simple myopic astigmatism, in Figs. 512,
513. The technique must be suited to the determina-
tion: (a) of the presence and the type of astigmatism,
whether myopic, hypermetropic, or mixed; (6) of
the direction of the ocular meridians of greatest and
least refraction; and (c) of the difference in refraction
in these meridians. The examination is best con-
ducted at long range; with the visual axes virtually
parallel, and the accommodation relaxed to the
extent habitual in unconstrained distant vision. The
test-object should be large enough to admit of easy
recognition of its finer details by a person of normally
acute perception, and not so large as greatly to
exceed the size of the field of direct vision at the
distance at which the tests are made. Examples of
such test-objects, made up of radiating lines or
groups of lines, or of rows of holes punched in opa
card-board and viewed by transmitted fight
shown, of about one-tenth of the actual size, in )
514. The transparent tests are intended to be h
in a window, from the small holes at the top of
card, against a bright background of frosted glass o
thin paper; the other test-cards are arranged to t
interchangeably on a pivot at the center of a lai
card representing the face of a clock.*
Fig. 514.
Viewed by an astigmatic eye at a distance of fh
to eight meters, the lines corresponding in directk
to one of its principal meridians are seen more clear
denned than those in any other meridian; the brigl
dots appearing fused in a continuous bright hi
in the same meridian (cf. Figs. 512, 513). In tl
* A small figure made up of radiating fine lines was used 1
Helmholtz 2 and by Donders 3 in illustration of the proposition th:
lines corresponding in direction to the two principal meridians
an astigmatic eye are seen alternately sharply defined or blum
according as the eye is accommodated in one or the other of i
two focal lines (cf. Fig. 511). Donders 4 and Burow 5 mounU
such a diagram in an optometer, with a view to determining tl
grade of astigmatism by observing the distance through which
was necessary to move the test-object within or beyond the prii
cipal focus of a convex lens in order to see a line distinctly in tl
alternate meridians of greatest and of least ocular refractioi
Javal 6 adapted this method to practical use by the invention (
a binocular optometer, in the form of a stereoscope, in which th
two eyes were fixed, respectively, upon two small dials (Fig. 515,
The test-objects shown in Fig. 514 are reproduced from a papei
bj- the writer of this article, in the Transactions oi the An
< 'phthalmological Society, 186S; diagrams -/, l>, c, were pubttshe<
with an introductory note by Donders, in an appendix to the Re
port of the Netherlands Ophthalmic Hospital for 1S67. 7
748
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Astigmatism
e£ of simple myopic astigmatism (Ami oro!
myopic astigmatism (M+Am) this meridian
f. Kit of greatest ocular refraction; tin- lines appear-
i mspicuously blurred, and the dots most
ri inctly separated, in the ocular meridian of least
on, at right angles to the first. In simple
idropic astigmatism (Ah) and in compound
•tropic astigmatism (11+ Ah) the lines are
tarply defined and the dots fused together
meridian either of greatest refraction or of
Fraction, according as they are viewed under
mi or minimum accommodation for the
i ance at which they are exposed. In mixed astig-
Fig. 515.
ism (Amh or Ahm) the lines are seen sharply
( tued and the dots confused in the meridian of
refraction under accommodation equivalent
t the hypermetropia in the meridian of least refrac-
i. the lines and dots then appearing as in the case
pie myopic astigmatism (Am).
The differentiation of the several types of astigma-
| a turns on their transformation to a common type
(in) by looking through a concave or a convex
lerical lens. The lens by which this transformation
i -fleeted is the weakest concave lens (in M+Am)
< the strongest convex lens (in H+Ah, Ah, and
. lh or Ahm) through which the lines in any meridian
i-ular meridian of greatest refraction) are seen
I urly defined. The (negative or positive) power
i this spherical lens, in dioptries, is the measure of
ametropia (myopia or hypermetropia) in the
Jar meridian at right angles to that indicated by
direction of the sharply defined line or lines
ular meridian of least refraction). The deviation
■ the meridian of greatest refraction from the vertical
found by directing the attention of the patient to a
■igram showing a large number of radiating lines or
| ! tors, and requiring him to indicate, in minutes of
ae on the clock-dial, the angle of declination of the
- e or sector which he sees most distinctly.
The refraction in the second principal meridian
greatest refraction) may be measured by making
stive additions of concave spherical glasses to
■ concave or convex lens by which the eye has
n brought into the condition of simple myopic
tigmatism (Am). In making this examination it is
nvenient to use a test-object showing parallel lines
: I c) set at right angles to the previously de-
r mined meridian of most distinct vision; controlling
e measurements for both meridians by further
iala with test-objects (Figs. 514, d,f, and h), display-
g crossed lines, or sectors, or rows of bright dots.
Direct measurements of the grade of astigmatism
made by correcting the eye for the meridian of
•st refraction, and making tentative additions of
ncave cylindrical glasses until a lens is found
rough which the lines or rows of dots in the two
incipal meridians appear equally distinct. Deter-
ined in this manner the expression for the refractive
lomaly is in the form, M+Am or H+Am, which
ay often be reduced to simpler terms. Thus when
=0, or H=0, the ease is one of simple myopic
itigmatism (Am); when H=Am. the case is one of
mple hypermetropic astigmatism (Ah); when
>Am, the case is one of compound hypermetropic
; tigmatism (H + Ah); and when H1 [-vessels and also per-
haps at the Mime time upon the glands and their
duets. All the astringents except alcohol produce
some sort of chemical action which promotes destruc-
tive metamorphosis. Alcohol, on the other hand, re-
tards these retrograde changes in the tissues. Astrin-
gents are classified as vegetable and mineral; but their
action is always a local one; and t he attempt to make
a division into those whose action is local and those
whose action is remote is unwarranted.
Vegetable astringents depend for their action upon
the contained tannic and gallic acids. Arranged
a.phabetically, the chief vegetable astringents are
galla, gambir, geranium, granatum, hamamelis,
hcmatoxylon, kino, krameria, quercus, rhus glabra,
uva ursi, and all other substances which contain tan-
nic acid. Among the mineral astringents may be
mentioned the dilute acids (acetic, carbolic, hydro-
chloric, nitric, sulphuric), alcohol, alum, bismuth sub-
nitrate and other bismuth salts, cadmium sulphate,
chalk, cocaine, cerium oxalate, copper sulphate, creo-
sote, ferric chloride and ferric salts, lead acetate and
subacetate, zinc preparations, especially the oxide
and the sulphate, and several other metallic salts.
Astringents are valuable styptics and hemostatics
and they also harden and restore tone to relaxed
tissues. They cause capillary vessels to contract,
and they constrict glands and their ducts. They
exert some control over inflammation and they di-
minish the secretion from mucous membranes and from
denuded surfaces. They excite contractions in mus-
cular fiber, and they cause spongy granulations to
wither away. When applied to an ulcerated or
denuded surface they bring about (through coagula-
tion of the protoplasmic albumin) the formation of a
pellicle which covers and protects this surface from
the atmosphere and from external irritants. Thus,
pain is lessened at the same time that healing is pro-
moted by astringents. With three exceptions all
astringents irritate more or less. They are there-
fore contraindicated in acute inflammation. The
three sedative astringents are lead acetate or (sub-
acetate), cerium oxalate, and bismuth subnitrate.
Antagonists and Incompatibles. — Vegetable astrin-
gents are incompatible with the "ic" and "ous"
salts of iron also with the salts of antimony, copper,
lead, silver, and zinc; with alkalies, alkaloids, and
glucosides; and with pepsin, albumin, gelatin, emul-
sions, and the mineral acids.
Uses and Therapeutic Applications. — To check ex-
cessive secretion from the skin, as in hyperidrosis
or in night sweats, to check secretion from mucous
membranes, as in the various catarrhs, to lessen secre-
tion from denuded and ulcerated surfaces, and to
arrest bleeding. It must always be remembered that
astringents are not to be used until the inflammation
reaches that stage in which the secretion from the in-
flamed part is beginning to be excessive. Where the
part can be directly reached, as in epistaxis, hemate-
memesis, hemorrhage from lower bowel, hemorrhoids,
rectal fissure or ulcer, prolapsus ani, subacute or
chronic conjunctivitis, otorrhea, etc., tannic acid is
preferable to gallic. In bed sores or where excoriation
is taking place, as in dermatitis intertrigo, alcohol,
bismuth, or tannic acid will be found useful as a means
of hardening the skin. Finally, since tannic acid is
chemically incompatible with the alkaloids and gluco-
sides, it may serve as a useful chemical antidote in
poisoning from these active principles. It accom-
plishes this good effect by throwing down a very
slowly soluble, or entirely insoluble, therefore inert,
tannate of the alkaloid or glucoside in question.
R. J. E. Scott.
751
Asynergia
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Asynergia. — This is a complex of syndromes
described by Babinski as being characteristic of
cerebellar defect. He speaks of it as a decomposi-
tion of movements and of their elementary constitu-
ents. The patient is incapable of combining the
series of movements. It is a constituent of certain
ataxias, or perhaps more properly speaking, a sub-
variety or separate group which is included in the
larger and more heterogenous group of ataxias.
(See Ataxia.) Babinski has included it with adiado-
chokinesia and cerebellar catalepsy, under the
general head of a " cerebellar syndrome."
Asynergia he defines as of two types. The major
type shaws itself in walking. Such a patient, sup-
ported by each arm, raises his legs very high, and
gradually walks away from beneath himself, and
would fall if not supported. In minor degree this
would cause the symptom of retropulsion so fre-
quently observed in paralysis agitans. There is
moreover a wavy line in the progression of the patient.
Patients with the minor type, on standing erect and
then bending the head backward, fail to arrange the
back and lower limbs in an adaptive series of arches.
The legs are held straight and stiff, and the whole
bend takes place from the hips or mid-dorsal region.
Naturally such attempts result in falling backward.
Again, such patients find it impossible to assume a
sitting position when lying flat upon their backs
with their arms folded. The legs come in the air in
spite of all effort to hold them down.
Asynergia thus described by Babinski, with the
other features of his cerebellar syndrome, cerebellar
catalepsy and adiadochokinesia, indicate lesions of
the cerebellum, but just where has not yet been
determined; certainly not all lesions of the cerebellum
result in this syndrome.
Thomas's olivo-ponto-cerebellar atrophy, a dis-
tinct cerebellar defect, does not show the syndrome
in its completeness — thus no catalepsy is known.
Lesions of the inferior cerebellar peduncle may
produce asynergia. It is not infrequent in multiple
sclerosis of the cerebellum, and is also present in
some cerebellar tumors. Its absence will not nega-
tive a tumor of this organ, but such a negative finding
probably would exclude the implication of the corpus
restiforme at least. As asynergia is rarely present
without a fairly rich complex of other symptoms the
topographical diagnosis is thereby rendered possible.
Smith Ely Jelliffe.
Atavism. — See Reversion.
Ataxia. — This will be considered here only as a
descriptive symptom, not characteristic of any one
disease, such as tabes, since such a disorder may
exist without it, and moreover a disturbance of
motor function may be found in a number of different
disorders.
It, like practically all other so-called symptoms,
is nothing but a rough grouping of functional derange-
ments which becomes manifest when certain con-
ducting tracts of the nervous system are out of
service, either temporarily or permanently.
The integrity of the conducting paths, both sen-
sory and motor, maintains the normal quality of a
function which is of value to the human animal
either in maintaining his own life, constructively or
defensively, or in perpetuating the species. Out of
these primary needs movements have resulted
which, as is well known, in man get to be smooth,
exact, and definite, i.e. they become related with
reference to time, space, and weight. They are
properly timed — agonist and antagonist — to control
time and spatial relations and to judge and choose
among relations between masses. They are, in
other words, adjusted to do useful work.
There are many disorders of movement, but
ataxia has been chosen from among them as the
752
subject matter of this short sketch. Here the d
turbance of movement shows itself largely as a d
turbance of space and time relations. There is
paralysis, no loss of ability on the part of the mus*
to move masses, either its own or external ma,-.-.
but the movements have become illy timed (
jerky, and illy spaced; they overshoot, or undi
shoot, or pass by the object intended to be moved
acted upon.
The movements designed for useful work becoi
jerky, irregular, inexact, and strained or floppy.
The defect in time relation expresses itself in d
turbance of order or sequence, that of space in t
rhythm, while that of estimation of molar resistai
shows in variations in strength.
Every motor act is extremely complex, and i
volves a number of innervation factors. These a
both motor and sensory, and a complete analysis
ataxia renders it necessary to scrutinize both seri
of arcs. These arcs moreover are not exclusive
spinal; they involve the whole cerebrospinal a s
It is by reason of this wide anatomical distribution
the sensorimotor arcs that an ataxia may result fro
lesions in very diverse portions of the anatomii
paths; such as for instance, a posterior column lumb
cord lesion, a cervical cord lesion, a cerebellar corti
lesion, cerebellar peduncle lesion, a cerebellorubr
tract lesion, a thalamocortical, or corticothalam
tract lesion, a vestibular path lesion, etc.
Theoretically, one could obtain identical types
ataxia from these variously located lesions, h
practically this rarely occurs, since few lesions
nature's experiment, disease, are strictly limited
their application to isolated functional, anatomic
pathways. For this reason, largely, it is found th;
these various ataxias are associated with oth<
defects which, in greater or lesser degree, stamp the
as spinal ataxias, mid-brain ataxias, cerebefh
ataxias, cerebral ataxias, labyrinthine ataxias, etc.
Classical peripherospinal ataxias are seen chief)
when the peripheral sensory pathways convcyii
knowledge of mass (i.e. weight relations), are inte
fered with. These occur in tabes (posterior root.-
in neuritis, alcohol or lead diabetes (peripher:
neurone), in rare cases of multiple sclerosis or syringi
myelia, hypertrophic interstitial neuritis, or in pre:
sures from tumors, bone disease, etc., on the po:
terior columns of the cord.
In the arms such an ataxia shows itself in th
finger-nose test (F. N. T.) or the finger-finger tet
(F. F. T.) by the wavy irregular approach, the ovei
shooting, or undershooting, or passing the nose o
finger, and the general attitude of uncertainty an |
apparent clumsiness of the whole movement. 1
the lower extremities such an ataxia shows itelf i
the knee-heel test by a precisely similar series o
uncertain wavering movements, and in walking b;
the classical irregular, staggering, uncertain gail
which is usually rendered much worse the moo ei
the help of the eyes, which aid in judging space rela
tions, is removed. The Romberg test brings thi
out to perfection. Certain tabetics with opt i'
atrophy and blindness either show no ataxia, o
show an improvement in the ataxia with advancinj
blindness. The reason for this is a matter of con
jecture.
Many such ataxias are associated with othci
signs of sensory loss or defect.
Ataxias of the head and neck are rarer but an
found, especially in tabes. The muscles of the fact
may show ataxias in grimacing, in speech, in swallow-
ing. These movements may be mistaken for choreii
movements, but are usually less rapid and forced.
Ataxia of the tongue (of tabetic peripheral, peripbero-
central origin) is not infrequent. In general pan
where central neurones are also involved, it is usually
an early and marked feature.
In tabes it may be borne in mind that any portion
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Ataxia, Fried relch'H
( the anatomical pathway may be involved so thai
., may have a spinal tabetic ataxia, a medullary or
. | brain tabetic ataxia, or a cerebral tabetic ataxia
aeral paresis). _
! peripheral am! antral ataxias arc the clas-
,1 ataxias of developed tabes of certain spinal
d degenerations, such as those seen in pernicious
in syphilis, Addison's disease, in pellagra,
| ergotism, in certain arterioscleroses of (he spinal
and in that complex group of disorders,
i mlly classed under the name of Friedreich's dis-
whieh there is defect of cerebellar tracts to a
or lesser extent.
of the peripheral or spinomedullary ataxias
ociated with the loss of tendon reflexes, as
las disturbances in deep sensibility (tuning-fork
These are aids in determining which anatom-
i hways are involved in the process which
about the functional disturbance. Thus for
ani-e it has been assumed that Romberg's sign
Largely due to involvement of the peripherospinal
■ of the vestibular. This is now considered
ibtful.
, In liar ataxias quite similar phenomena are
i with. Here, however, there is usually more
plication of time and space relations. The ataxias
e callable of separation into subgroups — the
Brgias and the adiadochokinesias (q.i\). In the
ibeUar ataxias per se one obtains with the F. N. T.
I 1'. F. T. wider excursions with usually slower
ions in the directions. The overshooting is
Inounced (asynergia) and may be brought out
having the patient mark out a line of definite
I gth on a blackboard or on paper. Here the
:ixic (asynergic) will make a shorter or longer line
in the example set. In grasping a glass of water
; • fingers are opened unnecessarily wide, and in
■ Iking the patient makes much wider excursions —
liken reeling gait — as Duchenne (who first pointed
the differences of spinal and cerebellar ataxia)
led it — the action of the antagonists being either
essive or insufficient, from the imperfection of
■ knowledge of space and time relations conveyed
i the cerebellar mechanisms. 1
Asynergia of the lower extremities may show
i elf in the tendency of the patient to walk out under-
lth himself, or vice versa. This is a feature of the
^pulsions and retropulsions of paralysis agitans,
heating that cerebellar mechanisms are involved
that disease.
This inability to time the related impulses in
lonist and antagonist is seen in the special sub-
riety of ataxia — adiadochokinesia. Here attempts
perform rapidly alternating movements — turning
ists, five-finger exercises, etc. — brings out clumsy,
j'kward actions. These signs characterize more
rticularly the ataxias, which result when the
ebellar paths are implicated. They are frequent
multiple sclerosis, in cerebellar disease, tumor,
enesis, abscess, hemorrhage, in Marie's ataxia,
d in severe choreas, in some beginning cases of
ralysis agitans, before the spasticity has developed.
■e eye control of space relations bears little upon
fir exhibition, hence these phenomena, drunken
it, asynergias, adiadochokinesias, etc., are not
ile much worse by closing the eyes. There is no
imberg. Certain associated oculomotor phenom-
a however are very frequent. These often
list in certain forced positions of the head, which
nil altered bring about equilibrium disturbances.
inthine ataxias, in addition to the symptoms
typical cerebellar ataxias, also show various
pes of horizontal and rotatory nystagmus. This
a complicated field, and is best taken up in the
Of nystagmus d/.v.).
Pontine ana mid-brain ataxias are difficult to
alyze. There are rarely pure in type since they
e due to lesions which are apt to include several
Vol. I.— 48
sensory and motor pathways. They are apt to con-
lain elements of both the spinal and cerebellar ten-
dencies. Lesions of the inferior cerebellar peduncle
alone are apt to can-" a lypieal asynergia.
Cerebral ataxias, for the I pari develop par-
ticularly from frontal lobe affections, wherein certain
thalamocortical pat hs are involved, The anatomical
localizations of these t halmocortical paths are not
yet definitely ascertained. The ataxia manifests
itself clinically, so far as gait is concerned, in a
manner closely related to the gait of cerebellar
ataxias, but the alaxia is less frequently associated
with the more special cerebellar Bubvarieties or
asynergia or adiadochokinesia. Moreover other
pecial sensory symptoms should permit a clinical
separation of a cerebral from a cerebellar ataxia.
Cerebral ataxias are apt to be unilateral, are rarely
so complete, although at times the titubation is very
pronounced.
Pronounced posthemiplegic cerebral ataxias are
not infrequent. They are naturally unilateral, are
rarely as complete as tabetic ataxias and are of I en
associated with sensory defect — incomplete or mixed
thalamic syndrome.
Cerebral ataxias when in .the gait seem to show-
little change if the eyes are closed. Slight increase
of staggering only may appear.
The special ataxias of speech — dysarthria, anar-
Ihria, etc., have precise analogies with the spinal,
cerebellar, and cerebral ataxias of other muscle
groups. They are more difficult of analysis how-
ever by reason of the greater complexity of the
speech mechanism.
Ataxias are present in the neuroses, psychoneu-
roses, and psychoses. Their individual separation
would carry one too far afield.
Smith Ely Jelliffe.
1. Thomas: Cerebellar Functions; Nervous and Mental Disease,
Monograph Series No. 12, 1912.
Ataxia, Friedreich's. — The condition known also
as hereditary ataxia was first described by Fried-
reich in 1861, and a detailed account was published
by him in 1863, with three autopsies. In 1876 he
published a further paper on the subject, with a
description of three new cases. From this time on,
through the investigations of Schultze, Rtitimeyer,
DeMe>ine and others, the affection came to be clearly
recognized as an hereditary disease of childhood,
affecting chiefly the spinal cord, and characterized by
a type of ataxia hitherto undescribed. W. Everett
Smith in 1885 published an important paper on the
subject of "hereditary or degenerative ataxia." in
which he described six cases in one family, with an
autopsy. He was able at that time to collect fifty-
seven cases from the literature. In 1890 Ladame
made a critical digest of the subject, published in
translation in Brain, in which he summarized the
knowledge up to that year, and gave full bibliograph-
ical references. Nine autopsies only had been record-
ed, and five of these were in Friedreich's own cases.
Oscar Richardson has recently described the post-
mortem findings in a second ease from the familv
reported in 1885 by W. Everett Smith. In 1893
Marie described a condition which he called cerebellar
heredoataxia allied to Friedreich's ataxia, but as he
I hen thought sufficiently characteristic to be deserving
of a separate classification. He based his conclusions
upon sixteen cases, in which among other symptoms,
the knee-jerks were increased instead of decreased or
lost, as in Friedreich's ataxia. Further investigation
has shown that this condition is more properly to be
regarded as a stage in or variety of the fundamental
process than as a distinct disease entity.
Pathological Anatomy. — The spinal cord has
usually been found small and somewhat imperfectly
753
Ataxia, Friedreich's
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
developed, which is in accordance with the apparently
hereditary character of the disease. The alterations
first described by Friedreich consisted in a degenera-
tion of the dorsal tracts, atrophy of dorsal roots, and
certain changes, slight in degree, in several peripheral
nerves. Later study has shown that wider areas of
the white matter are involved than was at first
supposed, and that the gray matter also takes part
in the degenerative process, though to a much less
marked degree. Degeneration of the dorsal tracts to
a very considerable extent is constant, with a probable
constant accompaniment of degeneration of dorsal
nerve roots, giving an appearance wholly analogous
to tabes, and leading to the assumption that the
primary sensory neurone, as such, is involved. The
direct cerebellar tract is degenerated; Gowers' tract
and Lissauer's bundle may be. Various observations
have been made regarding the motor pyramidal tracts,
and it is still in dispute whether they are in themselves
involved as neurone systems in the same way that the
dorsal tracts are. Degeneration in the region of the
pyramidal tracts decreases from below upward, and
disappears (Leyden-Goldscheider) at the lower level
of the oblongata. In Richardson's case, the patho-
logical anatomy of which he has described and which
he has given me the opportunity of studying, the
following lesions of the white matter were definite:
degeneration of dorsal columns throughout the cord,
and of dorsal nerve roots in the lumbar region;
degeneration of pyramidal tracts, of somewhat
iessening intensity toward the upper portions of the
lord, including the uncrossed tracts in the cervical
cegion; degeneration of direct cerebellar tracts, and
rn less degree of the region of Gowers' anterolateral
ascending tracts (see Fig. 519).
In the gray matter the cells of Clarke's columns
have, in certain cases, shown degenerative changes,
along witli the myelinated fibers of that nucleus.
Alterations in other portions of the gray matter of
the cord have been described, but are of somewhat
doubtful character. Very few observations on the
Fig. 519. — The Spinal Cord in Friedreich's Ataxia.
peripheral nerves have been made, but certain degen-
erations have been described which would be in
accord with the theory of a neurone degeneration.
The type of lesion in the cord is similar to that found
in other sclerotic processes, an overgrowth of neuroglia
following a greater or less degree of destruction of
myelinated fibers. The theory of a primary over-
growth of neuroglia has not been generally accepted.
Alterations in the blood-vessels in degenerated areas
occur, and also have been described in the pia and
nerve roots, but no characteristic significance is to be
attached to the changes found.
The cause of the foregoing anatomical alterations
has, in general, been sought in a defect of develop-
ment, of hereditary character, leading to early
degenerative changes in the spinal cord. The dis-
tribution of these changes in the relatively few cases
examined postmortem has led certain observers to
the assumption of a combined systemic disease,
which gains weight from the fact that the disea*
occurs as a family affection, and apparently does nt
depend upon faulty blood states or vascular cond
tions within the cord itself. Certain cases, howeve
do not show a sharply systematized degeneratioi
although the lesions are always of a quasi-system
character. The study of Richardson's case, to whic
I have already alluded, leads to the conclusion thi
neurones, as systems, are involved, though it canm
be said with certainty that groups of neurones,
which our knowledge is as yet deficient, may 'n<
also be degenerated. In support of this assumptio
is the distinct degeneration of dorsal nerve roots an
of direct pyramidal tracts, as well as the characterise
degenerations of the recognized neurone system
The most satisfactory conception of the disease
fore, is that in congenitally defective nervous systen
early degenerations of a systemic or quasi-systemi
character take place, chiefly limited to the spin;
cord, which progress exceedingly slowly, ultimate!
leading to characteristic motor and sensory disorder:
Symptomatology. — The most conspicuous featur
of (lie disease is a characteristic incoordination, whic
is best described as a combination of a tabetic and
cerebellar ataxia. The gait is uncertain, slrro
highly incoordinate, and accompanied by a considei
able degree of swaying from side to side. Stati
ataxia is well marked in the extremities and lieu
after the disease has progressed beyond its iaitii
stages. The Romberg sign (swaying with the eye
closed) is much less constant than in tabes, but ha
been described in certain cases. A further charactei
istic motor disturbance is peculiar involuntarj
chorea-like movements involving the head, whir
persist during rest, but are increased on intends
movement. At times a definite, so-called intentio
tremor may develop. True paralyses do not occtl
in the long course of the disease, except in the latt
more or less helpless stage, when weakness of niuscl
groups may develop, and finally paraplegia wil
contractures, which renders locomotion impossibl
Another very constant motor disorder, but not on
the earliest signs, is nystagmus, which is usually no
present when the eyes are at rest, but may be ekcite
by fixation, particularly in a lateral direction. Thi
sign should, however, be interpreted with caution
Disturbance of speech is a further important sign; it i
slow, difficult, irregular in utterance, and hard t<
understand. The tongue is tremulous and is the sen
of twitching movements, suggesting, in conjunctioi
with the speech disorder, disturbances of coordina
tion similar to those observed in the extremitie
and possibly bearing some analogy to multipli
sclerosis.
For reasons not easy of explanation the sensorj
sphere suffers in very slight degree, in marked con
trast to tabes. With but few trifling exci ption
muscle sense and skin sensibility, as well as thi
special senses, have been found unimpaired. Tin
occasional occurrence of sharp pains and of abnorma
subjective disorders of sensibility in the extremities
is of interest only because of the rarity of these. Ii
view of the constant extensive degeneration of sensor;
areas in the cord, and the high degree of incoordina
tion early developed in the disease, this lack o:
objectively demonstrable sensory disorders must 1"
regarded as one of the striking peculiarities of th<
disease. An appeal to vicarious or certainh addei
function in neurones remaining intact in an affectioi
of very gradual progression, may be suggested by waj
of explanation. Spiller 1 has recently called attention
to the fact that the lesions of Friedreich's ataxia are
by no means limited to the cerebellum and spinal cord.
On the basis of a painstaking pathological examina-
tion, he concludes that changes occur in the brain,
peripheral nerves, ventral horn cells, and in the mus-
cles. It remains obscure, however, why sensory
754
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Atelectasis
irdera are so conspicuously lacking in spite ol
feneration of the dorsal tracts. Spiller also
'cribes for the first time a degeneration in the
•> cases, finds thai in 1 13 08 e
disorders of sensibility are described, and in
mention whatever is made of sensory dis-
Pain appears to be particularly unusual.
The superficial skin reflexes, the pupil, bladder, and
tal reflexes show essentially no alteration, whi
loss of knee-jerk is constant in all well-developed
["rophic ami general vasomotor disturbances
lom been observed, and the sexual function
unimpaired. A frequent occurrence, which
n i eived as yet a satisfactory explanation, is a
\ of the foot of the nature of a talipes equinus,
ovarus, often with an elevated arch, shorten-
■ of the foot as a whole, development of so-called
Ot, with particularly strong dorsal flexion of
great toe. Scoliosis is also an occasional accom-
. Incut. Cerebral symptoms do not occur, ex-
: vertigo, and in the later stages of the disease a
ieral impairment of the mental faculties.
Diagnosis, Prognosis, and Course. — The symp-
M — early ataxia, loss of knee-jerk, choreic move-
club-foot, disorders of speech, nystagmus,
igressive helplessness, beginning before the
■i year — point unmistakably to Friedreich's
With the possible exception of so-called cere-
taxia, tabes, and multiple sclerosis, the differen-
;i isis from other organic cord affections should
no difficulties. The grouping of symptoms
en above is usually well marked and is unique.
The course of the disease is steadily progressive,
ginning in childhood and lasting for from twenty
forty years or even longer, death ultimately being
. e, in "many cases, to intercurrent disease, or to
-this or decubitus, induced by the cord changes.
ogy. — The actual cause of the disease re-
obscure. The facts that it occurs in children
i at the age of puberty, that cases have fre-
entiy been observed in the same family, though by
means constantly, that the cord, post mortem,
es indications of faulty development, have led to
ijestion that it is due to hereditary influences.
than this nothing of value has been found.
appeal to syphilis, alcohol, or various neuroses or
i-choses in ancestors does little to elucidate the
ttter. Nor is it profitable in a disease of this char-
ier to lay stress upon possible exciting causes. As in
disease, there is a predisposition, which is rather
statement of a self-evident fact than an explana-
'ii, so long as we remain in complete ignorance of
iat constitutes predisposition. The fact of ira-
te is that in certain families the affection has
1 in several members. As given by Gowers,
ty-five cases were distributed in nineteen families,
: 1 ten occurred in one family. Sporadic cases are
ibably more frequent than is ordinarily supposed,
has been a frequent observation that many cases
i ur in one generation in families in which the
rents or ancestors were not victims of the disease
-o-called indirect inheritance. The affection is,
■refore, to be regarded as one of the group of
ainily diseases."
Treatment. — In the present state of our knowl-
ige, treatment must remain essentially unavailing,
icept as directed toward the amelioration of symp-
ns. Systematic exercises (Frenkel), avoidance of
terexertion, careful attention to general hygiene,
lod food, and fresh air, with such drugs as are
itnptomatically required, must constitute our
tin reliance. E. W. Taylor.
I; i i i hi nces.
Partial I PHT.
1. Spiller: Jour. Ncrv. and Meat. Dis., 1910, xxxvii., 411.
2. Singer: Monat wh. f. Psych., \ wn , 480.
Friedreich : \ Irchxra in oil . I B63, i ■•'■ < p. 30] td< m,
1876, Ixviii.. p. 145, 1877, Inc., p. I M).
Smith: Host. Med. and Sun;. Joum., 1885, <■ x iii . p, 361.
Ladazne: Brain, 1890, xiii.,p. 167. Critical Review with bibliog-
raphy up t patches surround the collapsed lobules. The
:rmal breathing sounds are absent, and may be
: >laced by bronchial respiration and bronchophony.
ical resonance is increased, and in acquired atelec-
-is abundant mucous rales are audible over the en-
je chest. A very important and characteristic
hture of atelectasis is the suddenness with which the
I signs are changed. Occasionally, during an
lamination, dulness and bronchial breathing will be
ilaced by normal resonance and vesicular murmur;
i within a brief period, abnormal sounds may appear
1 disappear in different portions of the lungs. This
i happen in no other pulmonary disease, and de-
;nds upon the closing of the bronchi by plugs of
icus and their speedy removal by forced expiration
coughing, crying, etc.
Diagnosis. — The recognition of congenital atelec-
iis if extensive enough to give rise to symptoms, is
mparatively easy. The postnatal form is always
■ ■iociated with other morbid conditions which, in
Id cases, render the diagnosis difficult and some-
ues impossible.
Capillary bronchitis, catarrhal pneumonia, and
iar pneumonia are the diseases for which collapse
most liable to be mistaken. Catarrhal pneumonia
rarely developed except in portions of the lung
■ ady collapsed and hence cannot be differentiated
physical signs alone. Diffuse atelectasis differs
mi lobar pneumonia in the absence of fever, the
m note is more tympanitic, bronchial respira-
iii is less marked, and the crepitant rale is absent.
ie suddenness with which the physical signs are
manifested and reach their full development in
collapse is an important diagnostic point. If in tic
course of a bronchial catarrh Bymptoms of COD id. r-
able severity suddenly supervene, such as rapid and
shallow breathing, duskiness of the face, fainl cough
and feeble cry, with little or no increase in fever, the
nature of the attack can Bcarcelj be doubted. If
along with these symptoms tic physical signs of
solidified lung are present, tic chain ol evidence is
complete.
The thermometer renders valuable aid in differen-
tiating between the above diseases. Capillary
bronchitis is normally attended with only moderate
febrile movements, the mercury fluctuating between
H)l° F. and 103° F. A sudden exacerbation of fever
in bronchitis, in which the thermometer registers
104° F. or higher, strongly suggests the onset of
catarrhal pneumonia; on tl tier hand, a sudden
fall nt the mercury, without corresponding improve-
ment ill the symptoms, points strongly to collapse.
The careful diagnostician will rarely have difficulty
in correctly interpreting die symptoms of so-called
compression atelectasis due to tumors of lung and
pleura, pleuritic exudates or lesions of the abdominal
viscera.
Prognosis. — In congenital atelectasis, if restorative
measures are adopted early and the lesion is not
extensive, the prognosis is good. But if the child be
premature or feeble, or if the fetal circulatory openings
are unclosed the outlook is bad. The prognosis in
acquired atelectasis is always grave, and this is
especially so when whooping-cough is the complicating
disease. Convulsions are of bad omen. Lobular
collapse is the initial lesion in many cases of catarrhal
pneumonia, of which caseous degeneration and
phthisis are not infrequent sequels. Emphysema and
bronchiectasis, both in a measure compensatory, are
nearly always left behind when any considerable tract
of lung has been involved.
Treatment. — The treatment of congenital atelec-
tasis consists in the adoption of measures and remedies
to clear the air passages of obstructions, and to
strengthen the respiratory acts. First of all the
mouth, nose, and throat should be thoroughly and
speedily cleansed, the surface of the body stimulated
by the alternate application of hot and cold water,
with an early resort to artificial respiration should
these measures prove ineffectual. Probably of the
man3' methods of artificial respiration in use that of
Schultze is the most efficient. S. J. Meltzer 2 of the
Rockefeller Institute for Medical Research has
recently described a new method of resuscitation.
The condition of asphyxia in the newborn is an
emergency and there is little time to secure special
appliances. Meltzer's outfit is very simple and
could always have place in the obstetrical bag.
In crying and coughing, deep, full inspirations are
instinctively taken, and hence these acts should be
provoked. Nothing conduces more strongly to
perpetuate atelectasis than to indulge a feeble infant
in a vegetative existence. Infants should not be
permitted to sleep too long at one time, or to remain
any great length of time in the same position. The
body heat, often subnormal, should be carefully
maintained by swathing the infant in cotton or
flannel, and in extreme cases it may be kept for days
or weeks in an incubator. In acquired or post-7iatal
atelectasis remedies addressed to the bronchial catarrh,
pleurisy, or other associated diseases are indicated
and will be discussed in other volumes of the Hand-
book. It is only proper to remark here that those
remedies should be chosen which, like the prepara-
tions of ammonium, increase the flow of serum and
lessen the viscidity of the tough secretion which
occludes the bronchioles. If not contraindicated by
debility, emetics serve the twofold purpose of expel-
ling viscid phlegm from the bronchial tubes and
757
Atelectasis
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
producing powerful inspirations. Those emetics
only are admissible which act promptly and with
little depression, as sulphate of copper and ipecac.
Rapidly acting stimulants are indicated. Hot
immersion baths, made more stimulating by the
addition of mustard, and mildly irritating embroca-
tions to the chest are useful. Nutritious diet and
tonics, by which the respiratory muscles gain per-
manent volume and vigor, constitute our chief
reliance, as soon as the immediate danger is tided
over. W. J. Conklin.
1. Ryan: The Lancet, 1868, i.
2. Meltzer, S. J.: Journal of the Anier. Med. Association, May
11, 1912.
Ateleiosis.- — This is the name given by Hastings
Gilford 1 to the most important variety of essential
infantilism, i.e. infantilism for which no apparent
antecedent or coexistent cause can be assigned. (See
Infantilism.) The term is derived from Greek arfkeux,
meaning incompleteness or not arriving at perfection.
Ateleiosis is the result not of an arrest of development
Fig. 520. — A Case of Ateleiosis in a Boy Twelve Vears Old (on
the Left) ; the Boy on the Right is a Normal Chil 1 of Six Years,
the Brother of the Other One. (Gilford.)
but rather of a retardation of development. This
retardation may affect different parts of the body to
a varying degree. It may be more pronounced in the
bony and muscular systems, in the glandular organs,
in the nervous system, in the sexual apparatus, or in
any other part of the body. The rate of this retard-
ation may vary in different cases. It may begin at
any period in the life of the individual. The rarest
forms of ateleiosis are those in which the retardation
758
of development begins during fetal life. In most
the cases this retardation begins during infancy a
early childhood. There are cases recorded in wh
the delay in development did not manifest itself ui
after the period of adult life had been attained, i
characteristics of a case of ateleiosis are strikiii)
seen in an instance of the infantile type of the disea
Although the individual may have attained tl,
of maturity, he still has the comparatively large "in
and the comparatively long body and short limbs
the child; at the same time he has the unmistaka
physiognomy, intelligence, and thin high-pitch
voice of the child. The degree to which the indiv
ual manifests these characteristics of immatur
depends upon the period of onset of the i
The most striking symptom is the retardation
growth, associated with the failure of the epiphy:
to unite with the shafts of the bones. In one record
case the increase in length and weight, which uric
normal conditions should have been attained in ii
years, was spread over a period of thirty-five yea
The limbs are short, the proximal segments Dei
conspicuously so when compared to the distal,
that the midpoint of the body is near or at t
umbilicus, instead of being at the pubis, as in t
normal adult. Dwarfism, although present in t
large majority of cases, is not an essential charach
istic of this disease, for, as stated above, the delay
development may not begin until the individual h
attained his maximum stature. The sexual orga
Fig. 521. — Ateleiosis in a Man Aged Forty-two Years; Front
and Back Views. (Weber.)
may or may not reach their full development. 1
the former case puberty may be postponed for man
years. In the latter case the sexual organs ma
retain their infantile characteristics throughout lif
This is observed in the most pronounced forms of tl
disease. Based upon the degree of sexual develoj
ment, the cases of ateleiosis are subdivided into tl
sexual and asexual forms. In sexual ateleios
the sexual organs mature, the epiphyses unit' 1 , sn
the remainder of the body undergoes to a certai
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Alilrlosls
,.. «nt a corresponding transformation. Then growth
and the individual, although sexually mature,
,. therwise a child in his development. The nose
.. .■ more prominent ami sexual hair may
Occasionally, in the male, hair may grow
, he face.
ne of the important characteristics which serves
t( listinguish ateleiosis from other forms of infan-
Fig. 522. — Skiagram of the Hands in the Case of Ateleiosis shown in Fig. 521.
(F. Parkes Weber.)
ism is the fact that the former condition is trans-
ited by heredity, and the latter are not. The
redity may be direct, as in the instance cited by
lford, in which the disease was transmitted through
ree generations, implicating at least four individ-
ls; or the heredity may be familial, appearing
ily in two or more children in the same family.
le latter form of inheritance is the usual one. When
fferent members of a family are affected with
eleiosis, they may exhibit different types of the
sease. On account of the failure or retardation in
e development of the sexual organs, the natural
ndency for ateleiosis is to die out, as is the case
ith other degenerative manifestations. Another
sential distinguishing characteristic of ateleiosis is'
ie fact that unlike other forms of infantilism there
an entire absence of disease or debility in the
•evious history of the individual affected.
The ateleiosic may live the usual span of years,
id may even approach the age of the centenarian.
>seph Boruwlasky, the celebrated dwarf of the
ghteenth century, lived to be ninety-eight years
id. He lived in England during the greater part of
is life and earned a comfortable livelihood as an
bject of curiosity, being carried about in a sedan
hair by groomed attendants. In his autobiography
' Memoirs of Count Boruwlaski") he states that he
id not attain puberty until the age of twenty-five.
Gilford believes that ateleiosis may be explained on
he ground that it is a discontinuous variation or
mtation. This belief is based on the facts that
ateleiosis appears spontaneously, possesses a pro-
nounced individuality, and in occasional instanci
transmitted by heredity. In contradistinction to
ateleiosis, Bympl atic infantilism is regarded
continuous variation or fluctuation, depending upon
environmental conditions either within or without.
the organism, but bring also of a minor degree and
non-heritable.
The accompanying figure (1 ig.
520), taken from Gilford', Ulus-
trates a ease of ateleiosis. The
shorter boy aged twelve years,
affected with this condition, is
standing beside his normal six
year old brother. The former
shows the rounded contour,
height, proportions, and physi-
ognomy of the young child. No
cause of the retarded develop-
ment could be disco\ ered in this
Ca ■'. The patient was the only
abnormal member of a family of
eight children, and the delay in
development began at the age of
two years. At the time the pho-
tograph was taken the patient
was of the height and weight usual
in a boy four years old. There
were no signs of cretinism or of
rickets. The patient's epiphyseal
ossification was about one year
behind that of his brother of six;
dentition was delayed, and the
teeth were crowded. The patient
was a bilateral cryptorchid. He
was of fair intelligence, and two
years after the portrait was taken
played in one of the London
theaters " the double role of baby-
in-arms and man-about-town."
F. Parkes Weber 3 reports a case
of ateleiosis in a man who
although forty-two years of age
had the physical development of
a child of nine years (Fig. 521).
But his expression, the wrinkles
on his face, his attitude, his man-
ner of speaking, and his general behavior were rather
more those of an adult. With the exception that
during infancy he had had hydrocephalus, he was
much like other children until'he was nine years of
age. _ Then his growth and development ceased. At
the time he was observed by Weber his height was
47.7 inches and his weight was 69 pounds. His head
was rather large for the diminutive size of his body.
There was no hair on his face or pubes. No testicle
could be felt on the right side; the left testicle, of
about the size of a small cherry, was incompletely
descended. Mentally the patient was somewhat
childish. Skiagrams showed persistence of some of
the epiphyseal cartilages, but the amount of union of
the epiphyses with the diaphyses varied considerably
in different bones. It is pointed out that in the skia-
grams of the hands (Fig. 522), those epiphyses which
are not yet joined to the diaphyses are seen to be
bordered by a very deep shadow.
In all other forms of infantilism, apart from the
dwarfed stature and generally childish appearance,
there is no distinctive facial expression. But in
ateleiosis the physiognomy is distinctive, so that the
affected indi: viduals all tend to resemble one another.
This " stereotyped " expression of infancy or of per-
petual babyhood is referred to by Gilford as one of
the most striking manifestations of ateleiosis. The
characteristics of this expression are the large size of
the head, the broad flat face, the great breadth of
the nose and undeveloped condition of its bridge, and
the small size of the upper jaw, as the result of which
759
Ateleiosls
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
there is a tendency for the upper teeth to be crowded
together. In the fetal type of ateleiosis there is a
combination of imbecility and dwarfism.
Alexander Stingarn.
1. Gilford. Hastings: "The Disorders of Postnatal Growth and
Di-velopment", London, 1911.
2. . The British Journal of Children's Diseases, July,
1911.
'.i. Weber, F. Parkes: Proceedings of the Royal Society of Medi-
cine, June, 1910.
Atheroma. — See Blood-vessels, Pathological Anat-
omy of.
Athetosis. — This consists in a series of involuntary,
slow muscular movements usually most prominent in
the upper extremities, during which grotesque, fanciful
positions are taken. The patients have little or no
control over them. Clinically speaking they usually
follow a hemiplegic or diplegic attack, and hence were
referred by the original describers (W. A., Hammond,
who gave the name, Charcot, and others), to lesions in
the internal capsule. An immense amount of study
with exact anatomical data began with Bonhoeffer
in 1901, since which time a large number of studies
have been made, but it cannot be asserted with defi-
niteness as to the pathways necessarily involved which
can bring about athetosis. The chief results seem to
locate themselves about the mid-brain structures,
yet various points of view are held.
One scheme is as follows:
1. Spinal paths = Athetoid Movements (Wallen-
berg).
2. Rubrothalamic Paths = Tremor (Touche).
3. Rubrocortical = Chorea (J. J. Putnam).
Another arranges these as follows:
1. Tegmentocerebellar = Athetosis.
2. Rubrothalamic = Chorea.
3. Rubrocortical = Tremor — paralysis agitans.
Jelliffe in a paper on Benedikt's Syndrome ascribes
the athetoid movements to interference with the rubro-
thalamic and thalamorubral fibers; such movements
are frequently seen in the thalamic syndrome of
Roussy. Choreiform and choreoataxic movements
are referred by him to interference with the cerebello-
rubral pathways either in their mid-brain course, or
possibly in their cerebellar origins, whereas the purely
paralysis agitans and multiple sclerosis-like tremors
he believes are due to cutting off of the rubrocortical,
or corticorubral fibers chiefly in and about Forel's
field (H 2 ), as Jelgersma and Winkler have suggested.
They may be due to lesions in the red nucleus itself,
in which case they should play a greater role in the
Weber-Gubler syndrome.
These athetoid movements have been treated,
with a small degree of success only, by section of the
posterior roots. Smith Ely Jelliffe.
Athrepsia. — See Marasmus.
Atlantic City. — In order to facilitate a better under-
standing of the climate of Atlantic City, it becomes
necessary to refer to some of the differences in the
topography between the southern section of the
State of New Jersey, in which Atlantic City is located,
and that of the adjacent and nearby territorial
sections, such as the northern section of New Jersey,
and adjoining portions of Pennsylvania and New
York. Therefore, I shall endeavor, first, to point out
briefly some of the physical differences that, doubtless,
influence favorably the climate of this section.
If we draw an imaginary line from the Atlantic
Ocean through the Newark Bay, west to the east
bank of the Delaware River, at Trenton, for all
purposes herein required, this will separate New
Jersey into two territorial divisions which, for the
purpose of comparison, we will call the northern and
southern sections. The former, like the adjacent
760
territory of Pennsylvania and New York, thoug'
separated from the former by the Delaware, an
from the latter by the Hudson River, is rolling an.
mountainous, with intervening dale and plain,
large portion of which has an underlying clay subs'oi
and other portions, trap and shale rock. Th
southern section of New Jersey is composed chief!
of sand and an alluvial soil, undulating and slopin
eastward and southward to the water line, alon
which the coast is fringed with salt marshes, shalloi
bays, and broad lagoons.
The mean annual difference in temperature betwee
these two sections is 8° F. This fact has given rb
to may discussions, and has been the subject of muc
scientific speculation and, naturally enough, amon
the many solutions offered, the influence of the Gu
Stream has been much impressed upon the mind
of the populace in this section. There is little doulj
but that the difference in soil, geological formation:
direction and velocity of the wind, humidity, etc., ar
more directly concerned, not only in the differenc
in temperature, but also in other differences which
shall endeavor to show do exist.
First, referring to the possible influence of th
Gulf Stream upon the climate of Atlantic City, i
becomes necessary for one to understand the relativ
distance of the Gulf Stream from the coast at thi '
point which, in fact, is about 100 miles. Studie
from the standpoint of physical laws governing th
wind and water currents, one can scarce admit of an
perceptible influence that the heated currents froi
the Gulf Stream could exercise upon the local win
currents in the immediate vicinity of this city, th
distance between the two being too great. Neithe
can we appreciate that there would be any very grea
change in the ocean temperature exercised by th
Gulf Stream, at a point so far distant from the paren
source, though it is a fact well known that simila
or like bodies tend to an equalization of temperatun
but, in this instance, the body of water lying betwei
the shore at Atlantic City and the Gulf Stream i
too varied and enormous for one to conceive of an
great temperature change being effected in the equai
ization of temperature at this point. However, ii i
my purpose to recite, rather than discuss the differ
ences, and I shall leave this part of the subject for th
more versatile and scientific of my readers to deter
mine for themselves.
The fact that a great difference does exist in the-
different localities is emphasized by a fact long Bine
present and proven, in the monumental health resorl
which dot the southern coast of New Jersey, clue
among which is Atlantic City where, in no other par '
of the State has there been such expenditure for tin
comfort and interest of the health seeker; here
climate and comfort combine in their efforts t<
restore peacefully wearied muscles and tired brain
in a manner not to be found elsewhere. It is well f"
those contemplating climatic changes for improve
ment of health, or a health building sojourn, to knov
that those visiting the shores of the southern part o
New Jersey, where the temperature and climatii
differences are found most favorable, are not to b(
numbered by the hundreds, nor by the thousands, bu :
by the hundreds of thousands, and while the objeei
with some is primarily pleasure, secondarily, th<
stimulus given the functional activities, menta
impetus, and general renovation of the varied foree:
of the body are sure to follow. Again, while con
templating the above advantages, it is well to know
that here one escapes the debilitating influence
incident to the more severe and less equable climate!
of other resorts.
Before introducing the detailed summary of ll"
observations made in this city, some reference is due
Atlantic City not only as the chief health resort of the
New Jersey coast but, in truth, the most nearly ideal
health resort in America, if not in all the world.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Atlantic City
lantic City is situated on Absccon Island, five miles
mi the main land; the island ranges from one-
; lith of a mile to three miles in width and eleven
lung, and is entirely surrounded by sea water.
ie older or principal business part of the city
located on the northern and north-central part of
■ Island; however, the growth of the city of late
- been so rapid, when considered in conjunction
th the suburban residence sections of Chelsea,
ntnor, Margate City, and Longport, that it now
es the greater part of the island, and has a
iident population of 50,000 or more; its migratory,
. i-iting. population varies from 20,000 to more
in 300,000, according to the season of the year.
s patrons are no longer of the States, or of one
., for one may easily touch the customs,
■tilth, and industries of a dozen countries in a
orning's conversation in the corridors of the various
ml, not infrequently, the greater number in the
■rridors of his own hotel.
situated, by rail, fifty-seven miles southeast from
liladelphia, and 150 miles south by east from New
iving respectively one hour from the former,
1 three hours from the latter, connecting therewith
ie many trunk lines throughout the country,
antic City becomes more responsive to the interests
id comforts incidental to the demands of the health
g public than any other coast health resort. In
Idition to the climatic advantages, there are to be
iund many accessories in the way of large, commodi-
is, and comfortable hotels; splendidly arranged and
nitarily equipped cottages; good markets and
luntiful certified milk supply; varied and pleasant
itertainments; piers extending into the ocean,
cess to which may be had at a nominal figure,
here the advantages of an ocean trip are possible
ithout any of the inconvenience and disturbance
icidental to motion and limited space, such as
- sarily attaches to an ocean trip, the assurance of
cilled and readily attainable medical service in case
illness or injury; but these facts are so well and
■nerally known that a mere reference is all that is
-ary in this article.
One of Atlantic City's greatest and most attractive
■attires is the Board-walk, where the aged, the
ebilitated, and the convalescent, together with the
leasure seeker, may all freely enjoy the stimulating
a breezes and the hours of sunshine, through the
g! ncy of the rolling chair, as is not possible in any
her place. Here Atlantic City's patrons may tra-
e this elevated highway along the ocean front,
nd immediately on the strand, for a distance little
•s than ten miles, the same varying in width from
ity to eighty feet, in the central portion of which
ial comfort rooms have been accessibly arranged
ath the walk. Here, through the agency of the
hair, or a spirited walk, one can easily imagine him-
'lf on an ocean voyage for any period from an hour
o that of several months, and repeating it as fre-
Itiently as the opportunities afforded may permit.
With this introduction, I submit the important
iart of this article, bearing directly upon the climate
if Atlantic City, for which I am indebted to L. A.
fudkins, Section Director, TJ. S. 'Weather Bureau,
ocated in Atlantic City.
" The official records of the TJ. S. Weather Bureau,
■overing a period of nearly forty years, show con-
lusively that Atlantic City possesses a favorable
limate, whether the subject be viewed from any
me or all of the several elements, such as temperature,
trecipitation, wind, sunshine and cloudiness, etc.,
hat are comprehended in the climatology of a
lace. The most important advantageous climatic
ires of this celebrated watering resort are, per-
. the comparative mildness of the winter season,
the coolness of summer, the abundance of sunshine
throughout the year, and the general exemption
from heavy snows.
Atlantic t'ity has an average winter temperature
of 34°, the normal for th.- colde I m.. nth, January,
being 32.5°. The summer temperature a ■
70.5 , with July and August, as a rule, furnishing the
warmest weather. The normal temperature for -pring
i- 18°, and for autumn, .">7°. The annual mean temp-
erature is r,2°. For purpose of comparison, the
average winter and summer temp, i.i .... of several
of the large eastern cities an- herewith given:
Boston
\.'\\ York. •
Philadelphia.
Baltimore . . .
Washington . .
Pittsburgh.
Atlantic City.
Winter.
69°
32° 71'
33° 74°
75°
34° 7;',°
:i." 73°
34° 70°
"Figures sometimes fail to describe adequately
the conditions or circumstances to which they are
applied, and it is proper to say in this connection that
there ;ue many days in winter with seemingly low
temperatures that are a delight to the Atlantic
City visitor because of the fact that the sunst reamed
Boardwalk is a number of degrees warmer than the
figures representing the shade temperature. On the
other hand, the heat of summer is nearly always
tempered by the refreshing and cooling southwest
breezes, blowing directly from the broad expanse of
the ocean. The only wind directions that produce
excessive heat in summer are west and northwest, and
these are infrequent. The average number of day- in
Atlantic City with a summer maximum temperature
of 90°, or higher, is only two, as against from about
ten to twenty such days at places in the interior.
The highest temperature on record for the city is 99°,
this having occurred twice since the year 1S74.
During the period 1874-1911 there have been five
years with the highest annual temperature less than
90°, and twenty-seven years with less than 95°. The
lowest temperature for Atlantic City is 7° below zero,
this having been recorded once in December, 18S0,
and on two successive days in February, 1899. The
average number of days per year with "minimum
temperature 32°, or below, is eighty-four, and with
zero, or below, one. There have been twenty-seven
years since 1S74 without zero temperature, and the
actual number of days, 1S74-1912, on which the
temperature has fallen to zero, or lower, is only
twenty-one.
"The several seasons of the year are occasionally
subject to marked departures from their normal
weather elements, but, with respect to temperature,
the comparative equability of Atlantic City's climate
is well illustrated by the fact that the warmest and
coldest seasons on record have not been excessively
above or below their respective averages, except in
a few instances. The mean temperature for the
warmest and coldest winter, spring, summer, and
autumn, with the departures from the normal tem-
perature, are as follows:
Mildest winter
Coldest winter
Mildest spring
Coldest spring
Wannest Bummer. .
Coolest summer. . .
Warmest autumn. .
Coolest autumn
Mean Departure
temperature, from normal.
42° +S°
29° -5°
52° +4°
44° -4"
72° + 1 . 5°
69° - 1 5°
60° +3°
53° -4°
"It will be seen that the average temperature ol
the 1 warmest summer on record was only 1.5° above
the normal, and that of the coldest winter 5° below
the normal. The average date of the last killing
frost in spring is April 11, and of the first killing
frost in autumn, November 4. The earliest date
7G1
Atlantic City
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
on which a destructive frost has occurred in autumn
is October 1, and the latest date in spring April 25.
The earliest date on which freezing temperature (32°)
has occurred in autumn is October 10, and the latest
in spring April 30.
" September and October, with average tempera-
tures of 67° and 56°, respectively, are ordinarily two
of the most pleasant months of the year, on account
of their moderate temperature, the large amount of.
clear weather, and a marked decrease in the humidity
that is present in the midsummer months.
"It is a popular, but in the opinion of Weather
Bureau officials an erroneous, supposition that the
Gulf Stream exerts a marked influence on the climate
of the New Jersey sea coast. This ocean current is
distant 100 miles, or more, from the New Jersey shore,
and although its temperature is somewhat higher
than that of the surrounding water, there is hardly a
possibility that the stream has any effect whatever
on the climate of this locality. The comparative
mildness of the winter season is due to the influence
of the ocean itself rather than to the Gulf Stream.
"The temperature of the ocean at Atlantic City is
exceptionally favorable for bathing in summer. In
the summer of 1911 the surface water temperature
rose to above 70° in the latter part of June, and was
not below 70° thereafter during the season, except
occasionally and briefly in July. The water tem-
perature was 80° and slightly higher numerous times
in August, and remained above 70° until about
October 1.
"The average precipitation (rain and melted snow)
at Atlantic City is 40.82 inches. The precipitation is
quite uniformly distributed through the several
seasons as follows: Winter, 10.41 inches; spring,
9.72 inches; summer, 11.11 inches; autumn, 9.58
inches. August, with an average of 4.30 inches, is
the wettest month. There are four months, April,
May, June, and September, that are classed as dry,
each having an average rainfall close to 3 inches.
The average annual number of days with measurable
precipitation is about 125, the greatest annual number
on record being 143, and the least 101. Virtual
immunity'from heavy snowfall during winter is one
of the several favorable climatic characteristics that
attracts many winter visitors, whether bent on pleas-
ure or seeking restoration to health. That the
resort escapes in large measure the heavy snowfalls
that are common to the interior is accounted for by
the simple fact that, when conditions are opportune
for snow, the temperature often tends upward with
the approach of the storm center, thus frequently
changing the precipitation to rain. The average
annual snowfall is only eighteen inches, and the
average number of days with snow (November to
April inclusive), twelve. The normal amount for the
three winter months is about thirteen inches, January
and February naturally having the heaviest falls.
Snow is infrequent in November, and there have been
so few appreciable amounts in April in the past
thirty years that the average for the latter month is
merely " trace." It is uncommon for snow to remain
on the ground for any considerable time; on the
contrary it often disappears within twenty-four hours
after ending.
" Atlantic City is abundantly supplied with sun-
shine — an important climatic factor. The average
annual number of hours of sunshine is 61 per cent, of
the possible number. The averages for the summer
months range from 63 to 68 per cent.; September has
an average of 67 per cent., and October 63 per cent.
Less sunshine is received in winter than in summer,
but each winter month has an average percentage
exceeding 50, that for December being 55 per cent.,
for January, 52 per cent., and for February, 60 per
cent. No winter month in the last 16 years has
received less than 40 per cent, of the possible amount
of sunshine, and several winter months have had as
much as seven-tenths of the possible number o
hours. The average cloudiness (scale to 10) is 5.(
The average number of clear days per year is 122
partly cloudy, 135; cloudy, 108. Southwest wind
prevail from May to September, inclusive, an
northwest at other times.
" The foregoing statements cover the subject of th
climate of Atlantic City only in a general mannci
It must not be inferred from them that disagreeab!
weather is unknown here, although the authenti
Weather Bureau records prove beyond doubt tha
the sum of the good qualities of the climate largel
outweighs the unpleasant conditions that are en
countered in this city, as well as elsewhere, at times.
Philip Marvel.
Atlee, Washington L. — Born in Lancaster, Pa
February 22, 1808. He received the degree o
Doctor of Medicine from the Jefferson Medica
College, Philadelphia, in 1829. In 1834 he began th
practice of his profession in his native city. In 1-
he removed to Philadelphia. He died in that city
September 6, 1S78.
Stone, in his " Biography of Eminent America?
Physicians and Surgeons," says: "As a practitione
Atlee was most famous for his advocacy of tin
difficult operation of ovariotomy. Commencing it
performance and defending its propriety at a periei
when hardly another surgeon in the land darn
support him, he triumphantly vindicated its nierii
by the statistics of over three hundred cases in hi:
own hands, a large part of them successful in al
respects. From his own history of ovariotomy
sketched in his annual address as president, before tin
Philadelphia County Medical Society, we cull th.
more important facts. To Dr. Ephraim McDowel
is accorded the honor (now generally conceded) ol
being the first to perform the operation, in the year
1809. (See under the heading McDowell, Ephraim, in
a later volume of this Handbook, for further details.)
Dr. John L. Atlee, of Lancaster, Pa., brother of the
subject of this sketch, performed it on June 29, 1843,
on an unmarried lady, aged twenty-five years.
***** rj r _ Washington Atlee performed his first
operation March 29, 1844, on a married lady, sixty-one
yearsofage. It proved fatal. ***** His second
operation was performed in the city of Lancaster,
August 2S, 1844, on an unmarried lady, twenty-four
years of age. She recovered. ***** His third
operation, the first case in Philadelphia, was per-
formed March 15, 1849. Upon moving to Phila-
delphia he found ovariotomy everywhere decried. '
It was denounced by the general profession, in the
medical societies, in all the medical colleges. The
opposition went so far that a celebrated professor, in
his published lectures, invoked the law to arrest him
in the performance of the operation." In 1853, only
a few years after the excitement regarding the opera-
tion of ovariotomy had in large measure subsided,
Atlee again "startled the profession by his method of
heroically attacking uterine tumors with the knife."
His successes were numerous, and although few at
first dared to imitate him, he lived to see the opera-
tion approved and himself commended by the best
gynecologists of his time.
Of the various writings published by Dr. Atlee it
will be sufficient here to mention the titles of only
the following: "General and Differential Diagnosis nf
t Ivarian Tumors, with Special Reference to the
Operation of Ovariotomy," 1S73; and "The Treat-
ment of Fibroid Tumors of the Uterus," 1876.
A. H. B.
Atophan. — The trade name of an antipyretic and
analgesic synthetic compound, C 10 H U NO, (2-phenyl-
chinolin-4-carbonic acid), introduced as a substitute
762
REFERENCE IIAXDRt ><>K OF THE MEDICAL SCIENCES
Atresia
[ the salicylates. It occurs in the form of small,
lorless, acicular crystals, of a slightly bitter taste,
soluble in pure water, but readily soluble in nlku-
olutions and hot alcohol. Experiments by
icolaier and Dohrn have shown thai the exhibition
ihan is followed by a greatly increased output
uric acid ami the urates. According to Wein-
this increased elimination is not ,lue to a
production or to an increased solubility of
id in the organism, but rather to a selective
of the drug upon the secreting epithelium
the convoluted tubules of the kidney causing
excrete larger quantities of this substance.
te drug is therefore recommended as of special
in the treatment of acute gout and gouty
ons believed to depend upon a retention of
id in the economy and a deposit of urates in
its and fibrous tissues. It has been found
cful also in acute rheumatism and in sciatica and
her neuralgias, lumbago, and migraine. In cer-
es the administration of atophan causes more
;astric disturbance which may be avoided by
. simultaneous exhibition of small doses of sodium
arbonate. Obviously, the greatly increased excre-
ol uric acid by the kidneys might produce a
v to renal colic or the formation of vesical
and it is advisable therefore to combine the
'ministration of atophan with large doses of sodium
icarbonate and copious water drinking. The drug
i- tint 1 n observed to have any depressant action
i the heart.
Vtophan is given in doses of gr. vijss. (0.5) four
t8E a day to gr. xv. (1.0) three times a day. So-
ini bicarbonate should be given at the same time
doses of 5i. (4.0) three times a day, and a glass of
ain water or mineral water should be taken with
ich dose of atophan. The drug is found in the
:irket in tablets of seven and one-half grains (one-
alfgram). T. L. S.
\to\yl. — Trade name of sodium arsanilate or
idium aniline arsonate, C 6 H,N.As0 3 Na or C 6 II,-
, Tl AsO.OH.ONa +3H 2 0. Similar preparations are
nown as soamin and arsamin. It occurs in the
inn of a white, odorless crystalline powder, of a
lightly saline taste, soluble in five parts of cold
rater. Its therapeutic action is believed to be due
o the very gradual elimination of arsenic in the
issues, producing thereby a continuous but less
oxic and less irritating effect than arsenous acid.
t has been employed to meet the indications of
lie in anemia and in the malarial cachexia, but its
hief use is in the treatment of syphilis and of trypano-
omiasis, especially sleeping sickness. It is given
lodermically in doses of gr. i.-iij. (0.06-0.2) every
r day; it has also been given in much larger doses,
ven up to gr. x. (0.6), by intramuscular injection
nto the buttock. Although the drug has given
xcetlent results in the treatment of sleeping sickness,
t has fallen more or less into disfavor in consequence
if many cases of blindness from degeneration of the
iptic nerve which have followed its use. Muscular
md abdominal cramps and renal irritation have also
jeen observed after large doses. T. L. S.
Atresia. — Imperforation, closure, or absence of a
natural opening or passage. (Gr. a = priv. and rp^o-is,
i piercing.) There may exist an atresia of any one
of the external orifices or internal passages of the
body: Atresia pupillae, A. palpebrarum, A. oris, A.
inris, A. trachea 1 , A. oesophagi, A. bronchi, A. in-
ini, A. recti, A. ani, A. vagina?, A. urethrae, A.
c, A. uteri. The imperforation may be the
result of disturbances of development in fetal life, or
it may arise secondarily to local inflammatory pro-
cesses either before or after birth, or may be produced
by mechanical obstruction, pressure, etc. According
to the etiology we may therefore distinguish two
classes of atresia, the congenital ami the acquire^.
Pupil. — Congenital closure of the pupil of tie
not infrequently occurs, and is usually the result of a
persistence of the pupillary membrane which in fetal
life covers the lens and as a rule disappears in the
last month of pregnancy. Variou forms of this
malformation occur: the pupil may be' entirely
covered by a thick grayish membrane containing
blood-vessels, or by a network of fine threads in
which vessels run, or irregular brown or grayish
patches may appear in the pupil.
Acquired atresia of the pupil is of rather frequent
occurrence in adult life as tin- result of inflammations
of the iris and choroid, but it may take place at any
time, even before birth. In chronic iritis the pupil
may be partially or completely closed by vascular
connective tissue.
Eyelids. — Total imperforation of the eyelids is not.
of frequent occurrence. The congenital form is
usually associated with grave defects of development
which do not permit of extrauterine life. The edges
of the lids may be firmly adherent to each other and
to the eyeball (symblepharon). The condition may
be caused by a failure of separation of the conjunc-
tivae, intrauterine inflammations of the eye, or it
may be caused by amniotic adhesions. The latter
cause is probably the most frequent. One or both
eyes may be affected. Remains of the amniotic
adhesions may be found in the shape of tags, bands,
or firm membranes covering the lids and adherent
to them.
Acquired atresia of the eyelids (symblepharon,
ankyloblepharon) occurs after severe ulcerations, diph-
theritic conjunctivitis, burns caused by lime, hot metal,
and explosives. In cases in which there is complete
occlusion the edges of the lids are firmly united to
each other and to the eyeball.
Nostrils. — Complete atresia of the nostrils is rare
and is usually found in association with cyclopia. In
this type of monster the nostrils are represented by
one or two fleshy imperforate tags which are usually
placed in the forehead above the solitary eye. The
atresia of one nostril through a congenital obliquity
of the septum is not infrequent, and is of great practi-
cal importance because of the habit of mouth-breath-
ing and the chronic catarrhs of nose and pharynx
which are associated with it.
Acquired stenoses of one or both nostrils are also
not rare. The closure may be caused by new growths,
polypi, injuries, chronic catarrhal conditions, etc.
This condition is likewise of great practical impor-
tance.
Mouth. — Complete absence of the mouth is a very
rare occurrence, and is always associated with marked
defective development of the head and face. It is
most frequently the result of amniotic adhesions,
or of an abnormal tightness of the cephalic cap of the
amnion. Partial atresia (microstomia) is of more
frequent occurrence, but is rarely found in a viable
fetus. Congenital closure of the fauces is likewise of
rare occurrence.
Ears. — Complete failure of development of the
external auditory meatus occurs very rarely. The
lumen of the meatus may be filled with compact
bone or cartilage, or it may be closed by a firm mem-
brane of connective tissue in which small islands of
bone or cartilage may be present. With this mal-
formation there is almost always associated a de-
fective development or entire absence of the external
ear, and imperfect development of the tympanum and
internal ear. The site of the ear may be indicated
only by a slight indentation. In other cases a carti-
laginous canal may be present which is closed at a
slight depth by bone or membrane. Partial atresias,
hour-glass or symmetrical narrowing of the external
canal, are of rather frequent occurrence. In these
7G3
Atresia
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
cases the external ear may be normally developed or
show greater or less malformation.
Acquired atresia of the external canal is not rare.
Inflammations may cause thickenings of the wall of
the meatus, and stenosis or constriction may result
from the formation of connective tissue. Very fre-
quently there is a polypoid growth of granulation
tissue into the canal, and through the adhesion of the
granulating surfaces complete atresia of the canal
may result; or bands, bridges, and septa of connec-
tive tissue may be formed. A subperiosteal forma-
tion of new bone may lead to osseous atresia; in
other cases exostoses may block the canal. De-
tached osteomata sometimes develop in the granula-
tion tissue formed in inflammatory processes. Fur-
ther, eholesteatomata are rather frequently found
blocking up the external canal. In these cases all
parts of the ear may be perfectly developed and the
tympanum intact. It is therefore probable that
these formations owe their origin to a desquamative
inflammation of the lining of the canal. In very
rare instances they may develop from epidermoidal
cells which during the period of embryonic life have
found their way into the meatus. Plugs of cerumen,
foreign bodies, tumors, parasitic growths, etc., may
also lead to an acquired atresia of the auditory canal.
Trachea, Bronchi, etc. — Atresia of the larynx
through the formation of connective-tissue membranes
or through the adhesion of the walls is of very rare oc-
currence, and has been observed only in cases showing
marked malformations of the face. There may be
complete absence of the trachea, the bronchi being
given off directly from the larynx. In other cases
the trachea may be represented by a fibrous cord-
like structure, or its walls may be united by the for-
mation of connective tissue. Similar formations of
connective tissue may block the main bronchi, the
trachea ending in a blind tube. Partial narrowing of
the respiratory passages is not uncommon.
The acquired forms of stenosis of the trachea and
bronchi are for the greater part produced by con-
ditions external to these structures, new growths in
the neighboring lymph glands, aneurysms, etc. Ob-
struction of the passages themselves may be produced
by inflammatory conditions, foreign bodies, etc.
New growths within them are of rare occurrence.
Cardiac Orifices. — Atresia of the aorta is rare.
On the other hand, atresia of the pulmonary orifice
is a relatively common cardiac anomaly.
Esophagus. — Atresia of the esophagus throughout
its entire length is very rare. Congenital imperf ora-
tion of this organ is most frequently found in the
lower two-thirds, the upper third being open and
ending in a blind tube, while the lower closed portion
is represented by a thin cord-like structure. Associated
with the congenital atresia there is almost always an
abnormal communication with the trachea either
at the lower end of the upper portion or at the upper
end of the lower portion, which may be continued as
an open canal from the point of communication. In
other cases the middle portion of the esophagus may
be obliterated, so that the upper and lower portions
are separated from each other by an imperforate cord
of connective tissue. In these cases no connection
with the trachea may exist. As a rule this form
occurs late in fetal life and is most probably due
to inflammatory processes.
Acquired stenoses of the esophagus are of relatively
frequent occurrence and are of great clinical impor-
tance. They may be caused by pressure of tumors
in the cervical or mediastinal lymph glands and
thyroid, by mediastinal tumors, aneurysms, etc. The
lumen may be obturated by polypoid growths of
the mucosa, carcinoma, thrush, foreign bodies, etc.
Strictures are produced by contractions of scars re-
sulting from the effects of alkalies, acids, carcino-
matous and syphilitic ulcerations, etc.
Stomach. — Complete occlusion of the stomach is ex-
764
tremely rare. Occasionally the organ is very sma]
resembling a portion of the intestine. Congenital o
elusion of the pylorus is quite rare, while acquire
stenosis at this point is relatively frequent. 1
almost every case the latter is due to the obstructio
or constriction of the orifice by new growths, but
may be caused by healing ulcers or by pressure froi
without. Partial constriction of the stomach ma
occur in any part of the organ through the contraetii
of healing ulcers, new growths, etc. (hour-gla:
constriction).
Intestine. — Congenital atresia or stenosis may occi
at any portion of the intestinal tract. There
usually only a single such closure, but occasionall
multiple atresias may be found. The intestine ma
be entirely absent for a portion of its course, or t
represented by a cord-like band of connective tissui
The portion of mesentery belonging to the obliterate
intestine is also absent. The entire jejunum an
ileum may be absent, the duodenum ending in
blind sac. In such cases both stomach and duods
num may be greatly dilated. The most commo
site of intestinal atresia is in the region of the openin
of the ductus choledochus. If it is below the openin
the collection of secretions together with the swallowe
amniotic fluid may cause an extreme dilatation i
the duodenum and stomach. The lower portio
below the imperforation begins in a blind sac. I
other cases the atresia is located above the opening t
the common duct, so that bile passes into the lowe
portion of the intestine, as shown by the presence o
meconium. The genesis of the larger congenita
defects of the intestine has not yet been satisfactoril;
explained. Peritoneal adhesions, embolic infarctioi
of the mesentery, etc., have been thought to b
primary causes, but no conclusive evidence has yi
been shown. It is more probable that some essentia
defect of development, such as an abnormal axi
rotation, lies behind these malformations. Thi
smaller localized atresias occurring in late fetal lifi
are most probably the result of pathological proces
in the peritoneum, and in some cases this has bi
definitely shown. Such conditions are most fre
quently found in children with congenital syphilis whe
die a few days after birth.
Acquired stenosis of the lumen of the intestines is
not uncommon, the most frequent causes being m\\
growths, constriction of healing ulcers, peritonea]
bands and adhesions, etc. They may be found in
any portion, but are more common in the large in-
testine, particularly in the region of the sigmoid flexurf
and rectum.
Atresia of the bile-ducts is not rare. The common
duct may be represented by a fibrous cord; the
gall-bladder may be absent, and the intrahepatic
ducts may show obliteration. Some of these cases are
distinctly inflammatory, and may be due to congeni-
tal syphilis; in others both etiology and nature are
obscure.
Anus. — Of all the congenital atresias the most
common and important is that of the rectum and
anus. According to the location of the imperforation
a number of varieties of this malformation exist, the
most important of which are:
(a) In the simple form the anus is closed by a
connective-tissue septum of varying thickness. It
may be a very thin membrane so that the contents
of the rectum may be easily felt through it, or the rec-
tum may end in a blind sac some distance above the
anus. In other cases the free end of the rectum lies
in the pelvis and is usually greatly dilated. This
malformation is not always a primary defect of de-
velopment, but may be caused by an abnormal
growth of connective tissue. In other cases there
may be a complete failure of development of the
lower end of the intestine. In place of the anus
there is usually only a slight depression in the skin.
The sphincter is usually formed.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Atrophia PUonun Propria
(b) The large intestine may end in a blind sac far
ove the anus, which is usually not unhealed al all,
only by a very slight groove in (he skin.
i, i The anus may lie perfectly formed, but the
nun fails entirely or is converted into a solid
•and of connective tissue.
In these forms the sinus urogenitalis may be
irmally developed, or the original communications
tween the intestine and the anterior portion of the
iaoa may remain preserved, or the rectum may
en into the perineum anteriorly to the anus, or into
irotum, penis, bladder, vagina, uterus, or
ethra. VVe may, therefore, further distinguish
ch forms as: atresia ani vesicalis, atresia of the
ith fistula of the bladder; atresia ani urethralis,
resia of the anus with opening into the urethra —
mlly the membranous portion, as this malforma-
found almost exclusively in male individuals;
ani vulvovaginalis and uterina, atresia of the
lis with communication of the rectum into the
vulva, or uterus. In other forms both the
mi ami the sinus urogenitalis may open into a con i-
,:i closed space which has no external opening and
lich through the collection of urine and meconium
ay become greatly dilated. The more marked
alformations of this class preclude life, but some of
08 es are capable of surgical cure. Acquired
resias of the anus or rectum are not infrequent and
produced by new growths, cicatricial contraction
healing ulcers, syphilitic processes, etc.
Urethra and Bladder. — Total atresia of the male ure-
ira occurs rarely, and is found in association with
ilete absence of the external genitals. As a result
the collection of urine in the bladder an enormous
latation of the abdomen may occur which may be so
it as to prevent normal delivery. Rauber ob-
rved an adult male with complete absence of penis
hose urethra communicated with the rectum. The
osl frequent localized atresia of the male urethra is
the external meatus and orifice of the prepuce.
nperforation of the anterior urethra occurs rarely
a result of defective development of the urethral
iptum, and in the posterior portion as a result of
roliferations and adhesions. Congenital atresia
the female urethra also ocurs rarely, and may
feet the entire length of the urethra or only a por-
on. As a result of the congenital imperforation of
le urethra in both sexes, congenital dilatation of the
ladder, ureters, and pelvis of the kidneys results
om the retention of urine. Occasionally the urachus
mains open and there is an escape of urine from
le umbilicus, or there may be abnormal communica-
ons with the intestines, vagina, uterus, etc., by which
hich the urine passes.
Acquired atresia of any portion of the urinary pas-
• may occur as the result of cicatricial adhesions
nd contractions, new growths, tuberculosis, syphilis,
irnal pressure, etc. Gonorrhea and direct injury
re the most common of these factors.
Vagina and Uterus. — A congenital total atresia of
i" female genital tract may exist in connection with
total defect of the external genitals. The vagina
lay end in a closed space in common with the bladder
nd rectum (persistence of the cloaca). The most
ommon site of congenital atresia of this tract is at
1 opening of the vagina, which is closed by a mem-
irane of greater or lesser thickness (gynatresia). The
nperforation may be due to an abnormally thick
iymen (atresia vaginalis hymenalis). The closure
nay extend throughout the entire length of the
agina or occur at any portion. Complete absence
• f the vagina is rare, more frequently the organ is
epresented by a fibrous cord. The closure is due to
i failure of the epithelial layers to separate or to
econdary adhesions. Congenital atresia of the uterus
3 also rare. The occlusion occurs usually at the
ervix, which may be closed partly by mucosa or
>artly by muscle and connective tissue. This con-
dition may exist without other malformations and
remain undiscovered until puberty, when the collec-
tion of the menstrual discharges within the dilated
uterus and tubes may give rise to very important
symptoms. The atresias of the vagina may similarly
assert themselves.
(Induct*. — Complete absence of the tubes occurs
in connection with marked malformations of the
uterus. Atresia of either the abdominal or uterine
end may occur, or an imperforation may exisl in any
part of the tube. Acquired atresias of the tubes
are very Common, and most frequently involve the
distal and proximal portions. Chronic gonorrheal
salpingitis and tuberculo is :iv the most common
causes. Tubal gestation and sterility may result.
Acquired atresias of the female genital trad may be
the result of cicatricial contractions following ulcera-
tions, etc. (gangrenous vaginitis, tears, use of caustics,
Cervical amputations, retained pessary, tumors, etc.).
The majority of the atresias of the vagina and
uterus which are not associated with marked malfor-
mations are amenable to surgical treatment.
Aldbed Scott Wakthin.
Atrophia Cutis Idiopathica. — This term which
implied originallj- a spontaneous primary atrophy
of the skin has largely given way to the designation
"dermatitis atrophicans idiopathica," by which the
idea is conveyed that this form of atrophy depends
for its origin on a special dermatitis. The nature of
the latter is obscure, and it is conceivable that if
sufficient predisposition is present, due to structural
peculiarity (as defect of elastic fibers), any dermatitis
might result in atrophy. In a certain number of
cases external insults of the skin (the sun, wind, etc.)
appear to precipitate the dermatitis. There are
believed to be three clinical types of dermatitis
atrophicans which are parallel to the three types of
scleroderma: (1) a generalized or diffuse form; (2) a
form which affects the extremities — forearms and
hands, legs and feet, and face; (3) an isolated, circum-
scribed form. These differ among themselves only
in respect to localization. They have nothing in
common with the primary atrophies of the skin
which are usually described as atrophodermata.
Further information as to atrophying dermatitis
may be found under Acrodermatitis atrophicans.
E.P.
Atrophia Pilorum Propria. — By this term is meant
simple atrophy of the hair uncomplicated with ap-
parent disease of the scalp. Under it are included
at least three forms, namely: fragilitas erinium,
trichorrhexis nodosa, and monilethrix. They have
one feature in common, which is that the hairs are
friable, splitting or breaking with slight traction.
Fragilitas Crinittm. — This is also called scissura
pilorum. The characteristic of this disease is that the
hair is dry and splits either at its ends or in its con-
tinuity. It may be symptomatic or idiopathic.
1. Symptomatic Fragilitas Crinium. — This is a very
common affection of the hair, and is met with in
many diseases of the scalp, such as eczema, ringworm,
favus, and seborrhea. Whenever the scalp is abnor-
mally dry, and also in general constitutional diseases
in which the nutrition of the body is lowered, the hair
may become dry and split. It is seen chiefly in the
long hair of women. If the hair is viewed in mass it
looks as if it had been singed, if the case is a severe
one. In any case, if the hair is held in the hand in a
good light it will be noticed that the ends of the hair
are split into several diverging filaments.
2. Idiopathic Fragilitas Crinium. — In this form,
which is much rarer than the preceding, the hair splits
at the end without any apparent disease of the scalp.
The split may be at the free end, in the continuity of
765
Atrophia Pilorum Propria
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
the shaft, or within the bulb. The hair may be cleft
only at the end, or the cleft may run up the shaft for
a variable distance. If the cleft occurs in the con-
tinuity of the shaft the filaments may hold together
or separate widely. The disease is seen most often in
the long scalp hair of women. It occurs also in the
beard. There may be but a few hairs affected or
there may be many, giving the singed appearance
spoken of above. In some cases, as the hair splits
and breaks off before it has attained any great length,
the woman in unable to dress her hair,
and has to wear it cut short.
Pathology . — Usually, nothing
fin I her abnormal is found aboul I he
hair than that it splits. The hair
bulbs may be normal or atrophied.
Etiology. — We do not know what
the cause of the disease is. We
assume that it is a disturbance of
nutrition. In very long scalp hair
it may be due simply to a lack of
nutrition on account of the length of
the hair.
Treatment. — The split hairs should
be cut off above the cleft. Every
effort must be made to improve the
nutrition of the patient, ami to cure
any disease of the scalp. A little oil,
vaseline, or pomade should be rubbed
into the scalp several times a week.
In massage we have the best stimu-
lant, when properly done.
l/'i
Fig. 523.— Trichor
rhexis Nodosa.
in pediculosis.
Trichorrhexis Nodosa. — Also
called clastothrix, and nodositas
crinium. This is a disease of the hair
characterized by the appearance
along its shaft of one or more nodose
swellings, and by the breaking of the
hair through the nodes.
Symptoms. — The disease affects
most often the hair of the beard..
The patient notices, when handling
the beard, that there are irregulari-
ties upon some of the hairs; or else
he sees that his beard looks ragged.
( )n examining the hair there will be
found one or more whitish, gray, or
normal colored, shiny, transparent,
nodular swellings, not unlike the nits
of pediculi, excepting that they are
oval and involve the whole circum-
ference of the hair, not pear-shaped
and fixed on one side of the hair as
There have been found as many as
five nodes on one hair. The diameter of the nodes
varies with the diameter of the hair. The nodes are
usually on the upper third of the hair. The hair is
very brittle and easily broken by combing or handling
it, or the break may occur seemingly spontaneously.
The fracture takes place almost invariably through
the node. When the hair breaks completely the re-
maining end will have a frayed-out appearance. If
the ends do not separate, but the break is through the
node, then the appearance will be that of two small
Caint brushes pressed end to end. The fracture may
e longitudinal through the node. When many hairs
are affected we see the same singed appearance met
with in fragilitas crinium.
While the disease was first described as affecting
the beard, it is seen also on the scalp hair, especially
in women. The scalp hair being so much finer than
is the hair of the beard, the nodes are very much
.smaller and more apt to be overlooked. Sometimes
the nodes on the scalp hair are found only with the
microscope. The disease has also been met with on
the pubic hair, the scrotal hair, and the hair of the
labia majora, the axilla?, and the eyebrows.
Etiology. — The cause of the disease has not bee
determined. It may be a disturbance of the nutr
tion of the hair. By some it is thought to be a nei
rosis. McCall Anderson has reported a case in whic
the disease seemed to be hereditary. In some com.
tries, as about Constantinople, it is far more prevalen
in the scalp than in other countries. By some invesl
gators parasites are believed to be the cause of th
disease, and a microorganism is said to have beei
found. Others deny the presence of a microorg
Simple handling of the beard has also been c
with producing the disease.
Treatment. — Thus far treatment has been mos
unsatisfactory. Mercurial ointments may be tried
Gamberini recommends bathing with a lotion of thre
drams of subcarbonate of potassium in four ounci
of distilled water; or using inunctions of tannic acii
or oil of cade. Schwimmer advises an ointment o
seven grains of oxide of zinc, fifteen grains of sulphui
lotum, and two drams and a half of simple ointmenl
This is to be rubbed in night and morning. As far a
the beard is concerned the chief reliance is upoi
shaving, with the hope that after a time the hair wil
grow in properly.
Monilethrix. — This is also called aplasia pilorun
propria.
Symptoms. — This form of atrophy of the hair |
often mistaken for trichorrhexis nodosa, because lib
it it is marked by the presence of nodes on the hair
It differs from it in that the nodes are the normal part
of the hair, and in that the fracture in it takes plan
through the internodular part.
In the vast majority of cases the disease is con'
genital, though it may come on late in life. Thi
subjects are therefore usually in-
fants. They are commonly born
with normal appearing hair, but
after a few weeks the hair breaks
off from the whole head or from ||| v
patches, giving a stubbly appear-
ance to the hair, similar to what is
seen in ringworm. In some cases
the scalp is reddened and has on it
a number of small, scaly, elevated
cones, or perhaps pustules. From
the little cones protrude short hairs.
Many of them are bent, and all
break easily on slight traction.
They are seldom longer than a
quarter of an inch, and often are
no more than black points. To the
naked eye, or under the microscope,
these little hairs show fusiform swell-
ings with contractures between,
through which the fracture has oc-
curred. Sometimes complete bald-
ness results. All the hairy regions
may be affected. A general kera-
tosis pilaris may be present.
Pathology. — Under the micro-
scope the hairs will be found to Fig
have on them, at regular intervals,
alternate swellings and constric-
tions. The swellings, or nodes, are about one milli-
meter long, fusiform in shape, and darker in color
than the constricted parts. The latter arc aboul
one-third the length and diameter of the nodes.
The constricted parts contain neither medulla nor
pigment and may consist of the cuticular layer oi
the hair alone. There is atrophy of the hair bulbs.
The nodes are all along the hair from the root to t'i''
point. Fracture invariably takes place through the
internodular portion, and frayed-out ends may be
found. Sabouraud found that the constrictions
formed at two days' interval. Gilchrist believes that
the disease originates in the hair follicle very near
to the papilla. He was able to trace the fusiform
524.- V
thrix.
7GG
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Atrophy
s - lling to the lower fourth of the hair shaft, where
i .,, „,.,-,. constrictions in the walls i>f the hair
He found no change in the hair papilla'.
In many cases the disease is hereditary.
observers have reported instances of a number
- in the same family. At times it shows a
t lency to descend in the same sex, a peculiarity
I mi iii other dermatoses. It is probably a tropho-
'reatment has thus far been without effect. Stimu-
1: on might be tried, but the prognosis is bad.
lesides these well-defined forms of atrophy of the
have reports of allied diseases from single
jervers. Thus Crocker describes a case ol
a 'phy of the hair in which the distal ends of the
e bulbous and of lighter shade than the rest
liair.
>HAGMESls is' another abnormality of the hair in
■ ich feathers instead of hair are met with. This is
t doubtful character and comes down to us from
, which time a boy showing this anomaly is
en on exhibition in Bremen.
peculiar changes in the texture of the hair are
. by Ferber Virchow's Archiv, 1S66, xxxvi..
both patients were of nervous temperament,
I : their hair in a few hours would change from
ft and curly to become .straight and bristly.
. r a time the hair would assume its natural
ion.
\"om-Li Laqtjeati is an anomaly of the hair in
\ ich it seems to tie itself into knots. The loops of
t' knots catch dust. The hair looks as if ii
> h nits, but under the microscope it is seen that
i - the knots that give this appearance.
George Thomas Ja< ksox.
\trophy. — Wasting, lack of nourishment, wasting
ody due to defective nutrition. (Gr. a-priv.
3d Tpo$Ti. nourishment.) The word is at the pi
ed in pathology to signify the decrease in size
irgan or tissue which results either from a
in the size of its individual elements, or from
iliminution in the number of these elements, or from
combination of these two factors. We may speak,
re, of a quantitative and of a numerical atro-
] y, but a practical distinction cannot always be made
i these two forms, as a diminution in the num-
jr of the tissue elements almost always accompanies
: Increase in size.
In its narrowest sense the term is used to indicate a
rcase in size of the individual histological elements
■ ■ to a simple loss of substance without including
e idea of other retrograde changes. The essential
'a of atrophy is, therefore, separated from that of
generation, and the term should be applied only to
onditions in which the primary pathological
ange is a loss of bulk. This loss of bulk is not the
suit of a loss of essential form or structure, but is
te chiefly to a loss of the paraplastic material of the
II. Only rarely is it associated with the appearance
any new substances outside the cell. The ordinary
generations and infiltrations (fatty, mucoid, colloid,
aline, amyloid, etc.) may be associated with
rophy, and such combinations are usually spoken of
erative atrophy. The diminution in size and
imber without the presence of degenerative changes
usually called simple atrophy.
On the other hand, the meaning of atrophy must
)t be confused with the ideas expressed by the words
rcnesia, hypoplasia, and aplasia. These terms
ifortunately, have been used rather loosely as
nonyms with atrophy, but the best usage is to
■sign to each one a distinct technical meaning:
;enesia, total failure of development or destruction
a part after it has begun to develop; aplasia,
marked defective development of an organ: hypo-
plasia, under-development; atrophy, decrease in size
after development has b m this it
will be seen that the causes leading to these chat
operate at different period- of life: thus and
aplasia are the results of disturbances in early fetal
life: hypoplasia the result of changes occurring later,
bul at any period before complete development is
reached; while atrophy may occur at any time in the
history of the organism when any tissue or structure
has reached its full anatomical and physiological
maturity. The latter process i-. therefore, a r<
grade change occurring in parts that were originally
normal and perfectly formed.
All stunting- and defective development of the
body and it- parts, either intra- or extrauterine, are
to be considered under the head of aplasia or hypo-
plasia, and not under that of atrophy. Hut the cells
of an aplastic or hypoplastic organ may also undergo
a decrease in size due to the same causes that lea
atrophy of perfectly formed organs. A hypoplastic
organ may become atrophic: hence in its broadest
sense the meaning of atrophy m ended to
include the retrograde decrease in size of imperfectly
developed cells and organs. The fundamental idea
of atrophy is, therefore, a retrograde decrease in size of
either perfect or imperfect fills.
The decrease in size and the disappearance of the
tissue element - in atrophy must be referred to a failure
of the processes of restoration to keep equal step with
the never-ceasing processes of tissue waste and
destruction. All cells possess a histogenetic energy
which is manifested in the functions of nutrition,
assimilation, and reproduction. For all cells, for
every organ, for every individual, and for every
species there is a certain limit to the ultimate amount
of inherent histogenetic energy. This limit is fixed
by intrinsic forces acquired through the agency of
external forces in the process of evolution of the
species, and represents the physiological duration of
life of each organ, and of each individual of that
species. Could all external injurious influence-
avoided the organism would after a certain period of
time come to a physiological death through physio-
logical atrophy, or, in other words, a- soon as such
a limit of histogenetic energy is reached that the
ary vital functions of the body fail to be prop-
erly performed in a degree sufficient to preserve life.
We may, therefore, speak with propriety of a physio-
logical or histogenetic atrophy.
Further, the histogenetic energy of the cells is to a
certain extent maintained by means of certain stimuli,
and as a result of the removal of these stimuli an
inaction atrophy may result. Atrophy must result
also from any deficiency or disturbance in the supply
of nutrition, and likewise excessive consumption or
waste of tissue must lead to atrophy. Further,
atrophic changes may be set up by mechanical
hindrances to growth, as in pressure, constriction, etc.
On the other hand, the loss of normal pressure or
ten-ion may produce atrophic changes in the tissues
so affected, and the separation of an organ or tissue
from its nerve centers is usually followed by a similar
condition. We may consequently classify the various
forms of atrophy as histogenetic, inaction, lack of
nutrition, neuropathic and pressure atrophy. Only
the first of these, the histogenetic form, is essentially
an active process (endogenous cellular atrophy): the
cells are unable to assimilate the food brought to
them. The other forms are passive in character:
either insufficient food is brought to the cells, or
harmful substances are formed which injure their
nutritive function (exogenous nutritive atrophy).
Histogenetic or Physiological Atrophy. — This form
of atrophy is the result of a decrease in the histogenetic
energy of the cells. As stated above, the potential
energy of each cell and organ is limited in direct
relation to the part which its function plays in the
767
Atrophy
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
general economy of the organism. Hence the dura-
tion of life varies with different organs and tissues,
and in the life history of the organism from the very
beginning the processes of atrophy go hand in hand
with those of development. In the earliest stages of
growth up to the time of puberty there is a pre-
ponderance of cell growth over cell decay; in adult
life there is a period of equilibrium; but with the
beginning of old age the loss of histogenetic energy is
shown in the fact that cell decay preponderates over
cell restoration.
Even in earliest fetal life certain structures fulfil
their function and pass out of existence. In the
formation of the fetal placenta portions of the mem-
branes disappear at a very early stage, and in the
development of the chorion there is from the begin-
ning a progressive atrophy of the villi. The placenta
at term must be regarded as a senile organ. Portions
of the fetus itself, as the Wolffian bodies, the Wolffian
ducts, the ducts of Muller, the umbilical vesicle, the
omphalomesenteric duct, etc., disappear very early,
even in the period of most vigorous development of
the fetus. Numerous blood-vessels undergo oblitera-
tion even before birth, and very soon after this event
the closure of the ductus Botalli and the umbilical
vessels takes place. Likewise the casting off of
the umbilical cord must be considered under this
head; and later the shedding of the milk teeth is
another example of the disappearance of structures
that have fulfilled their aim and reached their limit
of existence. The disappearance of the thymus after
the fifteenth year is one of the most striking of the
histogenetic atrophies. During the period of most
active development it is one of the largest lymph
glands of the body, but soon after puberty it disap-
pears, becoming entirely replaced by fat tissue.
During middle life single portions of tissues, as certain
portions of the petrous and sphenoid bones, vanish.
Hyaline cartilage may also be regarded as an essen-
tially temporary structure, as in many individuals
it entirely disappears from the body during middle
life and is replaced by bone.
Some organs do not atrophy, but very early suffer a
cessation of growth, so that they become no larger in
the adult than in the new-born (adrenals, male
mammae, etc.). The failure of these organs to increase
in size is not due primarily to any failure of nutrition
or disturbance of circulation, and can be explained
only by the assumption that the original histogenetic
potentiality of growth has reached its limit. The
atrophy of the ovaries and of the uterus after the
forty-fifth year, before all of the ova are discharged,
must be similarly explained. In the case of the ovary
the primary change is in the blood-vessels of the
organ, which normally show sclerotic changes before
the blood-vessels of any other part of the body. The
menopause is essentially a process dependent upon
changes in the ovarian vessels, and to these changes
the atrophy of the Graafian follicles must be con-
sidered secondary. The atrophy of the ovary at the
menopause may, therefore, be explained by the
assumption that the histogenetic energy of the ovarian
vessels has an earlier limit than that of the systemic
vessels.
In the atrophy of old age (senile atrophy) the blood-
vessels, lymphadenoid tissues, muscles, and bone;
suffer most. The changes in facies, posture, and gait
of the old individual are dependent upon these condi-
tions. The brain may also undergo a marked atro-
phy, and of the internal organs the kidneys, liver,
and lungs ma}' suffer to a greater or less extent. On
the other hand, there are certain organs and tissues
which undergo but little senile change: the formation
of the red blood cells continues in old age without
decreased energy, and defects of epithelium, blood-
vessels, and connective tissue are as completely
repaired as in earlier life. There are very marked
individual differences as to the organ which shows the
768
greatest degree of senile change: environmen
disease, etc., may lessen the inherent histogenet
energy of certain organs so that they may beccm
prematurely senile, or atrophy to a greater degn
than others. Further, there are individual different
dependent upon the amount of histogenetic enert
inherited; the variation in this is a well-know
pathological fact. Nevertheless, in spite of the.
individual differences typical senile atrophy is alvw
confined to certain organs and tissues.
Senile atrophy is not only active but is also paasiv
as it depends not only upon the gradual decrease
energy on the part of the cells, but is in part tl
result of the narrowing and obliteration of the bloui
vessels supplying nutrition to the cells. The changi
in the blood-vessels are, therefore, to be regarded i
the most important of the senile processes, and it
probable that the chief part of the glandular atrophia
is secondary to these. For some of the so-ealle
histogenetic or physiological atrophies an absence <
loss of stimuli (retrogression of male mamma;, etc
may be in part responsible for the atrophy. Autc
intoxications may also play a part in the productio
of forms of atrophy included under this head.
Atrophy of Disuse. — The histogenetic energy <
many organs and tissues is dependent upon certai
regular stimuli. If these stimuli are removed for an
length of time an atrophy results which we may cs
an inaction or disuse atrophy. The atrophy of th
optic nerve after destruction of the eyeball; tli
atrophy of peripheral nerves and portions of th
spinal cord following amputations of the limbs, ar
familiar examples of this form. Likewise, if throng
any influence glands or muscles (myotenotomj
dislocation, paralysis, etc.) remain inactive for "
certain period of time atrophic changes occur. I
the case of muscle the loss of substance is usually no
very great. Even the bones undergo a loss of sub
stance when kept in undisturbed rest for severe
years. Further, the physiological atrophy of th
uterus and mammae after pregnancy may be includei
in this class. The common belief that sexual absti
nence may cause atrophy of the sexual glands has ni
more foundation than the occurrence of atrophy o
the lacrimal glands through abstinence fron
weeping. There can be no disuse atrophy of thh
kind of these glands. Such an atrophy can follow
the blocking or ligation of the vasa deferentia or tin
lacrimal ducts.
In the case of nerves, glands, and muscle, inaction
atrophy is essentially active, but as the result of the
cessation of function there is also a decrease in the
nutritive activity of these structures and a lessened
blood supply which leads to further disturbances of
nutrition. In other tissues the chief cause of the
atrophy is a decrease in the nutrition of the unused
part, but with this there is also a lessened power of
assimilation. The involution of the puerperal uterus,
by means of which the organ is restored to verj
nearly its original size, is a very complicated process,
partly atrophy and partly degeneration, involving
all of its structures, endometrium, muscle, and blood-
vessels. It is essentially active in its nature, but the
obliteration of its enlarged blood-vessels through
sclerotic changes and the organization of thrombi
plays a very important part in the retrogression.
Lessened tension and removal of certain stimuli
may play a role here also.
If the conditions leading to the inactivity of certain
parts are in operation during the period of develop-
ment and the tissues in consequence of disturbed
nutrition fail to reach their normal size, the process
is to be regarded in the light of a hypoplasia rather
than of atrophy. It is. however, impossible in all
cases to separate these processes, since in hypoplastic
organs there may be an atrophy or disappearance of
tissues which had undergone a certain degree of
development.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Atrophy
trophy Dependent upon Impaired Nutrition. — If
is a deficiency in the amount of nutritive
il brought to the colls these will undergo
., ,pliic changes. The degree and rapidity of the
B iphyare indirect relation to the degree of meta-
b c change of which the affected organ or tissue is
,, ihle. Hence adipose tissue quickly disappears if
it-forming substances are not adequately sup-
i it. The bones become softened and fragile if
it supply of lime salts is withheld for a period of
and it is also probable that a decrease in the
a 'tint of hemoglobin contained in the red blood cells
result of deficient absorption of iron. The
ii ire of rachitis, osteomalacia, and the various forms
i memia is as yet but little understood, and these
may he the result of more complicated disturb-
than the mere withdrawal of certain food
'.IS.
ical atrophies may result from disturbances in the
. id supply of certain regions following arterio-
-. thrombosis, or inflammatory processes in-
v . ing the vessels. Degenerative changes almost
ii iriably accompany this form of atrophy. If the
b id supply of any part is completely shut off,
results. When there is an insufficient
of food to the body as a whole, or if the fluids
body are not adequately restored, a general
a iphy of the body takes place. The fat, muscles,
bid, and abdominal organs suffer to the greatest
d ree. The fat disappears first and may be reduced
■ seven per cent, of its original amount. The
- may lose as much as fifty per cent, in weight.
C the abdominal organs the liver, spleen, and in-
t> ines suffer most. The brain, spinal cord, bones,
:rt muscle undergo but little loss of substance
e n in cases of death from starvation. Lipomata
a v remain unchanged in spite of the almost com-
.1 e loss of the normal fat tissue of the body. This
r larkable phenomenon has not as yet been ex-
■ined.
'uric Atrophy. — The histogenetie energy of the
i' 3 is most intimately connected with their physical
al chemical integrity, and disturbances of the latter
mi to a decrease of this energy. The presence of
lain foreign elements in the circulation leads
Diasionally to atrophy associated with degen-
Bftive processes. The protracted use of iodine may
itrophy of the thyroid and mammary glands,
a 1 in chronic lead poisoning the extensor muscles of
forearm may become atrophic. Toxic or in-
t 'amatory atrophy occurs also in various infectious
lases typhoid fever, diphtheria, mumps, gonor-
r a, syphilis, etc.) and also in cachectic conditions.
tointoxications also probably play a large role in
t production of atrophy, particularly in the case
c the kidneys, liver, heart, and nervous system.
1-use and neuropathic atrophy, perhaps senile atro-
i, are probably due in part to autointoxication.
"ressure Atrophy. — Closely allied to the atrophy re-
£ ting from insufficient nutrition is that produced by
utinued slight pressure. As the result of artificial
i chanieal pressure may be mentioned the exam-
]s of "corset liver" and "corset spleen," the con-
iiction produced by rings, belts, and garters, the
(inese foot, the flat head and flat nose of certain
1 !ian tribes, etc. Skin, muscles, and bone may dis-
ipear as the result of pressure from aneurysms and
1 ni ns. Varicose veins may likewise lead to the
Sophy of the neighboring structures. In scoliosis,
f 1U valgum, and pes valgus, atrophy of certain
irtions of the joints may be caused by the abnormal
ssure produced by an oblique position of the bones.
iter loss of the teeth the alveolar processes of both
. vs may disappear as the result of the pressure
bught to bear upon them in mastication. The
lull cap may present erosions which have been
pduced by the pressure of atheromata of the scalp
< by hypertrophic Pacchionian bodies. The inner
surface of the skull cap may present atrophil
as the result of increased intracerebral pressure.
In hydrocephalus ami hydronephrosis tie- brain and
kidneys respectively may undergo extreme atrophy,
and in any gland in which cysts develop the glandular
epithelium may become atrophic through pn
Further, atrophic changes may be caused in any part
of the body as the result of pressure from inflamma-
tory exudates.
The various forms of pressure atrophj are caused,
as a rule, by -light pressure continued through long
periods of time. It is the result of direct injury to
the tissue and of circulatory disturbances. It is
therefore passive in
its nature. If the
pressure is so great
that thi' blood
sels becoi tli
degeneration ami
necrosis must fol-
low. Inmany cases
the causes of the
atrophy resulting
from pressure are
complicated, me-
chanical force and
disturbances of nu-
trition playing the
chief parts in its
production.
Neuropathic Atro-
phy. — The question
of the existence of
trophic nerves and
trophic centers and
their relation to the
individual tissues is
still unsettled, and
the existence of a
neuropathic or tro-
phoneurotic atrophy
must at the present
time be viewed more
in the light of a
possibility than as
being an established
fact. It is not to be
doubted that as the
result of disturb-
ances of innervation
both atrophic and degenerative changes arise, though
it is probable that these changes are not entirely de-
pendent upon the loss of nerve influence, but for the
greater part are secondary to the loss of functional
activity and to disturbed nutrition caused by vaso-
motor changes in the regions supplied by the affected
nerves. As a result of these changes inflammations
are easily set up, even by slight causes which ordi-
narily produce no lesions, and the result of the inflam-
matory process may be either atrophic or degenera-
tive in its nature. The majority of the changes
following disturbances of innervation are not of the
nature of a true atrophy, but are degenerative in
character. The application of the term atrophy to
these processes is justifiable only by the fact that the
ultimate condition is a loss of tissue.
Disease of the anterior horns of the spinal cord or of
the motor roots is followed by atrophy of the corre-
sponding nerves and muscles. Anterior poliomyelitis,
progressive muscular atrophy, and bulbar paralysis
are well-known examples of this form of atrophy.
In syringomyelia and tabes dorsalis atrophy of the
bones and joints not infrequently occurs. Injuries
of the peripheral nerves may be followed by thinning
of the skin, exfoliation, loss of hair, and atrophy of
the glands of the skin. Disease or injury of the nerve
trunks of one side of the face may lead to atrophy
of the tissues of that side. Unilateral affections of
Fig. 525. — Pressure Atrophy of the
Spinal Column, Caused by the En-
croachment of an Aneurysm of the
Aorta. (After Ziegler.)
Vol. I.— 49
r69
Atrophy
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
the brain in fetal life or during early childhood may
cause an atrophy of the opposite side of the body
(congenital or infantile hemiatrophy). General
atrophy of the body occurs in progressive paralysis
and to a less extent in melancholia and dementia.
It is denied by many authors that these forms of
atrophy are neuropathic, and it is much more probable
that vasomotor disturbances, loss of function, and
general as well as local disturbances of nutrition are
the chief factors in their production.
Atrophy Due to Excessive Waste. — In all conditions
in which the repair of the tissue is exceeded by tissue
consumption a loss of substance must occur. In fetal
life and in the period of early development only a
portion of the substances taken into the body is
completely oxidized, the greater part is used in the
building up of tissue. In adult life the larger part
is burned up, the smaller remaining portion is used in
tissue repair. The two processes of waste and repair
stand in different relations to each other at different
periods of life, and must be considered as independent
processes. This is very clearly shown in those
pathological conditions in which tissue waste exceeds
tissue repair. Overuse of any organ leads to fatigue,
poisonous products of metabolism are retained, and
the cells are not given sufficient time for rebuilding.
If a condition of chronic fatigue develops as a result
of chronic overuse, anatomical changes occur. Chief
of these is a loss of substance. The brain is the most
important organ which may be so affected. Of the
glandular organs the testicles most frequently suffer.
Atrophy of the heart and voluntary muscles may also
occur as the result of overuse. The failure of compen-
sation in chronic valvular disease is also to be placed
in this category. Exposure to Roentgen and radium
rays produces atrophy of the testes, lymphoid organs,
and developing tissues. This atrophy is in part due
to an inhibition of cell-growth, but is also the result
of the death of individual cells and tissue-elements,
cell-regeneration failing to keep the organ to its
normal size.
Repeated severe hemorrhages, chronic suppurative
processes, long-continued excretion of albumin,
diabetes, fever, rapidly growing tumors, and many
other similar processes produce general wasting of
the body with marked atrophy of certain tissues.
In general the various cachectic atrophies are in
their nature and course very closely allied to senile
atrophy, and the microscopical appearances are
identical.
Atrophy Caused by Decreased Tension. — Through a
permanent loss or decrease in the normal tension, as
in the case of muscles, tendons, fasciae, and blood-
vessels after amputations, or of tendons after tenot-
omy, atrophy may take place. The involution of
the puerperal uterus may also be considered under
this head.
A large number of conditions, such as the decrease
in size of the orbital cavity after removal of the
eyeball and of the sockets of joints after unreduced
dislocations, are not properly included in this class,
as the decrease in size of the cavity is not of the
nature of an atrophy, but is usually caused by an
increase of tissue in and about the cavity.
Macroscopical Appearances. — The most striking
change in atrophic organs is their decrease in size.
This is directly dependent upon the decrease in size
and the diminution in number of the structural
elements. The muscles, kidneys, liver, and spleen
show this decrease in size to the most marked degree.
In extensive atrophy of the muscles as seen in pro-
gressive muscular atrophy the disappearance of the
tissues may be so marked that the impression is given
that there is nothing between the skin and the bone
(so-called living skeleton). In many cases, however,
there is a deposit of fat in the atrophic tissues which
may be so extensive that the normal size may be pre-
770
served or an actual increase may take place (atrophi
musculorum lipomatosa). The atrophic liver an
heart may likewise be increased in size throiw
fatty infiltration. •>
The size of atrophic lungs may be increased throue
the stretching of the atrophic alveolar walls and tli
consequent dilatation of the air spaces (atronhi
emphysema).
In the case of atrophy of fully developed bi
decrease in size takes place, but the Haversiai
and medullary cavity become enlarged (excenti
atrophy or osteoporosis). The spleen as a rule suffei
a symmetrical decrease in volume, while the livi
usually shows more marked loss of substance in li
left lobe than in the right.
If the atrophy of an organ proceeds symmetric:;!
in all parts a uniform decrease in size results \.
preservation of normal form. It, however, progress^
Fig. 526. — Excentrie Atrophy of the Lower Ends of the Tibia u
Fibula, with Osteoporosis. Natural size. (After Ziegler.)
most frequently with greater rapidity in one part than
in another, and as the result of this unequal atrophy
nodules and furrows are formed so that tin
comes to present a nodular or granular surface. This
is especially marked in atrophy of the glai
structures, liver, kidney, etc. As a rule atrophic
organs contain less blood and are drier than normal
ones. The increase of connective tissue, either
relative or actual, causes an increase in cons)
with loss of elasticity. As a result of the di ■■■■
blood content the natural color of the organ stands
mil more distinctly; hence atrophic muscle, especially
heart muscle, is much browner in color than ni
An increase of the normal pigment or an increased
deposit of hematogenous pigment is also a verj
frequent accompaniment of atrophy (brown atrophy
of heart and liver). In other cases the color of the
atrophic organ is lighter or more grayish than normal
REFEKKXCK HANDBOOK OF Till: MEDICAL SCIENCES
Atrophy
hlauseof the relative or actual increase of connective
I ue _ In all cases in which much tat is deposited
I colur becomes yellowish.
[icboscopical Changes. — The microscopical ex-
., nation of atrophic organs shows a. decrease in
. ami a diminution in number of the normal ele-
its. This may occur without other changes, or
i atrophy may be accompanied by a deposit of fat
,, pigment, or an increase in the amount of the
ml pigment, or it may occur in association with
degenerative processes. We may therefore
i. 5127. — Section of an Atro|
ular Atrophy. (Miiller's
liver cells of the central zone of the lobule contain
much hematoidin, while those of the peripheral
show an increased a unl of fat.
In tin' atrophic kidney there is a. decrease in the
size of the tubules due to a decrease in ize ami to a
diminution in number oi the epithelial cells. Many
tubules may be found containing few cells or com-
pletely Collapsed. As a result of the loss of inter-
vening tissue the glomeruli are bronchi closer together,
so that from twenty to forty may be found in one low-
power field. The epithelium ami capillaries Ol Hie
glomeruli also disappear, and as a result numerou
obliterated glomeruli are found. In atrophy of
the central nervous system the ganglion cells dis-
appear or become smaller, u Idle the neuroglia re-
mains in normal amount or becomes increased.
Atrophy of the lymph glands and spleen is shown
by a disappearance of the follicles and a diminu-
tion in the number of the lymphndenoid cells.
The trabecuhe are brought more closely together,
and the finer stroma is increased in amount. In
atrophy of bone the bone substance is decreased
in amount and the marrow spaces are increased.
With this there is usually an increase in the fatty
marrow, but it occasionally disappears, leaving
cystic spaces filled with fluid.
hied Muscle, from a Case of Progressive
iuid; Bismarck brown.) a, a. Normal
liar fibers; b, atrophic muscular fibers; c, perimysium internum, the
i , . f which, at ci, seem to be increased in number. Magnified 200
t rioters. (After Ziegler.)
(tinguish: simple atrophy, fatty atrophy, pigment
I, serous atrophy, and degenerative atrophy.
Itty and pigment atrophy are so closely related to
i lple atrophy that they are to be considered as
t iple atrophy followed by or associated with fatty
i titration and pigment formation. They should
1 carefully distinguished from the true degenerative
i ophies in which changes in the nature of the pro-
t ilasm occur from the very beginning. As a result
c these changes new substances are formed in the cells
i about them (mucous, fatty, hydropic degenerations;
liyloid, hyalin, etc., deposits). In these conditions,
oecially in the case of the pathological deposits
td infiltrations, the atrophy of the cells must be
i ;arded in many cases as a secondary process.
J serous atrophy the tissue presents the picture of
t ophy associated with edema. It occurs most
i quently in adipose tissue.
As a rule the more highly specialized portions of the
i -ties suffer to a greater extent than the connective-
tsue framework. This may be unchanged or, as
list frequently occurs, increased in amount. T u
newly formed connective tissue there is usua'Iy a
; ater or less degree of fatty infiltration. Through
3 increase of connective tissue and the fat deposit
3 normal pressure upon surrounding structures
iv be preserved unchanged. The fatty infiltration
ty, therefore, be regarded as being of the nature of
: -ompensatory process.
In atrophy of striped muscle the contractile sub-
tnce disappears while the nuclei of the endomysiutn
nliferate to a greater or less extent. In atrophy jf
e lung the alveolar walls become greatly thinned,
e capillaries disappear, and the air spaces become
reased in size or confluent through the disappear-
ce of the wall. As a result of the obliteration of
my of the smaller capillaries the larger vessels
ow a state of chronic congestion. The liver lobules
come very much smaller in atrophy of that organ,
connective tissue of Glisson's capsule is relatively
actually increased, and is more hyaline in character,
sembling scar tissue. The liver rods and cells are
leased in size, and there is a great variation
the size of the individual liver nuclei, many of
nich show a compensatory hypertrophy. The
ntral veins and capillaries are congested, and the
Course. — The course of the various forms of
atrophy depends wholly upon their nature. Total
atrophy occurs as the result of the exhaustion of
the inherent histogenetic energy, as in the case of
many of the fetal structures, the thymus, etc.
In partial atrophies due to other causes, such as dis-
turbances of nutrition, pressure, etc., a greater or less
degree of restoration is possible in all structures in
which the histogenetic limit has not been reached. If
the causes leading to atrophy operate in the early
periods of development, agenesia or aplasia may re-
sult. Certain organs, as the thyroid or sexual glands,
may be thus affected and their lack of development
may lead to retarded growth of other tissues. As
stated above, these processes are not of the nature of
true atrophies, but it is difficult in all cases to make
Fia. 528. — Lipomatosis of the Muscles of the Calf of the Leg,
Together with Atrophy. (Miiller's fluid, carmine.) Transverse
sections of a normal («) and an atrophied (ai) muscular fiber; a>,
transverse section of a tubular sarcolemma containing contractile
substance in a condition of disintegration; 6, bands of connective
tissue; c, fat tissue. Magnified 60 diameters. (After Ziegler.)
sharp distinction. The atrophy of certain fully
developed organs likewise may affect the growth of
other organs or even of the whole body, as in progres-
sive muscular atrophy where atrophic changes in the
bones follow those in the muscles.
In so far as the function of the organ is concerned,
the atrophy of its elements is of the greatest import-
ance. Atrophic muscles lose their contractile power,
atrophic glands their secretory function, osteoporotic
bones are easily broken, and atrophic skin is easily
injured by a very slight trauma. Further, the
771
Atrophy
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
atrophy of one organ or set of tissues disturbs the
function of other organs and leads to a general dis-
eased condition of the organism.
The prognosis in atrophy is favorable only in those
pathological conditions in which the cause of the
atrophy may be removed, and in tissues in which the
physiological limit of growth has not been reached.
Atrophy of the vital organs, heart, medulla oblongata,
kidneys, respiratory muscles, etc., not infrequently
leads to death. There may also result a complete
disappearance of certain structures caused by the
atrophy of the matrices which form them. In
atrophy of the periosteum the bone disappears, in
atrophy of the skin there is a loss of the hair and nails,
and in atrophy of the lymph glands there is a decrease
in the formation of leucocytes.
Treatment. — It is evident that only the purely
passive forms of atrophy admit of treatment. The
removal of the cause and the restoration of the
normal nutrition are the chief indications.
Aldred Scott Warthin.
Atropine. — See Belladonna.
Attention. — A definition of attention may run per-
haps something like this : Attention is an aspect or state
of psychophysical activity (will) pointed by interest
and expediency in certain directions for the purpose
of aiding efficiency, and is expressed in consciousness
in terms especially of the feeling of bodily movement
or innervations, active or inhibitory, and hence it is
discrete in occurrence, and either reflex or voluntary.
It is the direction aspect of organic activity.
Plato long ago said that attention was "a motion
which informs, improves and preserves the soul."
About eight hundred years after him, the great
Augustinus rather more definitely characterized
attention as "an active psychological operation,
associating images and ideas for memory, and inhibit-
ing images and desires in recollection." He, as Plato,
laid much stress upon its practical aspect, as important
in acquiring knowledge; it will be noted also that the
profound author of the "Confessions" suggested the
important theory of inhibition, one of the latest to be
elaborated in its physiological relations in our day,
notably by Ribot.
The varieties of attention have been very variously
named, and with consequent diverse degrees of appro-
priateness. Of them all, the classification of James
Mill and of Sir William Hamilton seems the most
accurate in the light of modern physiology: namely,
as reflex and voluntary. Attention, then, is sensory,
spontaneous, passive, involuntary, or, as we may pre-
fer to call it by analogy from physiology, reflex.
On the other hand it is voluntary or active; this term
"active" when applied to attention has little dis-
criminative use, however, for it appears that con-
sciousness is always an active state of experienced
succession.
Motion and change are the conditions of attention
even as they are apparently the essence of the whole
universe without and within — Heraclitus, the philoso-
pher of change, surely had an insight unexcelled.
Consciousness vanishes, if allowed to lapse into un-
changingness, and the conscious aspects of mind tem-
porarily are gone. Attention is then somewmat like
the needle swinging lightly to and fro over the card
of consciousness — it is well for the human vessel when
it swings so free, but it is even death to consciousness,
perhaps, when it grows rusted in its place! This
basal principle the physician, like the teacher, must
ever keep in mind as the underlying means to the
avoidance of fatigue.
In reflex attention the direction line evidently, as
has been said, other things equal, tends to follow the
course of the least resistance. Just in proportion as
. the attention is passive, reflex, mechanical, will this
772
be true. This "direction of least resistance" means
in its simplest terms that the strongest stimulation
would attract the consciousness, as indeed it actually
does or tends to do under certain conditions. Under-
lying always, however, the sensorium of a man or
woman are the personal concerns, and invariably
underlying these are the racial and other biological
interests. These facts mean that the determination
of reflex attention will normally tend to be a rcsul
of the nerve forces always pressing into the spinal
cord from the numerous sense organs, reacting against
floods of central nervous influence always preset
themselves there. These latter come on the one hand
from the habit-complexes of the brain and anterior
gray cord and on the other from the syndrome-ganglia
(sympathetic) of the vegetative life. Balance is
apparently the universal condition in bodily relation-
ships for at least all physiological advance in whatever
direction emphasizes the basal nature of this counter-
vailing principle: action is almost invariably the
result of the intermingling of energies more or
opposed in kind, in strength, in direction or in all i i
these. It is so everywhere else and there is no reason
apparent why the physiological conditions of reflex
attention should be unlike the rest. In the central
gray matter of the neural system the intermingling
forces, we may surmise, are streams of nen
influence coming from the many lesser circuit
nerve activity into which, as w-e have seen, the whole
is functionally divided.
In reflex attention, then, w-e must think in general
terms of the line of direction as the resultant of
influences coming into the cord from myriad sense
organs, from the brain, and from the sympath
and must suppose that these fuse and result in some
one or other of the innumerable adjusting movements,
partly phylogenic and partly ontogenic, of the
organism.
Voluntary attention has similar general neural con-
ditions behind it adapted to its different nature.
Instead of being the plaything of the most conspicuous
sensory stimulation reacting against a basis of biolog-
ical and personal interest and habit, voluntary atten-
tion may rise (apparently) superior to these vegetative
and mechanical conditions and be free as the will of
man is free. Theoretically and ideally the attention
may be independent of bodily conditions to any logical
extent. Moreover, the interest that is concerned in
this kind of attention, as in the other, may be as
arbitrary as you please even to pure caprice, or it
may be, theoretically, even entirely lacking. Hereof
course the theory of attention coincides with that of
the will as Bastian, for example, years ago so well
pointed out.
In practice, as in theory, then, the actual voluntary
attention has in the foundations of its neurology
apparently the same influences that are determinants
of reflex attention. Here, however, the most "con-
spicuous" stimulation exerts very little influence and
may even be quite subconscious, however great its
objective and physiological intensities. Again, the
stream of nervous influence coming as "biological
interest" (from the organs by way of the syn
thetic circuits of sensorimotor impulses) are reduced
so as to exert little seeming effect on the attention
line. That, however, under the usual conditions of
voluntary attentive activity in ordinary degrees these
bodily states do exert a considerable influence on the
attention we need not stop to further explain.
The stream of nerve impulses that exerts the
strongest control in voluntary attention comes usually,
it is clear, from these cerebrospinal unit-complexes
of correlated activity known as habit-complexes.
These have their neural locus chiefly in the mazes of
the brain, but none the less are mechanically under-
laid and executed by circuits of neuromuscular
activity correlated in the spinal cord. These furnish
the mechanical neuromotor guides by which appar-
REFERENCE HANDBOOK o|" THE MEDICAL SCIENCES
Augusta
< ly, either in actuation or in inhibition, forced
i ention maintains its bodily course of action, be it
\ ;ing or looking or whatever else the attentive
I ivity may be.
Alien we seek the general neural conditions of
- ,(| thought without intentional expression of any
i ..I, then are we turned back as usual on the psy-
,r impulses that innervate the expression-ap-
us of languaye-conct /its.
The notion of forced attention to trains of feeling in
1 ins other than more or less articulated words, is
, entially a contradiction, such trains of experience
I ng inherently reflex and so subconscious or else
, ouonally and plainly motor. (See G. V. N.
larborn: "Notes on the Discernment of Likeness
i 1 tjnlikeness, " Jour. Philos., Psychol, and Sci.
, vii., 3, February 3, 1910, pp. 57-64.)
The universal group action of the nervous system
i special reason why we need look for no simplicity
i the action of the mechanism of efficiency. In those
t nplex reactions and adjustments that are at the
da of attention this group action is particularly
t idamental. But another reason for the complexity
lie conditions, a more general one, lies in the cor-
l ponding complexity of the behavior of the human
i inal. Such considerations are trite, however
i portant, and would not be rehearsed here were it
I a habit of the psychologists at times to speak of
1 to expect a simple " theory of attention" like the
i ic-relations, for example, of the contraction of a
1 g's gastrocnemius. Obviously the intricacy of
i • human action system and of the behavior that
i responds, precludes hope of any such thing, of any
» t of simple action rule behind (or in front of) the
i ection of the attention-line. It is idle to seek a
lu'fl theory of attention. The best one may hope for
i • at least so it seems in our present relative ignor-
ice of the nervous system) is a concise descriptive
i ninary of the influences and conditions involved
i this phase of viatility. We may call such a
f nmary a theory, but with a use of the term, less
i icise than usual, now sufficiently suggested. If all
I empts at solution of the problem be thought
: angely incomplete, let us recollect how the philoso-
] er Herbart characterized attention in his awakening
I >sis of 1N22: " Hanc rem, philosophis nostri temporis
: ram, incredihilem abominandam. Surely the mod-
i i physiologist has at least an equal right to
hsphemel
Conspicuous among the many determining in-
I onces of the central nervous system for any at-
lltive innervation we may note four; viz., 1. The
] ative degree of vasomotor congestion in various
1 ictional groups of psychomotor neurons of the
jmpathetic, the cord, the cerebellum, and the
'. enspheres. This we may suppose of special im-
rtance as a determinant of the reflex attention line.
may be partially under the control of enzymic
bstances secreted in various parts of the brain.
2. Streams of nervous influence on the one hand
;>m numberless habit groups of neurons in the
i:itral nervous system proper, representing the
;rsonal interests (mostly habits) of the individual;
id on the other hand from the sympathetic ganglia
: d plexuses, standing for the person's basal bioli igica]
crests (instincts and vegetative habits, nutritional,
■tabolic, sexual, etc.).
3. In manner more or less like the relative vasomo-
Dongestion, the relative "fatigue-rest balance"or
bility to action, exerting influence on the attention-
e impulses in the nervous system, tending to draw
e effective balance of nerve action over its pathway
cause the latter is the way of the least resistance,
'lis determinant, with the "next included, is essen-
illy the "drainage" notion used in discussing the
sociation of ideas.
4. Tides of sensation influence from all the sensory
Ids pouring into the central nervous system, with
a tendency for the effectively strongest or im.-t
unusual to determine the attention line on the still
unknown principles of reflex distribution. In forced
voluntary attention this factor of viatility might be
nil, serving only to increase the inhibition strain.
The practical medical and educational bearings of
attention are too numerous, or too voluminous, to be
here rehearsed. Underlying them all. more or less, is
this corollary: the necessity of movement, change,
variety, for the best direction-control of both the
body and the mind. George V. N. Dearborn.
Auchmeromyia. — Bina-alia. A genus of flies,
family Muscidm, which contains a species, .1. de-
pressa, whose larva is parasitic in man in South
Africa. The "Larva' of Natal" belong in this genus.
The larva of .1. luteola, called the Congo floor-mag-
got, is a nocturnal blood-sucker, biting persons sleep-
ing on the floor of the hut but not those in ordinary
beds The bite is not believed to transmit disease.
The fly is harmless so far us known. See Insects,
Parasitic. A. S. P.
Audition. — See Hearing.
Auditory Canal. — See Ear, Anatomy and Physiology
of the.
Auditory Nerve. — See Ear, Anatomy and Physiology
of the.
Auenbrugger, Joseph Leopold. — Born in Graetz,
Austria, November 19, 1722; died in 1S09. Only one
of the few short treatises which he published possesses
any special merit; but that one, which calls attention
Fig. 529. — Joseph Leopold Auenbrugger.
for the first time to the valuable aid afforded by
percussion of the human thorax, in the diagnosis of
obscure diseases of the organs contained within the
chest, is alone of sufficient importance to render
Auenbrugger justly celebrated. A. H. B.
Augusta, Georgia. — Augusta is situated upon the
Georgia side of the Savannah river, which through
this region separates the states of Georgia and South
Carolina. Its latitude is 32° 28" north and its longi-
tude is 81° 54" west. By the river route it is 231
miles from the Atlantic Ocean and in an air line
about ninety or one hundred miles. The city proper
has an elevation of about 160 feet above the sea-level.
With its immediate suburbs it has a population of
approximately sixty thousand people. It is one of
the oldest as Veil as one of the most beautiful cities
in the south; and in industrial importance, the third
in the state.
773
Augusta
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
A canal seven miles in length furnishes water to
run its mills and other industries. Besides its public
schools, it has a high school for boys, the Richmond
Academy; The Tubman High School for Girls; a
Jesuit College; the Summerville Academy; well con-
ducted public schools; several private schools; and
1 m Medical I leparl menf of t he Cni\ ersil v of < leorgia.
Strangers sojourning in Augusta may, therefore, have
excellent school facilities for their children if they
desire. There are also an opera house, a public
library, and churches of the more prominent religious
denominations.
The old portion of the city is quite level, and the
streets are wide and beautiful. The chief residence
thoroughfare, Greene Street, is 175 feet wide, and
through its length of several miles, extend four rows
of majestic elms and oaks, many of which are a
century or more old. In the middle avenue, vehicles
are not allowed; this being stone curbed and grass
plotted, is reserved for pedestrians and as a play-
ground for children. The city has a water supply
that can hardly be excelled. It comes from the
Savannah river, which from its origin in the water-
shed of the Blue Ridge to Augusta, has on its banks
neither city nor village. As if for additional pro-
tection, it breaks into shoals which extend irregularly
for many miles above Augusta.
This water is taken five miles above the city,
carried by mains to reservoirs on the hill top, where
it is filtered and thence delivered to the city mains.
This water which is used for drinking and household
purposes, and in addition for protection from fire, on
analysis shows as follows, after filtration and delivery
into the city's mains:
Nitrogen as free ammonia 008
Nitrogen as albuminoid ammonia .044
Nitrogen as nitrites 000
Nitrogen as nitrates 090
t txvgen absorbed 1 . 100
Chlorine 4.000
Alkalinity 11.000
Iron 200
Free carbonic acid 4.S00
The city has an excellent sewerage system, which
plays an important part in its healthfulness. Accord-
ing to the report of the Department of Health for
1909 the total mortality (white and colored) has been
reduced from 27.78 per cent, in 1880 to 12.78 per
cent, in 1909.
Augusta is easy of access by nine railroads centering
here, and also by the Savannah river, which is navi-
gable from the Atlantic Ocean to Augusta. Crossing
the river at Augusta, there is a row of sand hills
which beginning in the region of Chester, South
Carolina, pass through Aiken, Augusta, and far on
into Georgia. On the crest of these hills at this
point are the villages of Summerville and North
Augusta. Summerville on one side of the river and
North Augusta on the other.
Summerville, has for more than a hundred years
been an aristocratic suburb of Augusta, and on
account of its healthfulness, was early known as
Mount Salubrity; it is also perhaps more generally
known as the Sand Hills. This suburb is connected
with Augusta by fine gravel roads and by a modern
electric [line which runs a fifteen-minute schedule to
and from the city. Since January 1, 1912, the
villages of Summerville and Monte Sano have been
incorporated by Augusta and are now within the
city's limits.
From these elevations one gets a sweep of land-
scape that is rarely excelled by mountain scenery,
the view extending far over the hills of South Carolina
anil the plateau and hills of Georgia. The hills are
covered with pines, elms, and oaks and such grasses
as will grow in a sandy soil. Wild flowers are abun-
dant, and the honeysuckle, Cherokee rose, yellow
774
jassamine, dog-wood, and other flowers, wild ant
cultivated, vie with each other to make the landscape
beautiful; and a multitude of feathered singers — mock
ing birds, cardinals, thrushes, robins, blue jays am
toward the latter part of the season, the whip-poor
will make the region a veritable fairyland in tin
spring.
The soil is very sandy and it is necessary to gi
down from eighty to one hundred feet on the hill ton
before striking water. No water accumulates oi
the surface of the ground, it being like a huge filter
and one can, in a few minutes after the hardest ra
go out and walk for miles without wetting the feet
Bad drainage is, therefore, practically impossible
This is not true, however, of the older and flatter por
tion of the city.
The meteorological data for this health resort are ii
a measure misleading since the main recorded dati
that we have are from the United States Weathe
Bureau, located 300 feet below Summerville or Nonl
Augusta. It is unfortunate that the Governmen
does not locate its bureau at its arsenal, which i- i
splendid property on the summit of the hill, on thi
Georgia side. A register was kept at this arsena
from 1849 to 1869. The observations taken then
during that period, at sunrise, at 9 A. M., 3 p. M., am
9 p. m. show the mean average temperature to b< a
follows:
January, 46.7°; February, 50.7°; March.
April, 65.1°; May, 72.2°; June, S0.9°; August, 79
September, 72.0°; October, 63.5°; November, 53.8'
December, 46.3°; mean temperature of spring, 65.3
summer, 79.9; autumn, 63.4; and winter, 47.9.
The mean annual rainfall for the same period was
spring, 37.17; summer, 14.4; autumn, 6.95; winter
5.92.
Mean number of fair days 238; cloudy days seventy.
Snow about two days in every three years. Un-
fortunately no record of the humidity was ma
Dr. Kenworthy, in an article on the "Climate i
Florida" has shown that Augusta has a mean tempera-
ture for the months of November, December, Jannai \
February, and March of 51.4° F. while that of Canne
is 50.8. He also pointed out that for these months
the mean relative humidity of Augusta (the city in the
valley, not the village of Summerville on the hill top)
was 2.5° less than that of Cannes and Mentone; and
one-tenth of a degree more than that of Jacksonville.
Florida.
The accompanying table for the city of Augusta
extends over a period of thirty-nine years and is
furnished by Mr. Emigh, of the United States Weather
Bureau Office in Augusta.
In studying this table it will be noted that Augusta
has not a tropical climate, but a bracing one, with a
large percentage of sunny days. Rain falls here oft- .,
when there is sleet or snow further north; but the soil
is so sandy that it quickly sinks in, and there is rarely
a day when one cannot play golf part of the day.
On the brow of the hill on the Georgia side and in
the old corporate limits of Summerville is the Bon
Air Hotel accommodating about 400 guests, Par-
tridge Inn with a capacity of about 120, many
select boarding houses, and a large number of furnished
cottages, which rent by the season. Here is located
the Country Club with its tennis courts and tun
unsurpassed golf courses of eighteen holes each.
This section is growing with great rapidity and
beautiful suburban homes are constantly being erected.
In order to accommodate the increasing number
of guests, a lage property about a mile beyond
limit of Summerville has been purchased on which
will be erected a large fire-proof hotel, golf links, ;i
lake for fishing and boating, etc.
On the summit of the North Augusta hills, over-
looking Augusta, is located the Hampton Ten
Hotel, with its accommodations for 400 guests; and
around it are numerous boarding houses and cottages
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
A iir.iiilimil
Climate op \ nSTA Georgia; Latitude, 32 28° N\, Longitude, 81 54* W
—
1 S "3 J §
« \ *s *s < /
7Vmpero7Hre.
\i age of normal
....
highest. .
west .....
maximum
of minimum
: last killing frost, .March 19
late of first killing frost, November 9.
imidity (8 &. u plus S p. m., divided by 2).
relative
. ng« absolute gr. per cu. ft.)
Precipitation.
A ago in inches
Wind.
I'i tiling direction. .
elocity in miles per hour. . . .
Weather (days).
age number clear
imber partly cloudy
-t number clear for ten years
Uest number clear for ten years.
age number cloudy
mber cloudy for ten years.
imber cloudy for ten years
_'■■ No, with 1-in. or more rain. .
rainy
iber rainy
i:
19
."7
64
7 J
79
82
80
64
.-.1
,v
iv
19
21
22
-•1
21
19
19
21
21
59
67
77.
^ 1
91
7'.
ss
41)
53
68
72
71
....
7.1
11
80
S4
93
100
103
105
1111
"1
B5
7-
6
3
1 1
10
16
58
11
29
22
•
7v
7 J
71
66
68
73
76
82
7v
76
77
77
2.36
2 . 72
3.20
3.88
7.04
7.94
6.56
1.15
1.38
1.85
3.50
3.23
l..v;
.-...'.7
3.71
W
W
\Y
W
S
\i:
NE
x\v
W
6.4
7.1
6.9
6.7
:, 9
.-.. i
5.1
4.7
5.2
5.6
5.4
5.9
11
10
12
13
13
10
10
9
13
17
13
12
9
9
10
10
12
14
11
1 1
10
8
9
'.1
14
16
20
15
21
19
16
16
19
24
19
IN
9
S
6
S
8
4
.»
5
7
11
11
7
11
9
9
7
6
6
7
8
7
6
8
in
11
H
13
13
12
12
11
10
12
13
11
15
7
6
4
4
1
1
2
2
3
3
s
11
10
10
9
9
10
12
13
7
6
8
in
G
6
3
6
5
7
9
8
3
3
2
5
12
1 !
15
13
14
1^
17
IS
13
8
8
15
64
71
7,1
105
3
71
1 . 75
47.89
W
5.9
113
12V
115
I rent. This suburb is connected by an electric
li- with Augusta and Aiken. Contiguous to the
re the tennis courts and Hampton Terrace
: ' links of eighteen holes. In the business portion
Augusta the Albion Hotel and the Genesta Hotel
i for the reception of guests the year round.
'he roads about Augusta are perhaps the besl
vouth, being built by convict labor and con-
I with a natural mixture found in the region,
ijich consists of pebbles, clay, and sand. This
r kes motoring, riding, and driving pleasant. Work
i low being done on a boulevard between Augusta
ai Aiken, a distance of sixteen and a half miles.
To sum up. from a health and pleasure standpoint,
i is easily the best all-winter resort in the
.v ith and is indeed excelled by few places anywhere.
1 climate is bracing and holds neither the inhospi-
trors of the North nor the debilitating and
c massing influences of the far South; it is moderately
and increased or diminished humidity can be en-
j ed by getting down into the river valley, or farther
i on the hill top; there is an absence of sudden and
cided atmospheric changes which characterize the
lions farther north, and the large percentage of
e my days makes it possible to spend most of the
t le out of doors.
or the reasons mentioned it is especially adapted
i diseases running a more or less chronic course, e.g.
. iahN disease, heart disease, bronchitis, asthma, etc..
i 1 indeed as a place in which convalescence after
i te diseases may be speedily and satisfactorily
i omplished. Thomas D. Coleman.
\urantium. — Sweet
trus.)
and bitter orange. (See also
1. AriiAXTii Amari Cortex. — Bitter Orange Peel.
ed rind of the unripe fruit of Citrus aurantuim
i ara Linne (Fam. Rutacea:) (IT. S. P.).
i2. ArRAXTii Dri.cis Cortex. — Sweet Orangt Peel.
' e outer rind of the fresh ripe fruit of Citrus auran-
l in sinensis Gallesio (Fam. Rutacen) (U. S. P. ).
The orange is a native of tropical Asia and is now
cultivated in all warm regions. Whether the bitter
and sweet forms were distinct species from the begin-
ning, or the sweet is a cultivated derivative of the
bitter, is a long-disputed question. Both are now
cultivated. The official sweet orange peel is used only
for its volatile oil and almost altogether as a flavoring
agent although the oil possi s some stomachic, car-
minative, diuretic, and diaphoretic properties.
The properties and uses of bitter orange peel are
quite distinct and it is an important medicinal agent.
Its aromatic constituent is chiefly in the outer, its
bitter ones in the inner layers, so that the properties
will vary with the relative amounts of these two parts.
It occurs in ribbons, shreds, or quarter-sections, rarely
in irregular pieces. The inner layer is white, the
outer of a dark or blackish-green or green-brown, and
more or less roughened with papillae. Its odor is
characteristic and its taste strongly aromatic and
bitter. Its volatile oil is described below. Its bitter
properties are due to narangin, aurantiamarin, and
aurantiamaric acid. Hespcridin is not bitter. It will
be noted that this is used after drying, while the sweet
orange peel is to be used fresh. Bitter orange peel is
an ordinary aromatic bitter, to be employed like
others of its class. The dose is two to four grams
30 to 60 grains). There is an official fluid extract,
dose npxv. to lx. (1.0 to 4.0) and a twenty-per-cent.
tincture, floss, to ii. (2.0 to 8.0). Of the sweet,
we have a fifty-per-cent. tincture, dose 4 to S e.c.
(1 to 2 fl. dr. ) and a five-per-cent. syrup, used
wholly a< a vehicle and for flavoring.
Oil of Orange Peel. Oh A Corticis. — "A
volatile oil obtained by expression from the fresh peel
of the sweet orange." This is purely a diffusive
stimulant, but is almost wholly used for flavoring.
Its preparations are the five-per-cent. spirit and the
twenty-per-cent. compound spirit, made with five
per cent, of oil of lemon and two per cent, of oil of
anise. This latter enters into the aromatic elixir.
Oil of Orange Flowers. Oil of Neroli. Oleum
Aurantii Florum. — A volatile oil distilled from the
fresh flowers of the bitter orange. (Neither the oil nor
i to
Aurantlum
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
the flowers are longer official.) This is used purely as
a perfuming and flavoring agent. The following are
the preparations: Stronger Orange Flower Water
(Aqua Aurantii Florum Fortior) is obtained as a
by-product in the distillation, being the water so used,
saturated with the oil. From this is made the Orange
Flower Water (Aqua Aurantii Florum) by mixing it
with an equal volume of distilled water. From this,
in turn, is made the syrup, by adding to S50 grams of
sugar enough of the water to make 1,000 c.c.
Oil of Petit Grains, not official, is distilled from the
unripe fruits of the bitter orange, and is very similar
to oil of orange flowers, but much less agreeable.
The use of orange fruit is like that of other laxative
fruits, with the special effect of citric acid. It is to be
borne in mind that, while a moderate use of oranges is
wholesome, the excessive use can bring on very
stubborn and severe dyspepsia, especially in tropical
countries. Henry H. Rusby.
Aurelianus, Cselius. — Born in Sicca, in Numidia,
but it is not known at what time his birth occurred;
some authorities stating that he was a contemporary
of Galen, who lived in the second century of our era,
while others claim that he must have been born in the
fifth century. Nor do we possess any knowledge
with regard to his life. The treatise which is attrib-
uted to him makes it clear, however, that he must
have been one of the greatest and at the same time
most practical physicians of ancient times. The
book here referred to bears the title: "Cselii Aureliani
de morbis acutis et chronicis libri viii." An edition
was published in Amsterdam in 1709. It is known
that Aurelianus wrote other medical treatises, but
unfortunately they have all been lost. A. H. B.
Auricle. — See Ear, Anatomij and Physiology of the.
Aurora Springs. — Miller County, Missouri.
Post-office. — Aurora Springs.
Access. — Via Jefferson City, Lebanon and South-
western Railroad — a branch of the Missouri Pacific
system — thirty-five miles southeast from Jefferson
City. Hotels.
This resort is located on a spur of the Ozark
Mountains, at an elevation of about 1,000 feet above
the sea level. The climatic conditions here are of a
most salubrious and attractive character and the
scenic beauties are unsurpassed. It was a visit to
this locality which led Bayard Taylor to remark:
" I have travelled all over the world to find in the
heart of Missouri the most magnificent scenery the
human eye ever beheld." The country may be
described as a succession of narrow ravines, and well-
wooded, high, dividing ridges, running in a general
cast and west direction, with picturesque streams of
clear water winding through and cutting the ridges
at right angles, forming narrow gorges, which have,
coursing down their sides, sparkling rivulets and
saucy brooks, fed by springs situated on the hillsides.
The springs are located under a magnesium limestone
formation at the entrance to a charming park and
near the headwaters of Saline Creek. The surround-
ing country slopes gradually to the southeast, and is
protected from the winter winds by the higher ground
to the north, while the cooler breezes of the summer
come from the south and west — down the Osage
valley. There are numerous springs in the neighbor-
hood, the principal ones being known as the " Round,"
the "Bluff," the "Healing," and the "Bath" spring.
A sulphur spring is located about seven miles farther
down Saline Creek. The Round spring has been
analyzed by Prof. Clifford B. Richardson, analytical
chemist, Department of Agriculture, Washington,
1). ('., with the following result:
One United States Gallon Contains:
Solids. Grains.
Calcium sulphate 2 . 42
Magnesium chloride 6.95
Sodium chloride 4 . 01
Ferrous carbonate 5.13
Ferrous oxide 0-93
Lithia 1 43
Total 20 . 87
This water is almost a pure chalybeate. It has a
sharp tonic effect on the physical economy, bracing
up the digestion, promoting the appetite, and inducing
healthful sleep and rest. Its best effects have been
observed in cases of dyspepsia, rheumatism, scrofulous
complaints, and renal diseases, and in the debility
resulting from nervous affections and uterine com-
plaints. Visitors will find excellent hotel accom-
modations and all facilities for hot, cold, and steam
baths. Emma E. Walker.
Aurum. — So far as determined, the action of gold
upon the animal system resembles that of mercury
more nearly than that of any other of the well-known
heavy metals. Locally, soluble gold salts are
powerfully irritant, and constitutionally, gold com-
pounds affect nutrition. In therapeutic doses they
tend, like mercurials, to improve nutritive tone, but
in poisonous quantities to derange it, with the
development of stomatitis and gastroenteritis, and,
in continued dosage, of emaciation and progressive
general enfeeblement.
The sole compound of gold official in the United
States Pharmacopoeia is that entitled Auri et Sodii
Chloridutn, Gold and Sodium Chloride. This is "a
mixture of equal parts, by weight, of anhydrous gold
chloride and anhydrous sodium chloride." (U. S. P.)
The compound is easily obtained by mixing in proper
proportion solutions of the two salts and evaporating
to dryness. It crystallizes in elongated prisms, but
is commonly found as "an orange-yellow powder,
odorless, having a saline and metallic taste, and
deliquescent when exposed to damp air." (U. S. P.)
The compound is very soluble in water, and the
solution has a slightly acid reaction. This prepara-
tion is locally irritant even to causticity; and con-
stitutionally is said to be of some slight value in
nervous diseases, hysteria, neurasthenia, chronic
alcoholism, tertiary syphilis, and diabetes. The
dose is about one-tenth grain (0.005) three times a
day, in lozenge or pill. R. J. E. Scott.
Auscultation. — See Diagnosis, Physical.
Auspitz, Heinrich. — Born in 1S35 in Nikolsburg,
Germany. After studying the different branches of
medical knowledge under such teachers as Bruecke,
Rokitansky, Skoda, Oppolzer, and Hebra, he began
his career, in 1863, as a "Privatdozent" of dermatol-
ogy and syphilis, and then later (in 1S75) he was
made a professor of the same branches in the Univer-
sity of Vienna. In 1S72 he was chosen Director of the
General Policlinic; and, upon the death of Zeissl, in
18S4, he was given the control of a Clinic for Derma-
tological and Syphilitic Cases in the Allgemeine
Krankenhaus. His death occurred May 23, 1886.
Auspitz deserves to rank as one of the leading
authorities in dermatology and syphilology of the
second half of the nineteenth century. He was a
prolific contributor to medical literature, his most
important publication being a "System der Haut-
krankheiten," Vienna, 1881. A. H. B.
Australia. — Owing to its great size, extending from
10° to 40° south latitude and 113° to 153° east longi-
tude, Australia presents many different climates,
776
i;i:iT.]:r.\ci: handbook OF the medical SCIENCES
Autogamy
On account, however, of its distance from the Ant-
arctic Circle (_\S°) and from the Equator (11°), there
are in reality fewer climatic variations than in other
great continents. (Encyclopaedia Britannica, 1911.)
The topographical features of the land also naturally
influence the climate. There is a low-lying coast
region, a highland or mountain region, and a great
arid interior region.
Before, however, considering the climate of this
country, it may be well to speak of the voyage
hither, which, whether from Europe or America, is a
long one and may be considered as a health measure
in itself. Formerly long sea-voyages were one of the
established means of treating tuberculosis, but now
are no longer, or rarely, recommended for this pur-
pose, although they may be of advantage for other
conditions. According to Weber (Climate and Sea-
Voyages in the Treatment of Tuberculosis: Boston
Medical and Surgical Journal, June 8, 1S99J, the
following characteristics are to be attributed to sea-
voyages: (1) purity of air; (2) slight range of tem-
perature; (3) abundance of light; (4) constant move-
ment of the air; (5) mental rest. As this author,
however, wisely remarks: "If one examines the
conditions of an ocean voyage more exactly, he
finds that these advantages are not always com-
pletely presented." The purity of the air is wanting
10 the sleeping cabins and saloons; the heat of the
tropics is oppressive; the treatment of a serious
illness on a sea-voyage is difficult; and there are
storms and calms. "From what I have observed,"
concludes Dr. Weber, " I would give it as my opinion
that sea-voyages can do good service in a certain
number of tuberculosis cases, but that in most cases
other climatic and hygienic methods of treatment
exercise at least just as good an influence." From
our present knowledge and experience, we should
modify this opinion by saying that "other climatic
and hygienic methods" are greatly superior to sea-
voyages in the treatment of tuberculosis, and only in
very exceptional cases would one recommend them
in the treatment of this disease.
The climate of the Coastal or Littoral region has an
average summer temperature ranging from 7S° in
the north to 07° in the south, and a winter tempera-
ture of from 59° to 52°; the difference between the
mean summer and the mean winter temperature being
not more than 20°, a range smaller than in most other
parts of the world. In summer the heat is at times
excessive, frequently exceeding 100° F. at Melbourne,
Sydney, and Adelaide; but the air is so dry that one
is not rendered particularly uncomfortable nor is it
enervating. The hot wind, which, "arising in the
great central Australian desert, sweeps across the
pastoral plains, rises over the range of mountains, and
descends with fury upon the coast," may raise the
temperature to 110° F. These hot winds are often
followed by cold blasts from the Antarctic Circle —
blasts which lower the temperature thirty or forty
degrees in as many minutes. That such hot winds
are not very frequent may be judged from the fact
that Melbourne, for instance, has only fourteen hot
windy days annually.
There is the usual amount of dust, that inseparable
accompaniment of a hot, dry climate. " In no coun-
try in the world," says Lindsay, " is the sky so seldom
overcast, or the interruptions to the pursuit of busi-
ness or pleasure so few."
The winters are mild. Snow and frost are rare
upon the lowlands and coast, and in many places are
quite unknown. The rainfall is fifty inches per
annum at Sydney, thirty at Melbourne, and twenty
at Adelaide. The rain comes in sudden deluges,,
as in tropical regions, and days of drizzling rain are
unknown. Owing to the variability of the climate,
the winds above mentioned, the heat, and the dust
this region is not to be recommended to invalids.
The highland regions, embracing the mountain
range of the Australian Alps and (he Blue Mountains,
which vary in height from :;, 1)11(1 to 7,0(10 feel, extend
from Queensland to South Australia. The mean
summer tempera! ore of this region is 05.4° F., and the
mean winter temperature, 11. I s . In winter, accord-
ing to Lindsay, the mountains are, for the most part,
deluged with rain and swept by winds. There are
but few places available in the mountains for invalids.
At Mt. Macedon, in Victoria, forty-four miles from
Melbourne, connected by railway, there is a good
sanatorium, " Braemar Woodend," situated upon a
plateau at an elevation of 2, 500 feet, and at Katoomba
and Mt. Victoria in New South Wale , seventy-seven
miles from Sydney, the latter at an elevation of 3,490
feet, are mountain resorts. The mean annual
temperature of the latter resort is 53° F., and the
annual rainfall about 35.7 inches.
The region of the Inland Plains, whose climate is
characterized by heat, dryness, and sunshine, is
divided into two districts: the Riverina in New
South Wales, and the Darling Downs. The Riverina
is the center of the sheep farming industry, and con-
sists of "undulating downs and rolling prairies,
destitute, for the most part, of trees or grass, but
producing large quantities of the salt-bush, which
affords excellent fodder for sheep." To the west of
this region is the great central Desert, and to the
east is the Darling Downs. The summer heat is
severe, the thermometer occasionally rising to 110° F.,
but on account of the extreme dryness it is not much
felt. " Hot winds and dust storms are frequent,
but days of still, cloudless sunshine form the rule in
summer." "In winter there is a little morning
frost, but the midday is always warm. Autumn and
spring present an almost ideal perfection of climate."
Accommodations are afforded in the towns, and
"almost every squatter's house has, or has had its
invalid visitant." There is railroad connection with
Sydney and Melbourne from this district. The
average rainfall is fourteen inches or less.
The Darling Downs, in Queensland, to the north-
east of the Riverina plain, have an elevation of 2,000
feet and are somewhat cooler and less exposed to the
hot winds; otherwise, the climatic characteristics
are similar to those of the Riverina. The range of
temperature is small, and so is the rainfall. Droughts
are not infrequent in these inland plains, and Hann
mentions the report of a reliable person, that at a
station in Darling, it had not rained for thirty
months. At times much suffering is caused by the
drought.
The inland regions of Australia offer undoubted
favorable conditions for early cases of tuberculosis,
such as have "pastoral tastes," as Williams says,
and " who are prepared to spend years in the recovery
of their health." To anyone in America, however,
the great southwestern plains of the United States —
Arizona, New Mexico, portions of Texas, or the
plateau of Mexico — offer similar, if not more favor-
able, climatic conditions nearer at hand.
For further information regarding Australia and
its climate, the reader is referred to Lindsay's "Cli-
matic Treatment of Consumption," London, 1887;
Williams' "Aero-Therapeutics," London, 1S94; the
"Encyclopaedia Britannica," 1911; and "Climatology
and Health Resorts" by Weber and Hinsdale, 1901;
to all of which the writer is indebted for much of the
above information. Edward O. Otis.
Autogamy. — A reproductive process occurring in
protozoans in which "secondary nuclei" are formed
from idiochromidia, and there is also sometimes a
differentiation into somatic and germ nuclei. The
secondary masses of idiochromidia in an individual
animal fuse in pairs, a sexual union, and then become
encysted. Such a process occurs in Entamoeba. See
Protozoa. A. S. P.
777
Autointoxication
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Autointoxication. — This term is employed in a
very comprehensive as well as somewhat indefinite
fashion, for the subject which it denotes is specula-
tive in character rather than strictly scientific. Thus
intestinal autointoxication is a condition sui generis
which has no connection with other forms of so-called
self poisoning. The term food poisoning usually
implies that the toxic substances are entirely exo-
genous — that they preexist ready formed in the
food. It is however confidently asserted that the
cleavage products of food, especially of protein,
formed in ordinary digestion, comprise some essen-
tially toxic substances, and that these are rendered
harmless ordinarily by conjugation or pairing.
Should the latter for unknown reasons fail to occur,
there would be free toxie material formed in the
intestine. In some alleged cases of ptomaine poison-
ing, in which the accused food showed no evidence
of decomposition, this possibility of toxic non-con-
jugated cleavage products must be borne in mind.
Technically this represents a type of autointoxica-
tion, for the poisons should be formed within the
digestive tract. In intestinal auto-intoxication of
another type, in which the symptoms are likewise
acute, the question of anaphylaxis enters; and we
know that anaphylaxis may be transmitted from
one generation to another, and may become of
familial incidence. Under this influence, even the
blandest substances may cause violent gastroenteric
irritation, the mucosa being supersensitive to the
contact of substances which do not disturb the ordi-
nary subject. Very little is known of the character
of the substances which cause these manifestations.
From the analogy of drug anaphylaxis we infer that
they are definite chemical compounds, chiefly con-
taining nitrogen — akin in fact to ptomaines. Many
cases of food poisoning so called are clearly anaphy-
lactic in character, the subject, or perhaps some of his
ascendants, having previously become sensitized to
the action of the toxic substance.
A third somewhat theoretical form of acute or
subacute intestinal autointoxication is believed to
be due to absorption of the end-products of intestinal
putrefaction, especially in intestinal insufficiency,
which are prevented from escaping by the natural
outlet. This somewhat speculative condition is known
as stercoremia. In extreme cases the systemic reaction
is similar to that in ptomaine poisoning. The syn-
drome associated often with constipation — headache,
mental depression, etc. — is sometimes spoken of as
mild stercoremia. Experiments on animals in which
the intestine is ligated have shown that actively toxic
substances are formed in the intestine. The condition
known as cholemia, due to disturbed excretion of bile,
may be thought of in this connection. This general
type of intestinal autointoxication, however, stands
in a definite relationship with the self poisoning due
to defective elimination to be dealt with later.
We may now consider quite a different type of
intestinal autointoxication; to wit, one eminently
chronic, producing its harmful effects only after
many years. This is highly speculative in character,
and in recent years has been greatly exploited as
the cause of premature senility. The accused sub-
stances are the result of putrefaction of protein, and
are universally present in the intestine, from which
they are taken up in the blood and excreted by the
kidneys. The constant presence in excess of these
substances, generally known as indoxyl, sulpho-con-
jugated acids, etc., is believed to be the most fruit-
ful cause of arteriosclerosis. The amount of these
substances in the urine is usually the measure of
the degree of intestinal putrefaction. One set of
authorities would eliminate these substances in excess
from the intestine by diet, while Metchnikoff and his
school seek to prevent their formation by encouraging
lactic acid fermentation in the intestine. (See Auto-
intoxication, Intestinal.)
778
From intestinal autointoxication we pass to another
form due to incomplete metabolism or oxidation
In theory all nitrogen which requires expulsion from
the body should be in the form of urea. If this proc-
ess is slow, incomplete, or disordered, a host of inter-
mediate substances may be formed which are believed
to be more or less toxic, to the extent of setting up
types of disease. This sort of autointoxication, how-
ever, is discussed fully elsewhere — under Gout and
Metabolism.
Another conception of autointoxication, differing
radically from any of the preceding, is bound up in
the fact that the internal secretions or hormones
which preside over many of the functional activities
of the body, are essentially toxic when produced in
excess or when the natural physiological antagonists
are not present to neutralize them. Some of these
substances when extracted from the proper organs
are found to possess a toxicity which is never exerted
in the state of nature upon the individual who
secretes it. A familiar example of a toxic substance
produced by an individual and toxic to the latter is
seen in Graves' disease, in which an excess of thyroid
secretion sets up a well-known toxic syndrome. Were
it not for the natural antagonists or correctives, all
of the enzymes and other physiological principles
would produce toxic or destructive effects. This
subject is considered under Thyroid, Thymus, Pan-
creas, Suprarenal Glands, etc.
Finally, there remains to be considered autointoxi-
cation from defective renal and hepatic excretion
which is summed up under uremia and cholemia, and
the cognate subject of the autointoxication of preg-
nancy which, however, constitutes a subject apart.
Still another type of antointoxication is fatigue
poisoning which is considered in the article with this
title. These do not exhaust the subject, for there are
a number of detached viewpoints, such as the tox-
icity of urine, blood, sweat, etc., of healthy and
diseased subjects. There is the matter of cytotoxic,
involving the essential toxicity of organ extracts to
animals. The original doctrine of Bouchard in drill-
ing with autointoxication was the demonstration
of the toxicity of animal fluids to experiment
animals. Diabetes with its terminal acidosis fur-
nishes an admirable example of autointoxication in
which, as a result of defective metabolism, a normal
food substance exerts toxic activity. It is not worth
while to pursue to its limits the subject of autointoxi-
cation, for it would come to mean almost the whole
of pathology. Edward Preble.
Autointoxication, Gastrointestinal. — Autointoxi-
cation may be defined as a state of poisoning of the
organism by products arising during the physical life
processes of the organism. Gastrointestinal autoin-
toxication, which is the narrower subject of this
article, includes all those intoxications, the sources
of which are found in the normal or abnormal
processes that take place in the gastrointestinal tract
and its appendages; these processes include the usual
chemicophysical changes that take place in the food
during its digestion as well as the products due to the
life activity of the microorganisms that inhabit the
digestive canal. It will be seen that our definition
at once excludes such pathological states as are due
to poisons accidentally introduced into the body,
or to processes not usually encountered in the
organism, such, for example, as occur because of the
successful invasion of the organism by infectious
agents of disease. It is true, of course, that every
clinical picture of an infectious disease, accompanied
by a toxemia, is a picture of autointoxication as
well, because of the failure, complete or partial, of
the usual defensive and excretory functions of the
organism, now overcome by the toxins of disease.
The latter, however, are the dominant factors in
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Autointoxication,
Gastrointestinal
ich cases, and they will be excluded from our
msideration.
In treating of gastrointestinal autointoxication
e have the digestive ferments and juices, the
ni-mal and abnormal products of digestion, and the
ormal and abnormal products of bacterial activity
, consider.
It has been pretty conclusively shown that the
igestive juices when introduced into the blood of
[mals prove very toxie. Charrin states that the
istric juice of a dog produces in a rabbit death
ceded by spasms and convulsions. Pancreatic
lice leads to lowering of blood pressure, respiratory
tnbarrassment, convulsions, and finally death. The
iwcrful ferments contained in such juices may lie
artially responsible; that they are not the only
ictors is shown by the fact that boiled digestive
i ices are likewise somewhat toxic. It has been
uggested that the toxie action of such material
lay be due to the products of digestion of the small
mount of protein matter which is, of course, present
11 all digestive juice. Clinically, the destructive
ction of pancreatic juice in acute affections of the
lancreas, and the highly irritant action of free bile
n the peritoneum, as well as the toxic symptoms
ccompanying jaundice, are well known.
It is very doubtful, however, whether any auto-
ntoxication is traceable to the digestive juices. The
erments undergo destruction during digestion; the
alivary ferments are destroyed by pepsin and hydro-
hloric acid, pepsin itself is destroyed by trypsin.
iVhile bile or its elements, when they reach the tis-
;ues or are introduced into the blood, have been
hown to be toxie clinically and experimentally,
n the normal course of digestion bile is changed in
he intestines and certain of its elements are regularly
eabsorbed without giving any evidence of ever
laving any toxic effect.
What has been said of trypsin and pepsin holds
rue of the ferments contained in the intestinal juice.
Such juice is toxic when introduced into the cir-
nlating blood of animals, but such toxicity may be
;lue to products of digestion as well as to the ferments.
That such entrance of intestinal juice into the cir-
culating lymph or blood takes place in autointoxica-
tion has not been shown.
It may be concluded that the digestive juices and
other elements of the secretion of the gastrointesti-
nal tract add to the toxicity of the intestinal con-
tents, but that they do not play any role in causing
autointoxication.
It is certain that various intermediate and final
products of digestion of the usual foodstuffs are
toxic. Albumoses and peptones have produced
acute poisoning in animals when administered sub-
cutaneously or through the circulation; what is
more important from our standpoint, peptone has
proved to be very irritant when introduced directly
into the gastrointestinal canal. Such further prod-
ucts of digestion of proteins as no longer give the
biuret reaction have likewise been shown to be fairly
toxic to animals. This question, however, is bound
with the problem of disturbances of intermediary
metabolism and does not belong directly to our
subject.
We now come to the processes of fermentation
and putrefaction upon which has been built the
theory of gastrointestinal autointoxication by Bou-
chard and his followers. It may be stated at the
outset, that while the possibility of mammalian exist-
ence without the intervention of bacterial activity
in the digestive tract may have been shown by some
experimental data and by the examination of the
gastrointestinal contents of animals of the Arctic
Zone, the normal human being harbors an enormous
number of bacteria of many varieties in his alimentary
canal, and their activity is as much a part of the di-
gestive process as the action of the digestive juices.
Strassburger lias shown thai from one-fifth to one-
third of dried feces consists of bacterial bodies and
Roger has enumerated over two hundred varieties
of microorganisms that have been found in the di-
gestive canal. Many of the varieties are nol patho-
genic; others are strongly pathogenic for animals.
II is fairly certain, however, that most of them pro-
duce substances in the course of their metabolism
which are partly, at least, re |i"ii ible lor tin' l.i ic
character of human excreta and of the content oi
I lie gastrointestinal canal. On the < it her hand, tic e
very substances probably react upon the bacteria
themselves and hinder their overgrowth when they
reach a certain concentration. Most of the bacteria,
though toxie outside of the gastrointestinal canal,
have adapted themselves to the defensive action of
the body juices and have become harmless to the
host. Iterter strongly believes that the chief sig-
nificance of such "obligate" intestinal bacteria lies
in their potential capacity to check the develop-
ment of others, not adapted to the organism, perhaps
casually introduced into it and capable of causing
injury. The number and variety of organisms in
individual eases vary greatly and depend upon the
character of the food, the character of the digestive
juices, the mechanical elements of digestion, and
finally the interaction of the bacteria between
themselves.
From our standpoint the products of bacterial
activity in the digestive tract are the important ele-
ments. The processes of decomposition may be
divided into "fermentative" or those involving car-
bohydrates, and "putrefactive" or those involving
the cleavage of proteins and allied substances. The
latter are much more important because of the tox-
icity of the resulting products.
Of the products of fermentation, carbonic acid gas
may be produced in quantities large enough to result
in "flatulence," but cannot be looked upon as causa-
tive of any but strictly local disturbance. More
important are organic acids, such as lactic, acetic,
propionic, and butyric, especially the first two. In
sufficient concentration these acids act as local
irritants, and may cause vomiting or diarrhea. In
addition, if rapidly absorbed, they may rob the body
of alkali and thus favor acidosis or acid intoxication
of the organism. " Beyond this fermentative proc-
esses probably play no role in autointoxication.
The products of putrefactive cleavage include
inorganic substances such as ammonia and sulphu-
reted hydrogen; compounds of the fatty series,
methane and methyl mercaptan; aromatic sub-
stances, phenol, scatol, indol; and finally organic
substances of basic nature and indefinite composi-
tion, ptomaines, toxalbumins, toxins, etc.
Ammonia is produced by many bacterial inhabi-
tants of the digestive tract, and locally may have a
slight irritant action. Numerous investigators have
shown that the blood of the portal vein contains
more ammonia than the general circulating blood,
the excess being changed in the liver and elsewhere
into urea. If this detoxieating action of the liver
is impaired, ammonia may be considered as a pos-
sible factor in autointoxication. Proof of this pos-
sibility, however, is wanting.
Hydrogen sulphide is constantly produced in the
intestines, the formation of iron sulphide with con-
sequent dark color of the feces after administration
of iron salts serving as proof of its presence. In vitro,
many varieties of the intestinal bacteria produce
this gas in abundance. The gas has been proved to
be somewhat toxie when introduced directly into
therectumsof dogs. Two actual conditions — hydro-
thionemia and enterogenic cyanosis — have been
traced to the excessive formation of hydrogen sul-
phide in the intestines; these are among the few
authentic varieties of autointoxication and will be
considered in the clinical section.
779
Autointoxication,
Gastrointestinal
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Methane is formed in too small a quantity to be
of any import. Nencki has attempted to show that
mercaptan is formed during putrefaction in the intes-
tine and others have proved that this gas is toxic
for animals. Still others, however, (Herter) doubt
even the formation of the gas in the intestines.
Of the aromatic substances phenol and cresol are
found in the intestine in small amounts at any one
time, though the total excretion for the twenty-four
hours may be fairly high. The only probable role of
these substances in producing autointoxication is the
damage to the liver cells which are called upon to
pair phenol to sulphuric acid, preparatory to its
excretion as phenol potassium sulphate in the urine.
Scatol behaves like indol, which is next to be con-
sidered, but is formed in much smaller quantities.
Its only significance may likewise be the damage of
the liver consequent upon its detoxication.
Much of the common lore about autointoxication
is bound up with indol or rather with its derivative
indican. Indol cannot be produced from proteins
without the intervention of bacteria, being derived
from the breaking down of tryptophan. Its quantity
in the stools varies from very small to very large
amounts and it may be looked upon as a fair index
of the amount of putrefaction going on in the intes-
tine. Indol in the stools, however, is not of as
much significance as indican in the urine, for thj
latter is a measure of the amount of indol that goes
through the intestinal wall. Herter has shown
pretty conclusively that indol is toxic for animals,
having a distinctly specific effect on their nervous
systems. Normally, however, the nervous system is
screened by the protective action of the liver, and the
condition of the latter organ and its ability to oxidize
indol may be responsible for the variety of effects
accompanying increased formation of indol in tha
body. We shall return to this subject in consider-
ing indicanuria clinically.
We have but to consider now those bacterial
poisons which have at first been looked upon as tli2
specific causes of gastrointestinal autointoxication,
namely, toxalbumins, ptomaines, etc. Putrescin
and cadaverin are basic diamins which are produced
in the intestines under certain conditions (Brieger),
but there is no proof that these substances which are
admittedly toxic are found normally or in the usual
cases termed "autointoxication." The most inter-
esting fact about these bodies is their occurrence
in the urine and feces of patients suffering from
cystinuria (see below). Other vaguely defined bodies,
that have been described by Selmi as ptomaines and
are somewhat related to plant alkaloids, have not been
studied sufficiently or indeed their existence verified,
to see in them the cause of autointoxication. Brieger
himself has cast grave doubt on any relation between
these bodies and symptoms of poisoning referred to
the gastrointestinal canal.
Of the bases, neurin and cholin, neurin has been
shown to be quite toxic and there is some evidence
to show that cholin may be formed in the decomposi-
tion of lecithin-containing substances, as, for example,
eggs. The well-known clinical fact that many per-
sons are very adversely affected by eggs in the food
may find explanation in this fashion; however, the
newer observations on anaphylaxis in general show
that such idiosyncrasies are much more complex
than mere susceptibility to this or that actual or
hypothetical substance derived from food.
It must be concluded from the above review and
from a study of the voluminous literature on autoin-
toxication that very little that is definite has been
done in the way of experimental proof of autoin-
toxication, and especially in regard to the substances
that can be accused of playing a role in causing this
condition. It has been shown that the human feces
and human urine are toxic to animals; that the
gastrointestinal tract contains substances that may
780
be very toxic when introduced into the tissues or th<
circulating blood of animals; that occasionally sub
stances are formed there that have some local in
jurious effects, that a few substances of this natun
are absorbed and may prove injurious either by vir-
tue of their own toxicity or indirectly by damagim
the organs concerned with their elimination. Thesi
conclusions, however, are far from substantiating thi
claims of Bouchard and his followers, who looker
upon the human body as a "laboratory of poisons'
ever in the danger of being greatly injured by the
results of its own life processes. They are far fron
giving support to the numerous physicians who look
upon gastrointestinal autointoxication as a very
definite condition diagnosed by the study of th'i
stools or the urinary coefficient. Instead it mav
be said that the laboratory has given almost nothine
upon which to hang a diagnosis of this sort. W<
must therefore turn to those clinical observations
which seem to support the doctrine of gastrointestinal
autointoxication.
It may be stated at the outset that the same
chaos reigns in the clinical aspect of gastrointestinal
autointoxication as in the laboratory study of it.
Numerous physicians, especially among the French,
accept unreservedly this diagnosis and have at-
tempted to explain varied clinical states by the con-
dition. Still others are absolutely sceptical of its ex-
istence. On the other hand, everyday medical practii :e
accepts the significance of autointoxication from the
gastrointestinal canal almost as an axiom. Witness
the care with which the digestive canal is cleansed
by various mechanical and medicinal means at the
outset of any acute disease; the readiness with which
the clinician attributes mild indisposition, slight rise in
temperature, malaise, any obscure untoward symp-
tom in the course of a prolonged illness, to a toxemia
dependent upon disturbance of the gastrointestinal
canal, upon constipation, etc.; witness the improve-
ment in symptoms and indeed the frequent "cure''
consequent upon clearing the intestinal canal of its
contents in the course of a short and obscure febrile
indisposition — a " febricula. " It may be granted, then,
from the outset, that autointoxication is a real far-
tor in disease; that, on the other hand, its actual
role is very difficult to estimate; that many condi-
tions presumably dependent upon it are due to
other unknown causes.
A utointoxieation in Infants.- — Finkelstein has re-
cently promulgated the theory, founded upon nu-
merous and thorough clinical observations, that in
infants food may become a source of autointoxication
not because of the changes produced by bacterial
life, but per se, because of a specific weakness of the
functions of digestion and absorption. Such poi-
soning usually takes place in infants already weak-
ened by chronic digestive disorders and is dependent
not so much upon the proteins of the food, which
were blamed in the recent past, but upon fats and car-
bohydrates. Bacterial toxins are to him only second-
ary etiological factors, simply showing that the
digestive canal of infants suffering from insufficiency
of nutritive functions is a very favorable field lor
the growth of various more or less pathogenic organ-
isms. His evidence for blaming food rather than
bacteria he finds in the very direct relation between
the administration of an excess of fats or carbohydrates
and the appearance of toxic symptoms; in the fre-
quently favorable effect of diminishing these elements
in the food; in the total absence of any specific bac-
terial infections of the gastrointestinal canal of in-
fants thus affected, and finally, in the absence of
any symptoms of intoxication in numerous infants,
in whom bacterial processes seem to be quite marked,
but who do not suffer from the specific intolerance for
certain food elements.
The following symptoms have been named by
Finkelstein as signs of autointoxication from food
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Autointoxication,
Gastrointestinal
Hong infants: (1) Disturbances of consciousness
aging from men' torpor to coma; (2) changes in
spiration, with irregularity and increase in fre-
iency; (3) alimentary glycosuria; (4) fever; (5) fall
blood pressure; (6) diarrhea; (7) albuminuria, and
en the appearance of casts in the urine; (8) loss of
light; (9) leucocytosis; (10) collapse, not explain-
ile by oilier causes.
Finkelstein's teachings have found a great deal of
pport in the observations of other podiatrists and
ive had a very marked influence upon the practice
-o-called artificial feeding; fats and sugars, rather
m proteins, being now specially watched, in the
od mixtures of infants suffering from malnutrition.
res of Circulation and Respiration. -
arious cardiac neuroses have been referred to the
fects of autointoxication, especially by writers of
le French school. Among these conditions have
i named bradycardia, tachycardia, pseudoan-
a, etc. The dependence of any of these upon
1'iiing from the gastrointestinal canal has not been
roved. In 1.S76 Henoch described an "asthma
t 'spepticum" a condition resembling usual cardiac
l lima of patients suffering from insufficiency of the
art: '■asthma dyspepticum," however, is supposed
p occur only in persons suffering from gastrointesti-
d disturbances, and is improved or cured when the
r are alleviated. However, mechanical causes,
ich as "high diaphragm" because of distention of
le stomach and intestines with gases, and complex
s conditions cannot be excluded in the etiology
f this affection and indeed they explain it as well as
ny predicated poisoning from the gastrointestinal
mal. Rapid evacuation of the stomach and intes-
nes in some eases has been followed by immediate
nprovement in symptoms, and this sequence speaks
gainst the presence of absorbed poisons in the blood.
Diseases of the Liver and Kidneys. — Many authors
ave been tempted to explain chronic degenerative
hanges in these organs by the effects of autointoxica-
on. Direct proof, however, has not been put forth,
hough there is much that is logical in supposing
hat these two great organs of transformation and
Hmination may suffer from small but constant and
prolonged damage consequent upon the action of
poisons absorbed from the gastrointestinal canal.
Is a general theory for the explanation of liver
irrhosis of obscure origin, of chronic nephritis, etc.,
he idea of autointoxication has its strong points, but
t must be understood that the poisons supposedly
tive in the case have not been isolated and very
ittle experimental evidence to support the theory
"ecu adduced; moreover,a great many cirrhotics
.nd nephritics, who show no cause for their condi-
ion in their history or physical state, likewise show
10 symptoms that can be interpreted as evidence of
issive gastrointestinal putrefaction or fermenta-
ion. The explanation of such chronic conditions,
herefore, remains a mystery still.
Neuroses and Psychoses. — It is not surprising that
uitointoxication should have been looked upon as a
lossible cause of nervous and psychic disturbances,
,vhen it is remembered how obscure is the etiology
if such conditions. Chorea, migraine, neurasthenia,
•ecurring vertigo, epilepsy, etc., have been explained
n this fashion, and it cannot be denied that disturb-
inces of the gastrointestinal tract have much to do
n*ith exacerbations in the course of some of these
liseases. However, the condition of the digestive
tract has everything to do with the state of nutrition
of the organism, and it is probable that frequently
■nough disturbances of absorption and assimilation
cause increase in the symptoms of nervous and psy-
chic disease, rather than the hypothetical poisons of
autointoxication. The truth probably is that in
such conditions as migraine, recurrent vertigo,
epilepsy, etc., absorption from the gastrointestinal
tract incident upon increased putrefaction or upon
simple .stagnation of feces be* an f constipation
acts as an exciting but not as a primary can
explains the frequenl relief of symptoms following
upon evacuation of the gastrointestinal tract in
condition as migraine. However, no authentic
"cures" of migraine ha e been demonstrated by
any methods that take the digl live canal only into
consideration.
Tetany has been pointed out by numerous authors
as a good example of autointoxication, being fre-
quently accompanied by dilatation of the stomach,
ami presumably absorption of toxins from that organ.
that this is not the only can-'- of so-called "gastric
tetany" is evident from the fact that this condition
is much more frequent in certain Localities, than else-
where, and among certain trades (tailors in Vienna).
Recently, the close relation between tetany in gen-
eral and the functions of the parathyroid glands has
been demonstrated. It seems probable that the pri-
mary cause of this condition is some insufficiency of
the parathyroids; the state of the stomach may fur-
nish the exciting cause, either because of absorption
of toxins or because of rellex conditions following the
frequently enormous distention of that organ. On the
whole, it seems more logical to rank tetany with
diseases due to disturbances of internal secretions of
glands, rather than as a pure example of gastro-
intestinal autointoxication.
Attempts to explain psychoses, with their baffling
etiology, by the theory of autointoxication have been
frequently made. However, no direct relation be-
tween the digestive tract and these diseases can be
shown and to predicate digestive toxins as the cause- of
them is, as one author properly states, simply "to
explain the unknown by unknown." Mere disorders
of digestion and of mechanical functions of the di-
gestive tract are said to be very frequent among the
insane, but they may be secondary to inappropriate
diet or bad habits due to the mental disease and not
the cause of it.
Discuses of the Blood. — Simple and pernicious
anemia, leukemia, chlorosis have all been looked
upon by some authors as due to autointoxication.
That absorption from the digestive canal is quite
sufficient to cause marked changes in the blood has
been shown by the demonstration of the relation
between certain severe anemias and intestinal
parasites. Tallquist has even succeeded in isolating
a specific hemolytic toxin from the body of Bothrio-
cephalic, and his observations have been largely
confirmed. But, of course, such anemia is not due
to autointoxication in the narrow meaning of the
word.
Grawitz looks upon autointoxication as a frequent
cause of pernicious anemia. He points out the fre-
quent history of digestive disturbances in such cases,
the granular degeneration of the red cells which
speaks for the action of some hemolytic toxin, the
increase of indican in the urine, etc. The organic
changes in the mucous membrane of the digestive
tract and the disturbances of secretion may likewise
be looked upon as favoring the absorption of poisons.
Moreover, it has been fairly clearly shown that great
improvement in the general condition of patients
with pernicious anemia as well as a favorable change
in their blood follows careful treatment of the diges-
tive canal with gastric lavage, frequent irrigations
of the colon, the administration of simple food least
apt to undergo putrefaction, etc., etc. It is true
that the blood of such patients at no stage reaches a
perfectly normal appearance — prolonged search usu-
ally shows cells and morphological changes typical
of a primary anemia — and that they usually relapse
after the treatment has been suspended. However,
this does not exclude autointoxication as a possible
cause of the disease, for such patients may suffer
from constant inability to protect themselves from
the poisons produced in the digestive canal; appro-
781
Autointoxication,
Gastrointestinal
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
priate treatment takes the place of such protection
for a time, but only for a time.
It may then be granted that the condition of the
digestive tract has a close relation to the development
of severe anemia, it will not be surprising, therefore,
if a closer relation between these will some day be
discovered; showing that a specific infection of the
digestive tract, comparable to the effects of Bothrio-
cephalus, is responsible for this grave disease of the
blood.
Still more insistent is the explanation of chlorosis
by autointoxication from the digestive tract. The
frequency of constipation and the increase of ethereal
sulphates in the urine of chlorotics have been pointed
out as showing the truth of such relation. More-
over, laboratory and experimental evidence has been
adduced. Thus Forchheimer claims to have isolated
peptone-like bodies from the urine of chlorotics,
whose origin he refers to the imperfect function of the
gastrointestinal tract. He has likewise shown that the
blood in the mesenteric veins is eighteen per cent richer
in hemoglobin than the blood in the corresponding
arteries, and he concludes that chlorosis may be due
to the disturbance of a hemoglobin-making function
of the intestinal epithelium. He has found clinically
that intestinal antiseptics act very favorably on
the course of the disease. The incidence of chlorosis
at puberty is explained by some authors by the
increased demand for blood by the generative organs
with consequent diminution in the supply of blood
to the digestive canal; others see a simple mechanical
relation, pressure by the internal organs of generation
causing constipation and this, chlorosis.
It must be said, however, that all such arguments
are very inconclusive. Constipation is so frequent
in young women that its occurrence with chlorosis
is not surprising. Moreover many chlorotic girls
are not constipated, though they may suffer from
other disturbances of the digestive canal. One other
Eoint is of importance: with exact diagnosis, chlorosis
as become a much rarer condition; incipient tuber-
culosis or a latent gastric ulcer has explained numerous
cases of severe anemia in young girls, who clinically
seem to have answered the old conception of "green
sickness."
Leukemia. — Because the digestive tract is fre-
quently diseased in cases of leukemia, gastrointesti-
nal autointoxication has been suggested as a possible
cause for this obscure disease. However, numerous
cases of leukemia run their course without showing
any involvement of the digestive tract, and others
develop such involvement only after the leukemia
itself has existed for a long time. Most striking in-
volvement of the tract is seen in cases of acute leu-
kemia in which degenerative and necrotic changes are
found in numerous portions of the mucous membrane
from the mouth to the rectum. The whole question
of leukemia is, however, in a transitional stage, at
present, older conceptions being changed because of
recent studies of the blood and pathological material.
Infection with some unknown organism, rather
than intoxication, may explain the etiology of this
disease, acute instances of which run a course very
similar to that of other severe infections, while chronic
cases show exacerbations marked by fever, chills,
great weakness, etc., that are not incompatible with
the idea of a chronic infective process.
Skin diseases. — Specific causative factors have
not been found for a great number of skin diseases
and it was to be expected that autointoxication
should be blamed for some of them. There is no
question, indeed, of the close connection between
the proper functioning of the skin and of the digestive
tract, and the everyday "hives" or urticaria shows
what absorption from the digestive canal may pro-
duce so far as the skin is concerned. This condition,
however, seems more to do with food products per se
rather than with results of digestion or decomposition
of food and therefore belongs more properly to ex-
amples of food poisoning. We must leave undis-
cussed, too, the more alluring hypothesis of anaphy-
laxis, under which head such idiosyncrasies as suscep-
tibility to strawberries, shell fish, etc., in the food have
been classed.
If other conditions, such as eczema, psoriasis, etc.
little definite can be said. Indeed, there are I
schools of dermatologists, one looking upon most
skin diseases as local conditions only, another seeinp
in them but the evidence of disturbance elsewhere,
especially in the digestive tract. These two school
differ accordingly in the treatment recommended.
No definite proof of autointoxication has been given
in these chronic skin conditions, and while it may
be true that in numerous instances regulation of the
digestive tract has led to improvement of the ski:
condition, it is no less true that numerous sufferers
from eczema, psoriasis, etc., are in the best general
health, and show no signs or symptoms of trouble with
the digestive tract.
We shall now note several rare conditions in which
the direct proof of autointoxication has been fairly
well established.
Hydrothionemia. — Violent gastrointestinal symp-
toms have been observed by Betz, Senator, Ewald.
and others in a few patients in whom an excessive
amount of H„S was demonstrated both in the fei -
and the urine. Somewhat related are the cases of
i nil rogenous cyanosis described by Stokvis and others:
in these patients, sulphemoglobin and methemoglobin
were demonstrated in the blood, during attacks of
severe enteritis accompanied by the clouding of con-
sciousness, prostration, etc. Both these condition;
appear to be actual ones and in them autointoxication
seems to explain all the facts. They are, however,
very rare, and this very rarity may be used as a good
argument against the light acceptance of autointoxi-
cation as a cause of numerous other pathological
conditions. Certainly, if autointoxication were a-
universal as some authors believe, then typical
examples of it due to one or another specific element
should be very frequent. This, however, is not at
all the case.
Acetonuria. — The appearance of acetone in the
urine occurs in several conditions and is usually
accompanied by nervous symptoms, by disturbances
of digestion, by vomiting, etc. Among the clinical
pictures showing this symptom may • be named
coma dyspepticum, cyclic vomiting, and sudden dis-
turbances in infants. However, neither the origin
of acetone in the intestinal tract has been shown nor
indeed its relation to the symptoms. There are
some conditions, in which acetone appears in the
urine in large quantities and for a long time without
causing any such grave symptoms as coma or violent
vomiting. It is possible, of course, that acetone i-
but an index of intoxication in such cases, and
the cause of it. It seems probable, too, that acetonu-
ria depends upon a disturbance of intermediary
metabolism rather than intoxication from any proc-
esses in the digestive tract.
Cystinuria and Diaminuria. — Persons who show
cystin in the urine are remarkable because of
presence of diamins, cadaverin and putrescin, in
their feces and urine. It seems quite proba
that the appearance of these substances is due to the
putrefactive changes caused by certain bacteria.
However, treatment of the digestive canal frequently
has no effect upon the cystinuria, and again some
patients have shown cystinuria, indeed, but no evi-
dence of intoxication. In any case, cystinuria is a
very obscure and rare disturbance of metabolism
and cannot be discussed here at length without fur-
ther reasons for classing it among evidences of auto-
intoxication. The same may be said regarding
atcaptonuria. In this connection we may point out
that numerous conditions, such as uremia, diabetic
782
i:i 1 I RENCE HANDBOOK OF THE MEDICAL si II v ES
Autolntoxlcatlon f
Gastrointestinal
.,, ma, exophthalmic goiter, acute yellow atrophy of
lu> liver, etc., etc., are more properly autointoxications
nan numerous conditions we have noted, and have
:i treated a- such by older writers on the subject
Bouchard, Ubu). However, increased knowledge
ho a that many of these conditions are due to
irbances of internal secretions of glands, and nol
my processes in the digestive tract; that othersare
ily related to disturbances of intermediary
ibolism, and not the simpler catabolic processes
hat take place during digestion; that still others,
lood as fast as formed. Furthermore, actively
unctionating tissues, such as the uterus and mam-
nary gland in pregnancy, show much more active
mtolysis than do the same tissues when in the resting
tate; and Schlesinger found that autolysis is most
apid in newborn animals. Schryver found evidence
hat animals which had been fed on thj-roid gland,
vhich increases the protein metabolism, showed a
nore rapid autolysis of the liver than control animals;
lowever, the writer has been unable to find any evi-
lence that thyroid extract increases the rate of autolys-
is under experimental conditions. Nevertheless, in
pile of this supportive evidence, it must be admitted
hat at the present time we are by no means certain
hat the enzymes that cause autolysis of dead tissues
lerform any part in normal metabolism, or, indeed,
hat these same enzymes really exist in the intact,
iormal cell in an active contidion.
Another interesting problem is the manner in
vhich the autolytic enzymes are kept from digesting
he living cells, and why they attack only dead or
njured cells; it will be noted that this question is
nuch the same as the old problem of the defence of
Vol. I.
-50
the gastrointestinal mucosa from the enzyme- of the
digestive fluids. There an- several observations that
bear upon this point. One is thai the blood serum
has a powerful inhibitory action upon the autolytic
processes, so thai if a large exce oi serum i pn • q(
m proportion to the amount of cells, as In e ■
exudate, autolysis may be held entirely in check.
This inhibition seems to be due to pecific anti-
bodies present in the serum, which are readily de-
stroyed by heat, by acids, and also by alkalies in any
considerable concentration. A bhi e antibodie are
particularly susceptible to acid-, the development of
an acid reaction in an autolyzing area greatly facili-
tates the process, while, SO long as the tissues are
kept alkaline, autolysis is prevented. Furthermore,
the autolytic enzy s, independent of any question
of antibodies, with a few exceptions act much better
in an acid than in an alkaline or neutral medium.*
Therefore, it may well be that in the living tissues,
bathed with the normal quantities of constantly
changing blood and lymph, the autolytic enzymes
are held in check by the antibodies of these fluids;
and at (he same time the great neutralizing power of
the bl 1 plasma prevents the de\ olopmenl of an
acid reaction from any of the products of cellular
metabolism. As soon as circulation is stopped by
any cause, since the supply of antibodies is thus cut
off, autolysis can begin after a latent period during
which, presumably, the effect of the antibodies
present is being exhausted; once autolysis is started,
the formation of volatile fatty acids favors greatly
the activity of the enzymes, and so the process soon
begins to increase greatly in rapidity.
Another possible factor in the defence of the cells
against their own enzymes is that to a certain degree
the autolytic enzymes of each organ are specific for
the cells of that organ (Jacoby). For example,
liver extract will not digest lung tissue, or kidney, or
spleen. Leucocytic enzymes, however, seem to be
capable of splitting foreign proteins of all sorts.
(The digestion of one cell by enzymes derived from
some other cell is called hctcrolysis.) Still another
reason that may be advanced to explain the attacking
of a cell by its own enzymes immediately after its
nourishment is shut off, is to be found in the con-
ditions of chemical equilibrium. During life constant
new supplies of proteins are being brought to the cell,
and the products of proteolysis are carried away or
oxidized as fast as formed; when circulation stops,
the process of splitting goes on without the introduc-
tion of any new supplies of material, and hence the
tissues are not replaced as fast as they are destroyed,
and the products of their decomposition accumulate
for lack of any means of destroying or removing
them. There can be no question that the supply
of food-stuffs is of essential importance in determining
autolytic changes, for it has been found that bacteria
and yeasts begin to undergo autolysis when they are
taken out of nutrient media and placed in distilled
water or salt solution. So long as the bacteria are
supplied with nourishment, autolysis is not marked,
but when nutrient material is lacking the autolytic
decomposition is no longer repaired, and the bacteria
disintegrate. Presumably the same rules apply to
the individual cells of complex organisms.
Lastly, it must be considered that enzymes exist in
the cell to greater or less extent in their inactive
zymogen form, and are perhaps changed into the
active form as needed, and inhibited or changed back
again when their work is temporarily finished.
Autolysis in Pathological Conditions. — All
absorption of dead or injured tissues, and of organic
foreign bodies, seems to be accomplished by means of
the digestive action of the enzymes of the cells and
* There are a few autolytic enzymes, notably those of the leu-
cocytes and bone marrow (Opie), anil an enzyme in the spleen
(Hedin), that act best in a slightly alkaline medium.
785
Autolysis
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
tissue fluids. We may distinguish between the
digestion brought about by the enzymes of the di-
gested tissue itself, or autolysis in the limited sense of
the word, and digestion by enzymes from other cells or
tissue fluids, or heterolysis, although in ordinary
usage the word autolysis covers both processes.
Heterolysis is accomplished particularly by the
leucocytes, which contain enzymes capable of digests
ing not only leucocytic proteins but apparently
every other sort of protein, from serum albumin to
catgut ligatures. The heterolysis may be intracellu-
lar, in the case of substances engulfed by phagocytes;
or extracellular, either by enzymes normally con-
tained in the blood plasma and" tissue fluids, or by
enzymes liberated by the leucocytes and fixed tissue
cells. On the death and dissolution of a cell the
intracellular enzymes are released, but it is not
known to what extent the enzymes may be secreted
from intact living cells. So far as pathological proc-
esses show, the amount of liberation of enzymes
from normal cells is very slight, if any; and the diges-
tive enzymes present in the blood plasma seem to be
very feeble, but this is perhaps because they are held
in check by the antisubstances of the serum. Patho-
logical autolysis and heterolysis, therefore, are brought
about chiefly by enzymes liberated from dead or
injured cells, and both these processes seem to take
place in the softening of pathological tissues, etc.
An infarct undergoes gradual absorption because the
dead cells are digested by their intracellular en-
zymes, exactly as they are when the tissue is removed
from the body and allowed to undergo experimental
autolysis. In addition, in the case of the infarct,
leucocytes wander in and disintegrate, and their
liberated enzymes help in the process. It is because
of the heterolysis by leucocytic enzymes that a
septic infarct becomes softened so much more
rapidly than does an aseptic infarct, and by compar-
ing the rate of autolysis in these two kinds of infarcts
we see that cellular autolysis is a very slow process
as compared with the heterolysis accomplished by
leucocytes.
It is probable that the products of autolysis are
toxic, and the aseptic febrile condition occurring in
patients with large areas of aseptic necrosis, or with
sterile hematomas, and sometimes called "ferment
fever," may perhaps be the result of the absorption
of the substances produced by the action of the
autolytic enzymes. It is well known that albumoses
and peptones are toxic, and it is quite probable that
some of the other products of proteolysis are poison-
ous; and it has been repeatedly shown that they are
hemolytic. Some of the symptoms of suppuration,
particularly the fever and chills, have been ascribed
rather to the autolytic products than to the bacterial
poisons, particularly as aseptic suppuration is accom-
panied by fever. In all conditions associated with
autolysis albumoses may appear in the urine, and it is
quite probable that they would cause more or less
intoxication before being eliminated.
As specific instances of autolysis in pathological
conditions may be mentioned the following:
Necrotic Areas and Exudates. — The processes that
take place in a local area of necrosis must be funda-
mentally quite similar to those occurring in a corre-
sponding piece of tissue kept in an incubator under
aseptic conditions. The rate of the changes as
actually observed, is, however, very much slower in
the case of the dead tissue within the living body,
which is probably due to the inhibitory effect of the
blood serum; indeed, if we add a large volume of
blood serum to tissues placed in the flasks for experi-
mental autolysis it will be found that the rate of
autolysis is greatly lessened. In the case of very
large areas of necrosis the central portions are found
to undergo softening much faster than the peripheral,
undoubtedly because removed from the inhibitory
action of the serum. The disappearance of nuclear
staining, which is the usual microscopic indication of
necrosis, is probably due to the digestion of the
nucleoproteins by the proteolytic enzymes and the
nucleases, for if sterile pieces of tissue which have had
their enzymes destroyed by heating are implanted
into animals they are found to retain their nuclear
staining for several weeks. The rate of autolysis
under experimental conditions, as shown by the
nuclear changes, is in decreasing order, as follows:
Liver, epithelium of the convoluted tubules of the
kidneys, spleen, pancreas, collecting tubules and
glomerules of the kidney, alveolar and bronchial
epithelium of the lung, thyroid epithelium, myo-
cardium, voluntary muscle, squamous epithelium
of the skin, cortical cells of the brain, connective-
tissue cells, endothelium of blood-vessels.
If chemotactic substances are formed in a necrotic
area the leucocytes that enter cause very rapid
heterolysis. In caseation, for example, there is
practically no autolysis, but if iodoform is injected
the leucocytes that invade the area at once cause
rapid softening, with the formation of "sterile pus."
Suppuration is an example of very rapid autolysis
and heterolysis, particularly the latter brought about
by the great number of leucocytes that are always
present. As living cells do not undergo digestion, we
do not get suppuration, no matter how many leuco-
cytes there may be present, unless there is also present
necrosis or some non-living protein material, such
as fibrin, for the enzymes to attack; this is well
illustrated by the absence of suppuration in erysipelas,
in spite of extreme infiltration with leucocytes.
Exudates undergo autolysis, as Opie has pointed out,
in direct proportion to the number of leucocytes, and
in inverse proportion to the amount of serum. If the
amount of serum is relatively very great, as in many
forms of serous pleuritis, the antibodies of the serum
hold the enzymes of the leucocytes in check, and there
is little or no autolysis; but if the leucocytes are very
abundant and the amount of serum small, th< u
autolysis will occur. In this connection it should be
recalled that the enzymes of polymorphonuclear
leucocytes are remarkable in acting best in an alkaline
medium, so that it is not necessary for an acid reac-
tion to be developed in order that they may become
active. The mononuclear cells seem to contain an
enzyme acting best in slightly acid solution.
Pneumonia. — The resolution of the exudate in lobar
pneumonia is a striking example of autolysis by
leucocytes, and its great rapidity undoubtedly de-
pends upon the fact that the process occurs in the
alveoli, and out of direct contact with the circulating
blood and its antibodies. The important fact that in
the resolution of pneumonia the alveolar walls escape
digestion while the exudate is being taken away, is
due to the normal resistance of living cells to digestive
enzymes, which in this case is certainly at least
partly due to the presence of abundant blood in the
alveolar walls; in case the nutrition of a pneumonic
area is cut off by thrombosis the autolytic changes
then involve also the affected lung tissue, resulting
in purulent pneumonia, gangrenous softening, or
abscess formation. As evidence of the autolytic
nature of resolution we have the presence of albumi
and peptones in the sputum and urine of patients
after the crisis of lobar pneumonia, and leucin and
tyrosin have been found in pneumonic lungs.
Liver Degenerations. — In a number of pathological
conditions of the liver, of which acute yellow atrophy
is the type, autolytic destruction of the parenchyma-
tous elements is the chief cause of the anatomical
changes observed, and perhaps also of many of thi
clinical features. In acute yellow atrophy, for
example, we have a rapid decrease in the size and
weight of the liver because of disappearance of a
large proportion of the hepatic cells, and in this condi-
tion leucin and tyrosin may be found in the urine,
while in the blood, and especially in the liver itself,
786
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Automatic Actions
ere may be found any and al of the products of
oteolysis. Similar conditions exist in pho phoru
lisoning, in the diffuse necrosis observed in the liver
i <■-- of delayed chloroform poisoning, in some ca es
puerperal eclampsia, and in certain infectious
mditions with hepatic necrosis, especially in Weil's
e. It would seem that in these conditions we
,,■ the liver cells injured by some poison that
ps the synthetic activities or kills the cells outright,
it does nol injure the an l oly tic enzymes, so that the
accomplish the disintegration of the cells.
ably the reason that the liver is peculiarly liable to
,ch intra vitam autolytic destruction lies in the fact
it is notably possessed of the most active auto-
enzymes.
1'imliiiorlcm Changes. — These are undoubtedly due
. two factors, bacterial action and autolysis. Under
linary conditions the former effect is so conspicuous
nit autolysis is not prominent, but there are in-
in which postmortem decomposition is purely
itolytic. The best example is furnished by the
gration of the fetus that is retained within the
idy of the mother after its death from whatever
se; the maceration of the tissues, and the disin-
ation of the viscera, are the result of autolytic
rocesses. In the "ripening" of meat kept at low
•mperature to prevent bacterial action we have a
ise of slowly continued autolysis, and even in fish
id meat cured with brine, autolysis seems to take
ice in spite of the strength of the salt solution used,
he softening of the muscles after rigor mortis is
robably also the result of autolytic decomposition
the clotted muscle proteins. The microscopic
langes that occur in tissues undergoing postmortem
composition are readily explained as the effect of
itolytic attack upon the cellular structures, and are,
i fact, quite the same as those occurring in necrotic
eas within the living body.
Tumors. — As necrosis is a prominent feature of
talignant tumors, autolysis results in their softening
iid breaking down, showing that tumor cells possess
titolytic enzymes as well as the normal cells of the
idy, and there is no conclusive evidence that these
izymes are at all different from those of normal
^sites. It is possible that the products of this
vtensive autolysis that occurs in tumors have an
nportant influence in the production of cancer
ichexia. Extracts of malignant tumors have a
ecided hemolytic property, which very probably is
ue to these products of autolysis, and their absorp-
on into the blood may have to do with the anemia
f cancer patients. On account of this hemolytic
roperty, blood-stained exudates produced by malig-
ant growths in the serous cavities usually will be
>und to owe their color to hemoglobin rather than
) red corpuscles. The action of radium and x-rays
pon malignant growths has been ascribed to the
(feet of these agencies upon the autolytic enzymes;
>*euberg found that although most enzymes are
estroyed or inhibited by radium emanations,
titolytic enzymes form an exception, for cancer
te exposed to radium rays undergoes autolysis
ister than control specimens. Products of protein
ydrolysis may be found in tumors on account of their
utolytic disintegration. The fact that ulcerating
arcinoma of the stomach liberates its intracellular
nzymes into the gastric juice has been utilized in
liagnosis, the stomach contents in such cases being
ble to hydrolyze polypeptids and liberate free
mino-acids, which normal gastric juice cannot do.
N'eubauer and Fischer, 2
Leukemia. — The abundant elimination of uric acid
ind other purin bodies in leukemia is probably due
o the autolysis of leucocytes that occurs in this
lisease. Leucocytes obtained from cases of myeloid
eukemia show very active autolytic properties, which
ire comparatively slight in leucocytes from lymphatic
eukemia. Corresponding with this, the evidences of
autolytic proct e are much more prominent is t
of myelogenous leukemia, h seems quite probable
that an important factor in this autolysis i- thai the
proportion of ieucocj serum in the circulating
blood is greatly raised, 80 that the antibodies pre enl
in the blood are inadequate in amount to bold the
leucocytic enzymes in cheek, as normally occurs. It
has been found experimentally that leukemic orj
especially the spleen, undergo autolysis more com-
pletely and more rapidly than do normal orga
The effect of x-rays upon thi- ( ea e i po iUv the
result of their action upon the intracellular enzymes,
as in the case of cancer.
Autolysis of Bacteria. — As previously men-
tioned, bacterial cells present no exception to the
general rule that all living cells contain autolytic
■ ■ i i / \ iocs. This property of bacteria is shown as soon
as they are removed from culture media and placed
in non-nutrient fluids, such as water or salt solution:
then the bacteria begin to undergo Si If-digestion in a
few hours, as if their enzymes attacked the bacterial
cells when there is nothing else for them to act upon.
Likewise, if bacterial cells are placed in antiseptics
that do not destroy the autolytic enzymes, such as
toluol and chloroform, autolytic disintegration
begins to take place at once. In this way it has been
possible to liberate from bacterial cells the poisonous
substances that they contain, the etnlotoj-ins. It is
probable that such bacteria as owe their pathogenic
properties to endotoxins produce their effects only
when these are released through disintegration of the
bacterial cells by autolysis or when the bacteria are
digested by the enzymes of the infected organism.
On this account it is possible for a perfectly immunized
animal to be killed by the injection of large numbers
of such bacteria (e.g. typhoid, colon, cholera) through
overwhelming with great quantities of endotoxins.
even when every bacterium has been killed by the
protective agencies of the animal, since when the
bacteria are killed the endotoxins are liberated by
digestion of the dead bacterial cells. Autolysis of
many pathogenic bacteria liberates poisons producing
the same symptoms as are characteristic of anaphy-
lactic shock (Rosenow).
Part of the tissue digestion that occurs in infected
areas may be due to the action of enzymes liberated
by the infecting bacteria, but as compared with the
effect produced by the leucocytes this influence is
probably negligible. Certain of the products of
autolysis of tissues are antiseptic and it is possible
that a certain degree of resistance is conferred by
these substances in local infections accompanied by
tissue destruction. Conradi believes that it is the
accumulation of these antiseptic products of the
autolysis of bacteria that accounts for the gradual
dying out of bacteria grown on artificial media. It is
quite possible that bacterial toxins may be destroyed
by autolytic enzymes, for it is known that toxins are
attacked by proteolytic enzymes.
H. Gideon Wells.
1. Midler und Joohmann: Deutsches Arch. f(ir klin. Med., Vol.
xci., 1907; Miinchener rned. Wochensehrift, No. 26, 1906.
2. Neubauer und Fischer: Deutsches Archiv fiir klin. Med .
Vol. xcvii., 1909.
The Bibliography of this subject is given by Salkowski, Deutsche
Klinik, 1903 (11), 147; A. Oswald, Biochemisches Centralblatt,
1905 (3), 365; and hi the chapter on Autolysis, in Wells' "Chem-
ical Pathology."
Automatic Actions. — By the term automatic ac-
tions, as applied to living bodies, we mean those move-
ments which go on without any outside stimulus, the
causes being in the body itself. For the sake of under-
standing them more clearly it is necessary to divide
them into certain classes, which, so far as the higher
animals are concerned, are as follows:
787
Automatic Actions
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
The Automatic Actions of Vegetative Life.
— Under this head we have: (a) those of the re-
spiratory neuromechanism; (6) those of the cardiac
neuromechanism; (c) those of the vasomotor neuro-
mechanism; (d) those rhythmical movements of the
stomach, intestines, spleen, and bladder which occur
without apparent reflex stimulus.
The automatic actions in these classes may be
modified by voluntary or other extrinsic influences,
but they are, nevertheless, essentially independent of
them. Thus the respiratory movements may be
modified by volitional impulses, but they in the main
go on rhythmically and independently. The mechan-
ism of this process of automatism is well illustrated
in the cardiac movements. The pulsations of the
heart depend upon the stimuli rhythmically sent out by
the intrinsic ganglia and the cardiac muscle cells.
The cells which originate these stimuli receive no
excitation themselves except that furnished by the
aliment from the blood. This aliment is constantly
building up these motor cells into a more and more
unstable condition. When the instability reaches a
certain limit, the cell decomposes or explodes with a
discharge of its force, after which it immediately
begins to build up into instability again; and so the
process goes on. This explanation applies to all the
rhythmical automatic movements of vegetative life.
The movements are performed by unstriped muscles,
or the muscles of internal relation. The more detailed
knowledge of the process, with the chemical changes
and electrical phenomena are to be found in the
larger technical works on physiology. They have no
specially enlightening value on the intimate nature
of automatism. After all it is a question of a steady
supply of fuel to a pulsating engine.
The Autonomic System. — Some physiologists have
given the name autonomic to the activities of the
sympathetic nervous system. This is well enough,
only it is to be remembered that the autonomic
actions are not the same as automatic. Thus many
of the activities of the sympathetic are reflex. Auto-
matic actions, however, are done not only by the sym-
pathetic but by the cerebrospinal nerves or by both
acting together.
The Automatic Actions of Voluntary Life. —
A second and much more striking class of auto-
matic activities includes those involving voluntary
muscles and the mind. They appear in various forms
and in varying complexity according to the part
of the nervous system which they involve. They
may be divided as follows:
(a) The Motor Automatisms. — The harmonious
movements of the eyes, the muscular adjustments
called forth in the use of the voice, and of the jaws,
mouth, and throat in suckling are illustrations of
motor automatism. The movements of the body
and limbs in standing, sitting, walking, and in the
various acquired dexterities, such as those of dancers,
players, jugglers, acrobats, and skilled artisans, all
are done automatically. Being, in man, acquired by
practice, they may be spoken of as secondary auto-
matic actions. They have for their anatomical
substratum certain arrangements of nerve fibers and
cells in the cerebellum, basal ganglia, and spinal cord.
The conscious mind, though taking no active share,
first fathered them, and stands in ready connection
with them. It starts or stops the machinery, just
as by touching the pendulum we start or stop a clock
that has been wound. Physiology teaches also that
all voluntary acts tend by repetition to become
automatic. For voluntary movements, by repeti-
tion, are more and more easily and quickly performed,
until at last they no longer possess the elements,
such as duration and intensity, necessary to arouse
consciousness, and they are then done automatically.
(6) Psychical Automatism. — There is another class
of automatic activities closely related with the fine-
going. Here volition and normal consciousness have
no share at all, and the whole psychical life, so far a-
it appears at all, is automatic. The mind becomes a
real machine, working in certain established grooves
unmodified by any volition or by any external 01
internal stimulus except such as gives it the start;
just as the boy trims the sails and fastens the rudder
of his toy boat, then launches it to sail as its mechan-
ism directs.
This psychical automatism is represented in lower
animals by many of their instinctive acts. In fol-
lowing its instincts the animal obeys no consciou
purpose, but is impelled by unfelt stimuli from within,
these stimuli being furnished by the peculiar anatom-
ical arrangements and nutritive needs of its nervous
system, inherited from its ancestors. Instinct cover-
in the lower animals, however, both the acquired
aptitudes and the psychical automatisms in man.
This psychical or cerebral automatism is perfectly
illustrated in the conditions known as trance and
somnambulism. Here consciousness, while not ex-
actly abolished, is in an aberrant state (see Conscious-
ness, Disorders of), volition is suspended, but thought,
feeling, and sensorimotor activities continue, and
the body responds in systematized and apparently
intelligent acts.
Subconscious Menial Actions. — The following state-
ments regarding subconscious action made ov;-r
twenty years ago, were even then a commonplace
among psychologists and physiologists. It has
recently been "rediscovered" and extraordinary em-
phasis laid on the importance of the subconscious
activities. These activities are in a way automatic
i.e. they may go on from one phase to another
through the stimulus of association. But technically
psvchic or cerebral automatism must be accom-
panied by some definite motor act.
There are two distinctions which in a medical study
of psychical automatism must be made: First, sub-
conscious cerebration is a different thing from the
psychical automatism which we are describing.
The term subconscious cerebration should be limited
to that very large share of our mental life which runs
on beneath consciousness. Few persons in carrying
on a train of thought bring every link in the logical
chain into consciousness. We pass with a step from
the first term to the last, the intermediate process beii?
subconscious. In the association of ideas, one menial
picture is often followed by another apparently re-
mote, the missing links not rising into conscious view.
Subconscious cerebration, therefore, refers simply to
the subconscious part of our ordinary thoughts and
feelings, and is one of the modes in which the mind
naturally acts. Second, cerebral automatism, as
understood by some writers, is made to include
cerebral reflex acts, i.e. all the mental acts which
arise involuntarily in response to a stimulus. Thus
we are told that the ready response of emotion at a
dramatic climax, the instant formation of judgment
where certain simple and common conditions are
present, are all examples of cerebral automatism.
From this same point of view, the common sense of
mankind is but the automatically formed judgment
upon the various affairs of life, which rises alike in the
great mass of men. There is propriety in this view,
and lines of distinction must be somewhat arbitrarily
drawn. Nevertheless, the acts referred to are much
more typically reflex than automatic acts, as, for
example, when a novel situation excites at once
spontaneously a burst of laughter. And it is better
to limit the term cerebral automatism to those con-
ditions of the mind in which spontaneity is abolished
for a time and the psychical mechanism acts entirely
apart from any conscious stimulus with this result of
purposeful acts.
Cerebral automatism, as thus limited, is patholog-
ical and has a medical importance. It is a condition
that is brought about by a number of causes, and
788
REFERENCE HANDBOOK or TDK MKDICAI, SCIENCES
Automatic Actions
.ikes a somewhat different clinical picture accord-
Ely. Cerebral automatic slates may be classified as
ilovvs: The epileptic, the somnambulic, the hyp-
itic, the automatism of inebriety, of insanity, of
reotic intoxication, of syphillis, of injuries to the
ad, and of overwork or cerebral exhaustion.
Epileptic Cerebral Automatism. — The anio-
nic menial stale which occurs in epilepsy accom-
nics much more frequently petit mal than hunt mal.
generally follows the attack, but someti
ecedes it, and still more rarely takes its place, in
lioh latter case the terms psychical epilepsy
lines Jackson), masked epilepsy (Esquirol),
ilepsia larvata (Morel) have been applied. It is a
msitory psychical disturbance, and only one of
i era) forms which occur at this period (see Epilt psy).
of epileptic automatism are numerous. In the
npler forms, the patient proceeds to do some ordi-
rv but inapposite act. Often he begins suddenly to
idress, or tries to go upstairs, and will climb upon
hair, or table, or shelf. Sometimes he picks up an
ject and destroys it of throws it down or puts it in
s pocket. Much more complicated acts may be done.
patient of Le Grand du Saule's, after an at tack, found
at he had taken passage in a steamer for Bombay.
■ wet's tells of a carman who, after an attack, drove
r an hour through the crowded streets without
cident. Trousseau relates the case of an architect
10, when seized with an attack, would run quickly
nn plank to plank without falling; and Gowers,
ain, had a young lady patient who, during the
ileptic automatism, would play the most difficult
isic. A patient of mine while riding a bicycle would
,ve an attack and continue to ride skilfully through
e city streets. In some cases the emotional faculties
e more involved, and attacks of transitory mania,
furious impulse, occur.
Artificial Cerebral Automatism, Hypnotism,
IANCE. — In the condition known as hypnotism,
vnce, or the mesmeric state the phenomena of
rebral automatism are very well shown, and an
iderstanding of it gives the key to all the cerebral
tomatic states. When the hypnotic condition is
oduced artificially in a man lie is instructed first
fix his attention upon some particular object,
a bit of glass, which is held slightly above the level
vision, so as to put the ocular muscles upon a
rtain strain. After a few minutes, in sensitive
Meets, the psychical activities seem to lose their
uilibrium and to be concentrated in one particu-
' direction. Little force is left to supply the rest of
e conscious functions of the brain, and the mental
e of the subject is working in one field. The
ind is but a point. The equilibrium of psychic
ice being once overturned, it continues unstable,
d can be turned in one direction or another,
cording to the suggestion of the manipulator,
ms the hypnotic thinks that he sees a beatific
sion, and every capacity of his mental being is
pended on the feelings that such a vision excites.
• he is told that he is a murderer, and must die, and
is overpowered with fear and remorse. Or his
ind is directed to the idea that one side of his body
insensible; he then feels no pain on that side.
any case, his mental energies are all so absorbed
' some single dominant feeling, that ordinary
nsory impulses coming up to the brain impinge
ritlessly upon consciousness, but they cannot pass
e fchreshhold and awaken no sensations. The hyp-
itic is to all intents and purposes anesthetic,
ind and deaf to everything except an expected
ggestion from the operator, which is the only
ik that holds him at the time to the external
irld. Under the domination of some particular
ea or feeling, his mind may automatically cause him
perforin many complex and apparently intelligent
ts. The concentration of nervous force upon some
particular function, such as thai of sight, hearing,
or touch, exalts these senses, so thai vision is clearer,
hearing more acute, and the touch more sensitive
ee Hypnotism, Somnambulism). Such is, in brief,
the physiology of hypnotic automatism.
The psychology of this Condition may be staled in
oiher ami more technical and elaborated terms, I or
example, there is an intense concentration of atten-
tion, a morbid degree of Suggestibility and self-ab-
sorption or a lowering of the threshold of conscious-
ness to the suggestion.
It is not the purpose of the writer, however, to inter-
pret the subject in terms of the modern psychologist.
Sue 1 1 interpret at ions seem simply to add to our voca-
bulary but not. to our knowledge.
Although the hypnotic condition is usually pro-
duced artificially, certain persons of a highly sensitive,
nervous temperament an? subject to spontaneous
attacks, just as other persons suffer from the similar
c tit ion of somnambulism. Indeed, spontaneous
hypnotic attacks are a kind of day somnambulism.
Individuals thus suffering are generally of a hysteri-
cal temperament, with deficient will power, and
their hypnotic attacks may accompany, or be com-
plicated with, attacks of catalepsy, ecstasy, or
hysterical seizures of various kinds. There are per-
sons who have a congenital tendency to fall spon-
taneously into hypnotic states. Such was the case
with a patient of Le Grand du Saule's, who, whenever
he got into a state of excitement or expectancy,
would fall off into a hypnotic sleep. Some of the
reported cases of morbid somnolence belong to this
class (see Sleep, Disorders of). In other instances
the tendency to spontaneous trance states is ac-
quired, as in a case reported by Finkelnburg: a young
woman, having been once mesmerized by a pro-
fessional, ever after was subject to spontaneous
attacks of trance.
The condition of trance, or one closely allied to it,
is induced voluntarily by the so-called trance speakers.
It may also be brought on by some periodically occur-
ring affection, as was shown in a case related by
Dr. B. F. Berkley. 1 A married woman, aged thirty-
nine, for years suffered from trigeminal neuralgia,
which finally ended in a severe form of tic douloureux
occurring every two weeks. After each attack she
fell into a state of "somniloquence" lasting for an
hour or two. During this time she would preach on
religious topics with some amount of eloquence. She
was a modern illustration of the similar states into
which the priests of the Delphic oracle went when
uttering their prophecies.
Hypnotic states are generally brought to an end by
the passes of the manipulator. If the patient is left
alone the hypnotic state continues for some hours,
passing finally into true sleep, from which he awakens
spontaneously. In some persons who are subject or
have been subjected to periodical attacks of hyp-
notism, the mind recalls in one attack what occurred
in the previous one. After such a person comes out
from an attack he has no recollection, as a rule, of
what was done in it. There are considerable varia-
tions in the degree or intensity of the hypnotic state.
In the slighter degrees it resembles considerably that
of profound reverie or abstraction. There is a distinc-
tion, however, between the absorbed reverie of the stu-
dent and the absorbed contemplation of the hypnotic.
In the former case the mind is constructing and build-
ing under a certain kind of voluntary direction; in the
latter the mind is going automatically over old ground.
Traumatic Cerebral Automatism. — Very rarely
injuries of the head produce such a pathological
change in the brain as to make the person injured
the subject of periodical attacks of cerebral auto-
mat ism. In these cases the mental condition is the
same as if the patient walked in his sleep or had been
artificially hypnotized.
789
Automatic Actions
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
One of the most typical cases of this kind is that
related by Mesnet, of the French soldier who, after
suffering from a severe injury of the head, used to pass
into automatic states lasting for days. He would
then unconsciously go through all the routine actions
to which he had been accustomed, such as dressing,
taking a walk, smoking, etc. These attacks are gen-
erally in form of epilepsy.
The Cerebral Automatism op Inebriety. — ■
Medical literature contains striking instances in which
the effect of the long-continued abuse of alcohol has
been to induce periodic attacks of cerebral auto-
matism. Under the influence of excessive drink with
perhaps some pathological condition associated with
it the patients fall into a state very much resembling
that of hypnotism. In this condition they may go
through the ordinary routine of life in so perfect a
manner that no one would recognize the peculiar
aberration of the mind. After a period of hours, or
even of a day or more, normal consciousness returns
and they remember nothing of what they have been
doing. One of the most remarkable illustrations
of this kind was that of a railway conductor who,
after passing into the automatic state, would take
charge of his car, run the train, collect tickets, make
change, and do all the other duties of his position.
Finally, after returning home and awaking, he could
remember nothing of what he had done.
Briefer and less typical attacks of cerebral autom-
at ism occur undoubtedly in very many cases of
chronic inebriety. They are perhaps often only cases
of amnesia from drink.
Syphilitic Cerebral Automatism. — Cerebral
syphilis sometimes produces states of automatic
mental action, though these are not of a very typical
kind. The syphilitic poison causes a kind of somno-
lent or stuporous condition, in which the patient
appears incapable of voluntary intelligent acts.
When roused and set upon ordinary tasks or routine
duties, he goes through them automatically and
almost unconsciously. Such cases are certainly rare
at the present day and under modern methods of
treatment. When they occur the suspicion of a
luetic petit-mal should be entertained.
The Automatism op Brain Exhaustion and
Brain Disease. — Luys 2 relates the history of a
young man who had been for several days engaged in
making calculations of compound interest, w'hich had
caused a great tension of his mind. One evening,
after dinner, he was about to go to sleep when, as he
says: "Without the slightest encouragement on my
part, in a state between sleeping and waking, I began,
without the smallest volition on my part, to calculate
and go over again exactly the same problems as when
in my office. The cerebral machine had been set in
motion too violently to be stopped, and this involun-
tary work went on in spite of me, and in spite of all
the means I endeavored to employ to cause its cessa-
tion, that is to say, for from about three-quarters of an
hour to an hour and a quarter." Many persons, after
an evening of exhausting study, on retiring to bed
have experiences somewhat similar to the above.
Healthy persons also discover a little of this cerebral
inertia in their disinclination, or even absolute inabil-
ity, voluntarily to leave a task in which they are
absorbed.
Dr. O. O Gibbs 8 relates the history of a large,
muscular man, aged fifty-five, who showed, in a
permanent and exaggerated form, this kind of auto-
matic condition. The person in question had been a
hard drinker and smoker, but had suffered from no
disease. His family at last noticed, however, that
his mind was somewhat affected. His memory failed,
and he would tell the most absurd stories. Gradually
his intelligence diminished and his will became
impaired. When he began to do a certain thing he
790
had no power to stop himself. If he went to the ban
to throw down hay he would never stop, unless inter
fered with, until he had pitched off the whole mow
If sent out to bring in an armful of wood he wool
never stop until the pile was all in, or the room \va
full. When he once commenced to eat, it seemed a
if he could never cease. As his mind became
affected he gradually lost the power of balancini
himself, and showed a constant tendency to go
ward when standing, and to tip over backward whei
sitting. He slept much. His strength gradual!'
failed, and he died with no marked symptoms
The diagnosis of cerebral softening was probabl'
correct, although no post-mortem examination wa
made.
The Cerebral Automatism op Insanity. Th.
condition of cerebral automatism has been incorrect!'
classed as one of the forms of insanity. Cerebri
automatic acts occur in various forms of insanity
perhaps most strikingly in primary dementia and Ii
epileptic insanity.
Perhaps the automatic cerebral life in the insane i
best shown in dementia, in which disease only th
lowest of the mental functions remain, and the suffer,
is guided only by the impulses and stimuli of hi
vegetative system.
In secondary dementia, and in idiocy and othe
states of mental enfeeblement, the mental activities
so much as remain, are more or less automatic
Medicolegal Relations op Cerebral Autoiu
tism. — In conclusion, I have space only to call atten-
tion to the very evident medicolegal importance of e
knowledge of cerebral automatic states. This applie-
especially to the more frequently occurring form-
such as those of artificial, epileptic, and possibh
inebriate, automatism. There is no doubt thai
an epileptic automatic is irresponsible, morally, foi
his acts, while in inebriate automatism the court?
would sustain the medical view.
Charles L. Dana,
References.
1. Berkley, B. F. : Western Journal of Medicine and Surgerv
X. S , vol. vi., p. 204.
2. Luys, J. B.: The Function of the Brain, p. 1S3.
3. Ciibbs. O. C. : Pennsylvania and Independent Medical
Journal, 1S59, ii., p. 12.
Automobile, Hygienic Relations of the. — The motor
car has provided a source of health to a great many
people; in others it has developed some quite un-
pecedented ailments, and even diseases. Many gel
physical benefit from the motoring that could hardly
come to them in any other way. Used rationally,
that is, with moderate speed, by those unable for one
reason or another to exercise themselves in walking,
rowing, riding, or the like, it is a veritable blessing.
While plenty of fresh air is inhaled, the appetite is
improved, the emotions are soothed and satisfied by
ever changing scenes; and hitherto unfamiliar aspects
of life interest and divert from introspection.
Among the functional and other disorders attribut-
able to the habitual use of the automobile the fol-
lowing are worthy of mention.
Neuroses. — The nervous system is affected in
many by reason of the excessive strain consequent
upon high speeding over uncertain roads, minute
attention being constantly essential for the avoidance
of obstacles. The eyes are strained to discern wind-
ings in the roads and conceivable obstructions.
Collisions with other vehicles must be guarded
against. The brain is strained in the constantly
repeated effort to decide on the instant which way lo
turn to avoid danger of all kinds. The nerve-; are
strained because they must be ever ready to signal to
the muscles essential for the government of the
REFERENCE HANDBOOK OF THE MEDICAL S< IKXCF.S
\ ill'. in. -Ml.'
nachine. The nerve messages hurry upon one
mother trying to shorten the time of their delivery
I this in l urn exhausts and paralyzes the neurons
vliicli must take ami forward these messages. The
notorist, if his psychism is not to be badly affected,
nusl !»' a man of naturally <|uiek perception, iron
htvc, and imperturbable self control. Then the pas-
engers constantly fear sudden jar or accident; their
cles are fixed involuntarily; the hands are
•lenched, die jaws set; the whole nervous system is
igid at attention, in anticipation of untoward
lopments.
Attacks of hysteria are common among women.
specially young married women, who motor ex-
tvely; these attacks are due to relaxation after
train in a long and rapid run. and are not serious in
itherwise normal people. There is also nervous
irostration to which men are at least as prone as
.11. These affections seem to be increasingly
ommon among motorists. They yield slowly to
reatment and (except in naturally healthy people
vho motor infrequently) have a cumulative effect
.Inch it is difficult to treat successfully.
Women seem more susceptible than men to all the
lihnents brought on by fast riding, and they are not
.1 by nature to cope with wind and weather, and
he strenuous outdoor life contingent upon motoring;
he meeting with hard knocks and hairbreadth escapes
■xhausts rather than fortifies them. Their nerve re-
ictions have not been trained for fast motoring and
heir more timid natures require increased effort in
>rder for self control. Such cases of hysteria arise
avariably in women not up to par as to their nervous
ystems. Yet the excitement of automobiling ap-
>eals to them; the more they get of it the more they
The ever-increasing stimulation inherent in
his indulgence is bound sooner or later to end in
ollapse. Deafness, paralysis, melancholia — such
iffeetions then supervene. For such cases complete
ibstinenee from motoring and entire rest are
ibsolutely essential, though mild motoring later on
nay help in the cure.
Nervous prostration is due to the general psychic
iverstrain, increased perhaps by having the body
jrotectcd with impervious wraps. This affection
■omes on gradually, maybe not till after several years.
Jne is perhaps unaware of any illness until he gives
nit, loses power and control over his nerves, and
suffers a final breakdown. Sports too liberally
ndulged in are just as prostrating as overwork or
worry.
Sexual impotence has been observed by Notthafft of
Berlin in several cases of wealthy married men fond of
automobile speeding, and in one case of a chauffeur.
Notthafft slates that others among his colleagues have
noted the same phenomenon. The sexual depression
1 \ eloped in from three months to three years after
lal devotion to the sport. It seems due to a
erebral neurasthenia induced by the nervous strain
of speeding, for the normal tone is recovered when the
patients drive their cars at a low speed, such as does
not require the mental concentration and the anxiety
which would tend to neurasthenia.
Obstetrical and Gynecological Conditions are
what affected by the automobile. Edgar 1 is
inclined to believe that the unfavorable influ-
ence of the motor on pregnancy has been somewhat
'•xaggerated, and that the motor is in many instances
unfairly set down as causative of miscarriage. The
middle third of pregnancy is more liable to be thus
affected than any other. Certain women appear to be
cially susceptible to the abortifacient influence of
the motor and certain conditions within the pelvis
appear to favor this tendency. One type is especially
prone to the unfavorable influence of the vibration and
the circulatory changes induced by excessive motor-
ing; this is found in women with relaxed uterine sup-
ports, not only multigravidae, but also primigra
in whom even in the middle third of pregnancy tl
is a tendency to procidentia ulirn. even after the
Uterus rises well out of 111'' pelvis, the presenting part
hangs low. Thi i are cases in which, in prim
ami occasionally in multigravids, the lira. I . i
the pelvis and di a ad •.'.ell down toward tin- pel ic
lloor before the fortieth week. I CI ivi
in these cases is liable to interrupt pregnancy. With
limitations regarding speed and fill igue, Fdgar permits
even patients who have suffered from abortion to use
the auto bile subsequently. In threatened mis-
carriage, presumably caused by excessive motoring,
Edgar finds low implantation of the placenta an im-
portant factor. On the whole he considers the effect
of automobiling either a negative or a wholesome one.
E. P. Davis,- speaking of Motor Car .Miscarriages says
he has observed that a great shock or injury may bo
better borne by pregnant women than frequently re-
peated shock, such as that transmitted by the sewing
machine to the foot. Cases cited by him illustrate that
motoring during the early months of pregnancy is fre-
quently followed by abortion. The danger seems to bo
that the rapid motion of the automobile subjects the
patient to small and frequent jars. Abortion follow-
ing motoring is slow and insidious, without bright
hemorrhage and pain. These abortions are likely to
be incomplete and to require curetting. Motoring is
dangerous in the early months of pregnancy, but in
the later months, and with reasonable precautions as
to smoothness of roads and moderation of speed, it
may prove very salutary.
Eye Troubles. — C. Clements, 3 points out that
the chauffeur must be an accurate judge of pace and
distance, and this necessitates perfect and binocular
sight and quite unusual acuteness of vision. In a
series of cases of motorists who consulted him regard-
ing their eyesight after having undergone a number of
minor mishaps, most of these latter might, have been
much more serious but for sheer luck. In all these
cases there were errors of refraction — mostly hyper-
metropia; in all, too, the danger of accidents that
might arise from visual abnormality disappeared
with correction of the error of refraction. In most
of these cases the accidents occurred about dusk and
at turns of the road, the motorist miscalculating the
distance and running into a ditch or bank. Both eye
and nerve strain will emphasize an error of vision or
a deficiency of muscular tone. Clements has observed
that the convex goggles worn by autoists are practi-
cally hyperopic lenses; and that they may just turn
the balance in favor of spasm of accommodation.
We have long subjected locomotive engineers to
certain visual test; this should certainly also obtain
for motorists.
"Auto-eye" is a spasmodic affection of the ciliary
muscles; speeding over an unknown country, at a
rate approaching a mile a minute, is a greater strain
than the normal human eye has thus far had to bear.
The "auto-eye" will not be a long time in developing
if the organ is not fit to begin with, and if the strain
of business life, strong cigars, and other excesses have
diminished capacity for meeting the unnatural
demands upon the sight.
Conjunctivitis is due to wind and dust coupled with
high speed; it has various forms from a simple hyper-
emia to a contagious purulent exudation. The treat-
ment is that ordinarily given for this inflammation.
Muscular Strains. — Wryneck is frequent among
women motorists; the head becomes twisted by
reason of the tense strain, the result being manifest
when the run is over. The return to the natural
position causes severe pain from the strained tendons
and ligaments. Women have been made hysterical
by this affection; there is no occasion for alarm, for
the return to the normal is quickly achieved by
massage.
791
Automobile
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
"Auto-leg," that is, stiffness, lameness, and pain in
walking, is due to sitting in a fixed position for hours,
while the nerves and muscles are under strain. It
is a form of cramp and passes off within a reasonable
time unless the patient has passed middle life, when
it may be obdurate. Even the latter cases, however,
yield to massage and to a lotion, except when there is
a tendency to sciatica. Sciatica, indeed, is brought
on by the strain of a long series of rides in which the
nerves and muscles undergo consecutive shocks
through bumping and jolting— strain of which the
patient may hardly be conscious at the time, but
which may manifest itself perhaps a day afterward.
Only time, _ nutrition, and temporary avoidance of
the cause will bring such patients back to the normal.
Respiratory Disorders. — For most people unac-
customed to motoring a speed beyond twenty miles
an hour makes respiration difficult by reason of the
pressure of the wind. All grades of exhaustion may
result from this; and possibly the heart may be
dilated. _ D. Bryson Delavan, 1 makes some valuable
observations: Whilst in theory pulmonary diseases
should be much increased by motoring, such is practi-
cally not the case. Nevertheless acute catarrhal
states of the ears and the air passages, and advanced
tuberculosis with elevated temperature should cer-
tainly contraindicate motoring. In suitable cases the
automobile is a valuable agent; but Delavan insists
upon good roads, well-paved, dust-free streets, and
the enforcement of laws against smoke and fumes —
laws such as have been made and are enforced in most
European cities.
The occupation of tester of automobiles is a natural
concomitant of this industry. Such an one passes a
number of hours daily in the automobile, and is
subject to the ill effects of the exhaust pipes while
thus engaged. Nasal deflections and like abnormal-
ities which in other occupations may pass unnoticed
develop in this class of men pathological conditions
requiring treatment. The use of the motor predis-
poses to the extension of acute conditions that are
present; and these individuals suffer especially from
extensive complications when they use the open
machine. Cases of facial paralysis develop, with
the motor car as the especial causative factor, and
attending ear and throat complications. When
these testers take high speed they are apt to keep
their mouths upon; with speeding they develop the
"automobile face," and so are prone to extra danger
of infection.
_ Mouth breathing is here as vicious as in any other
circumstances; the air, unwarmed as it would be in
nasal passage, enters the bronchi and is bound to
result in congestion or catarrh. Extensive pneu-
mococcus infections are said to have resulted in this
way. And motorists certainly "take cold" by
exposure and by dust irritation.
Before the wind-shield came into use the motor car
was responsible for many cases of sinus disease —
especially of the frontal sinus, induced by the air
pressure and strong currents of cold air against the
face.
Tetanus. — An odd iniquity attributed to the
automobile is that in England at least tetanus has
increased despite the use of tetanus antitoxin and of
increasing knowledge of the mode of invasion of the
disease. Between 1SS9 and 1900 the average number
of deaths from this cause in England and Wales was
between thirty and forty. In 1900 there were sixty-
six; in 1902 there were 201; from 1903 to 190S 257,
257, 248, 254, 226 and 180 such deaths respectively.
The British Medical Journal has suggested that the
motor car is the cause of this increase. One would
think the contrary, because the concomitant reduc-
tion of the number of horses in the streets and roads
would diminish the amount of animal excreta lying
in them. But simultaneously the distribution of the
792
remaining excreta has been greatly increased by the
dust-raising powers of the motor cars, so that the
germs harbored therein have been scattered far and
wide.
Most human beings are at present not fitted for
high-speeding; those who thus indulge themselves
must generally pay somehow for the undue and lone-
protracted stress and strain. All motorists should
from time to time consult their physicians regarding
any possible conditions which may develop, and which
they would themselves be unable to detect.
Chauffeur's fracture is practically a Colics'
fracture produced from a "back fire" of the motor
which suddenly throws the crank handle back in the
opposite direction from which it is being turned.
The cause is a premature explosion in the cylinder'
from the spark lever being too far advanced, or by
reason of a short circuit in the electric wiring, or of a
slipping of the commutator. The fracture always
comes upon the handle being pushed down, the
resulting back-kick producing a blow on the palm
exactly the same as falling on the ground and striking
the palm. The shock is transferred to the radius
which fractures at its weakest point — the epiphyseal
line. However, the line of fracture does not follow
this epiphyseal line entirely through the radius from
side to side, but separates the triangular piece on the
outer thumb side. This is by reason that the epiphy-
seal line takes this direction; and most of the force of
the blow is on this side, due to the way the handle is
grasped with the thumb around it, the pressure being
exerted at this point. There is little or no displace-
ment of the fragment, reduction is unnecessary, and
the permanent results are usually good.
The injury is not always of the type thus described;
the line of the fracture, the number of fragments, the
amount of impaction, the backward displacement, the
involvement of the styloid process of the ulna, the
swelling, tenderness, and pain may be just as varied as
in the Colles' fracture produced in the usual way.
If the patient is aged eighteen or younger, a com-
parative radiograph of the normal wrist should lie
made, as union of the epiphysis will not take place
until that age.
A crank handle has been patented 5 to prevent
this accident; there is in this handle a crank lever
which is composed of two parts held together by a
spring clutch. This will withstand any steady pull;
but a sudden shock will break the handle in two,
fracturing the handle rather than the wrist. Many
cars are now being equipped with "self-starter.-."
so eventually the "chauffeur's fracture" will be of
historical interest only.
The radiograph has been most valuable in the
diagnosis and treatment of these fractures. There
should be two views: anteroposterior, with the palm
on the plate; and lateral, with the thumb up, the tube
centred directly over the radius. The lateral view is
very important, as it will show what deformity may
be present; the anteroposterior view may disclose no
deformity, though there may be great displacement.
If any deformity is shown by the radiographs the
fracture should be reduced, placed in an antero-
posterior splint in the usual way and then radio-
graphed in the lateral position only, to see if the
position is good. The typical chauffeur's fracture
can be taken out of splint within a week, massage and
passive motion begun, and recovery completed within
three weeks. Severer types will take longer.
John B. Hubkr.
References.
1. Edgar, James Clifton: American Journal of Obstetrics and
Disease of Women and Children, June, 1911.
2. Davis, E. I'.: .Medical Record, January 30, 1909.
3. Clements, f'.: British Medical Journal, December .8. 1906.
4. Delavan, D. Bryson: Medical Record, August 20, 1910.
5. Scientific American, January 6, 1912.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Autopsy
Autopsy. — Synonyms: Postmortem examination;
ropsy; Latin, Autapsia rmlan rica, sectio, obductio;
Frencn, nicropsie, autopsie cadaveriuqe; German,
•henschau, Sektion, Obduktion. An examination
>f the body after death, to investigate the condition
of the various part- of tin' body, to note any changes
in the organs, and to determine as far as
possible tin' cause of any such changes.
[The modifications of the technique of an
autopsy, advisable in cases in which medi-
colegal considerations may be involved, are
i in the article, following this, entitle, 1
Autopsy, medicolegal relations of tin .]
General Coxsideratioxs. — An article
intended, as this is, to aid
the general practitioner in
making a postmortem ex-
amination would fall short
of the mark were it to give
simply the various cuts to
be made in order to expose
and permit of the examina-
tion of the different organs.
While it would be out of the
question, in a handbook, to
detail all the possible alter-
ations in the viscera, and
the method of their recog-
nition, yet there are several
points, apart from the ques-
tion of the cuts to be made,
which deserve attention.
The sooner after death
an autopsy is made, the
better, as putrefactive
Fia. 530. changes modify the appear- Fig. 531.
ances of pathological as
well as of normal organs.
In case an autopsy is to be held, the undertaker
should be requested to postpone the injection of any
embalming fluid until the examination has been
made, as the preservative fluids modify considerably
the appearances, owing to the coagulation of albumen
and the alteration of color produced thereby. If for
any reason the autopsy is to be
made late, it is desirable, where
this is possible, to have the body
kept on ice.
What shall the physi-
cian take to the house,
and what ma} - he rely on
finding there? He should
take instruments, twine,
a sponge, and a rubber
sheet a yard square. The
fewer instruments he can
get along with the better;
there is less to carry;
fewer to soil, and less
liability of leaving any
behind.
One needs a stout
knife from seven to nine
inches in length, of which
half belongs to the
handle, half to the blade.
The blade should be from
three-quarters of an inch
Fig. 532. to an inch and a quarter
in width, varying accord-
ing to the length (Fig. 530).
Also a sharp-pointed scalpel and a medium-sized
pair of scissors. A pair of small, probe-pointed scis-
sors, as represented in Fig. 531, is very useful, though
not absolutely necessary.
One needs also a pair of forceps (Fig. 532) and a
large needle (a sail needle that can be bought at
Fig. 533.
a hardware store for a few cents will answer the
purpose).
Two other instruments, not absolutely essential,
though very convenient, are
the costotome (Fig. 533), a
StOUt pair of shears for cutting
the ribs when calcified, and
the enterotome 1 1 ig. .":: i . a
pair of long-handled scissors
having one blade terminating
in a rounded, hooked end,
used in opening the intesl
This outfit \\ill serve for any
autopsy in which the brain and
cord are not to be removed.
To open the head, a saw
(Fig. 5Sr,). a chisel I ig. 536),
and a hammer having the
handle terminating in a hook
(Fig. 537) are necessary.
To remove the spinal cord,
a chisel known as a rachitome
(Fig. 538) is very useful,
though the ordinary straight
chisel will answer the purpose.
One of the first requisite- in
an autopsy made in a private
house is cleanliness, and in no
way is this so much aided as
by having a good sponge; a
medium-sized, soft, lamb' —
wool sponge is the best. The
physician should never rely on Fig. 534.
finding this article at the
house, but should take one with him. After the
autopsy it can be washed with soap and water, and
i- 1 lien ready for use at the next autopsy. The better
the quality of the sponge the longer it will last and
the better work it will do.
nAt the house there can be obtained the
following articles: half a dozen newspapers,
several pieces of old cotton cloth, a slop
pail, and, if there be no running water, a
J pitcher of water.
The physician cannot be too
; t careful to avoid wounding the
| If feelings of the family in the house
where the autopsy is made. A
room left in a state of confusion,
or the soiling of carpet, chairs, or
utensils with drops of blood, not
only gives offence to the friends,
but often prevents the careless
physician getting permission for
autopsies in the future, as the
family are very likely to give
their neighbors an account of Dr.
A.'s slovenliness.
In making an autopsy in a pri-
vate house, it is often necessary
to alter the position of table,
chairs, or the like. Before any
change is made, it should be the
duty of the physician to take
mental note of the arrangement
of articles in the room, in order p IG ggg
that, when the autopsy is finished,
everything may be restored to its former
place.
All articles required in making the ex-
amination should be obtained before the
autopsy is begun.
The body will be found either upon a
Fig. 535. bed, with or without a board under it, or
upon an undertaker's frame set on horse-,
or in an ice box. In any of these positions the ex-
amination can be made without moving the body,
unless the head is to be opened, which cannot be
793
Autopsy
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Fig. 537.
done with the body in an ice box except the head be
raised and supported above the level of the box.
The clothing covering the trunk should be torn
down the middle line, in front, and drawn to either
side. Newspapers should then be tucked in at the
sides of the body, beneath the head and over the
pubes, so as to cover the clothing, but to leave exposed
the whole anterior surface of the
trunk from the chin to the pubes.
Should any fluid be spilled later, it
will fall upon the paper and not soil
the clothing.
The rubber sheet should be spread
out on the floor near where the
operator stands; the slop pail is to
be placed upon it; the sponge
should be moistened and be laid
near the hand, ready for instant
use; the instruments are to be
placed upon a newspaper spread
out upon the thighs of the corpse.
All appliances are to be made ready
before any cutting is done. Once a
beginning is made, the performer's
hands become so bloody that noth-
ing can be touched later without
soiling.
The physician should examine
his hands carefully with reference
to the presence of cuts or abrasions
of any sort. If there be any, they
should be covered with contractile
collodion. Do not use flexible
collodion; it is likely to peel off
during the autopsy. [The use of
rubber gloves is preferable.] While
performing the autopsy the operator
should be careful to avoid scratch-
ing, cutting, or pricking his hands.
If there is a suspicion in his mind of a wound received,
it is best to wash and examine the .place at once.
The man who performs an autopsy may well apply to
himself Spenser's line, " Of hurt unwist most daunger
doth redound." Any wound should be thoroughly
washed, squeezed, sucked, disinfected, and covered
with collodion. The writer's experience leads him to
believe that specialists in pathological anatomy,
having their hands, as they do, almost daily in contact
with dead bodies, are far less liable to infection from
scratches or cuts than are those who only occasionally
make an autopsy. Hence the greater importance
of care in this respect on the part of the general
practitioner.
Every autopsy should be thorough, and should
be made according to some definite method. The
physician ought always to bear in mind the fact that
an autopsy once made is made for all time. There
is no going back, as there is to the bedside, for further
examination in regard to obscure points. Whatever
is to be observed must be observed before the physi-
cian leaves the house. Further, when organs or
parts are separated in the dissection their relations
are lost. Hence the importance of noting certain
points before organs have been removed or their
relation to other parts lost. A proper order in the
various steps in an autopsy is of the first consequence.
That method is obviously the best by means of
which the most will be discovered and the least over-
looked. Nothing but practical experience can deter-
mine such a method, and the one given here is that
which has been found by repeated trials to give the
best results. It is essentially the method taught by
Virchow and his pupils.
Method of Making a Postmortem Examination.
— An autopsy consists of two parts — the external
examination or inspection, and the internal examina-
tion. In a medicolegal autopsy the inspection is of
794
the first importance. In the ordinary autopsy
inspection should consist in noting the size, develop-
ment, and nutrition of the body. Under the head of
nutrition the amount of subcutaneous adipose tissue
and the size of the muscles should be observed, the
former by pinching up a fold of the skin. The pres-
ence or absence of rigor mortis, the degree of lividity
of the dependent portions, should be noted. Among
the common abnormalities are variations in the color
of the skin, edema of subcutaneous connective tissue,
localized or diffuse, and localized lesions of many
kinds. A greenish discoloration of the abdomen, if
present, should always be noted, as it indicates that
putrefactive changes have begun, and this fact
modify the interpretation of appearances observed in
the internal organs.
Internal Examination. — In the majority of autopsies
performed by the general practitioner the examination
is limited to the thorax and abdomen. In case the
head is to be opened it should be done before the
thorax, otherwise much of the blood in the veins
will have escaped through the divided superior cava,
and a correct determination of the amount of blood
originally in the brain cannot be made. The spinal
cord is best removed after the brain, but before the
thoracic and abdominal cavities are opened, espe-
cially in a private house, because of the soiling which
is sure to take place from escape of blood from the
latter cavities, if they have been first examined,
when the body is turned on its face.
The best order of procedure, then, is brain, spinal
cord, thoracic and abdominal organs. Inasmuch as
only the thorax and abdomen are examined in the
majority of cases, the method of doing these will be
given first, then the method of examination of the
brain, and finally that of the spinal cord.
The character of the incisions in an autopsy is the
opposite of that of the incision in an ordinary dissec-
tion. In a dissection one uses the point of a scalpel
held like a pen, the fingers and wrist alone being
moved. The point of the knife describes the arc of a
circle, thus making a series of irregular
nicks. Although such cuts are well
adapted to the isolation of parts in an
anatomical dissection, yet tliey are the
worst possible for removing organs and
displaying the interiors, requiring much
time and leaving an irregular, hacked
surface. The cuts to be made in an
autopsy are long, sweeping ones, using
the whole cutting edge of a large knife
held firmly in the fist in a line with the
forearm; the wrist should be kept im
movable, the elbow and shoulder joints
alone being moved. In this way one
may rapidly make large incisions having
smooth surfaces and a straight bottom.
One other point is wwthy of mention.
All parts should be put upon the stretch
when they are incised; but put them
upon the stretch first, then cut. Never
try to seize and cut at the same time, as
one is in this way liable to cut one's self.
To examine the thorax and abdomen,
take the large knife already described
(Fig. 530, grasp it firmly in the fist,
make an incision in the middle line
anteriorly, beginning at the sternal
notch and ending at the pubes. The
knife should be held parallel to the Fig. 538.
body, so that its whole cutting edge is
brought into use. Over the sternum the incision
should be carried to the bone; over the abdomen, to
a depth varying with t lie thickness of the abdominal
wall, going nearly but not quite through it.
It is best to carry the long primary incision to the
left of the umbilicus, so as to avoid the round liga-
ment. Next, by means of- several short cuts carry
REFERENCE IIAXDHOOK OF THE MEDICAL SCIENCES
Autopsy
the incision through tin; abdominal wall at the tip nf
the sternum, making it long enough to admit two
fingers. Insert the fore and middle lingers of the
left hand into this incision, and make strong upward
and outward traction on the right half of the
abdominal flap. This serves the double purpose of
drawing away the flap from the intestines, thereby
lessening the risk of cutting them, and it puts the
abdominal wall upon the stretch, permitting of its
easier incision. Now complete the cut through the
abdominal wall to the pubes.
\e\t divide the pyramidales muscles at their
attachment to the pubes; this allows of a greater
ral withdrawal of the flaps, and gives better
opportunity for the examination and removal of the
abdominal organs. In some countries it is customary
to make transverse counter incisions in the abdominal
wall from the umbilicus outward. This is a bad
practice. It is unnecessary so far as room is con-
cerned, and there is the disadvantage of increased
mutilation, more sewing, and greater liability of
leakage.
While the long primary incision is being made the
operator should have the sponge ready to absorb any
fluid that may escape. If there be much fluid in the
abdominal cavity, it should be removed at this stage.
The next step in the autopsy is to determine the
position of the arch of the diaphragm. To do this,
insert the right hand, palm upward, beneath the ribs;
pass it along the inner surface of the ribs until the
highest point of the diaphragm is reached, remember-
ing to go, on the right side, to the outside of the
falciform ligament of the liver. Put the forefinger of
the left hand upon the external surface of the thorax
corresponding to the position of the fingers inside.
Withdraw the right hand and, beginning at the
clavicle, count downward ribs and interspaces until
the finger of the left hand, previously placed on the
outside, is reached. This gives the position of the
arch. Its usual position is the fourth rib on the
right, and the fourth interspace or fifth rib on the
left. It is lowered when the lung is solidified, and
when there is fluid or gas in the pleural cavity. The
fluid or gas may be so abundant as to bulge the
diaphragm downward. (To determine presence of
gas in pleural cavity, see later.)
The next step is the removal of skin and muscle
from the anterior surface of the thorax, so as to lay
bare the sternum, cartilages, and bony ribs for a
distance of two to three inches outside the articular
line.
The abdominal flap is seized in its upper part by the
left hand, and turned forcibly outward; by doing this
the rectus abdominis at its point of origin, the lower
margin of the ribs, and the attachment of the dia-
phragm are exposed. The heel of the blade of the large
knife is now placed upon the origin of the rectus, and
by means of a single sweeping stroke, carried just
above the lower border of the ribs, the rectus and the
diaphragmatic attachments are severed. Then seize
the flap a little higher up, turn it forcibly outward so as
to put the muscles on the stretch, and divide the parts
which have been made tense. Continue the cuts
in like manner until the ribs on the right side are ex-
posed, removing all the muscle with the flap so as to
leave the ribs clean. Repeat the process on the left
side. Then expose the sternoclavicular articulation
by dividing subcutaneously the tissues that cover it.
Before removing the sternum a general inspection
of the abdominal cavity should be made, to note
whether there be an increase in the amount of the
serous fluid normally present, or abnormal contents.
The reason for making the cursory examination at
this stage of the autopsy is that if there be fluid in
either of the pleural cavities, some of it will be likely
to escape into the peritoneal cavity on removal of the
sternum; hence it would be impossible to determine
later whether fluid found in the abdominal cavity
was there originall\ or had come from the pleural
r:i\ ity.
If pneumothorax is suspi cted, the pre ence of gas
in the pleural cavity should be determined at this
stage of the autopsy. It is best done by making a
double fold of the skin flap over the anterior portion
Of the I liorax On the suspected side. Water is poured
into the space between the folds, making a little pool.
The sharp-pointed scalpel is now driven through the
muscle of an intercostal space, where the water lies,
and the effect noticed. If there be gas in the pleural
cavity, it will escape by bubbling through the liquid;
otherwise the water will disappear through the
opening. One must not mistake the collection of
gas from putrefactive changes in the pleural cavity
for gas winch has collected during life. If present
from putrefaction, it will be double-sided, and then-
will be other evidence of putrefactive changes in the
tissues.
The sternum is now to be removed. This is done
by opening the sternoclavicular articulation, and
dividing the cartilages of the ribs about one-eighth of
an inch from their junction with the bony ribs. The
knife to be used is the small pointed scalpel already
described. The guide to the position of the sterno-
clavicular articulation is the tendon of the sternal
attachment of the sternocleidomastoid muscle. In-
sert the knife above the clavicle about one inch
outside this tendon; then by an up-and-down
motion divide the soft parts till the tendon is reached;
turn the knife so as to enter the joint; then follow
the joint in a semicircle, with the same up-and-down
motion of the knife, not trying to guide it, so far as its
vertical direction is concerned, for the plane of the
joint is a constantly varying one; hence the import-
ance of holding the knife loosely in the fingers and
letting it take its own course. Do not remove the
knife after the joint has been opened, but continue
the incision outward along the under border of the
clavicle for an inch outside the joint, then turn the
knife at right angles to its former position and cut
the first rib. In opening the sternoclavicular joint,
care should be taken not to carry the point of the
knife below the inner part of the joint, as the in-
nominate veins lie beneath and are liable to be cut.
The costal cartilages are to be cut in the place indi-
cated above by a quick, forcible stroke with the scalpel,
the heel of the knife striking upon the next rib below
as the blade incises the rib. In this way the blade is
prevented from going too deeply, and thereby in-
juring the lung. All the cartilages having been
divided, the sternum is to be depressed below the
level of the bony ribs and the intercostal muscles cut,
the knife being held parallel to the ribs to avoid
cutting the lung. Remove the sternum by lifting its
lower end up, cutting the attachments of the dia-
phragm to it, and also the tissues of the anterior
mediastinum, keeping as close as possible to the
posterior surface of the sternum so as to avoid opening
the pericardium. When the under surface of the
sternoclavicular joint is reached some difficulty will
be experienced in removing the sternum, owing to the
resistance offered by the firm ligaments of the joint,
but by prying the sternum outward these ligaments
are put upon the stretch, and can then be readily cut
with the point of the knife.
The sternum having been removed, a general view
of the anterior mediastinum should be taken, espe-
cially with reference to the presence of serous fluid or
pus in its meshes.
The Heart. — Although the heart is the first organ of
the thorax to be examined, yet the pericardium should
not be opened until a cursory view of the pleural cavi-
ties has been taken with reference to the presence of
fluid; for here, as in the peritoneal cavity, fluid present
may have come from the pericardium, if that be first
opened.
Open the pericardium by seizing the anterior por-
795
Autopsy
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
tion of the parietal layer with the forceps and,
lifting it up (if there be adhesion of the pericardial
surfaces, as a result of earlier inflammatory processes,
it will be made apparent by the inability to raise the
anterior portion of pericardium), nick it with the
scissors; cut upward as far as the reflection of the peri-
cardium upon the aorta; then cut downward to the
right and also toward the apex. The incision will
have the form of an inverted Y. Lift up the heart
and note the contents of the pericardium and their
character (serum, fibrin, pus, blood). Also note the
appearance of both pericardial surfaces. Examine
the heart with reference to its size, shape, and the con-
traction of its walls. Then open the four cavities of the
heart in situ, to determine the character and amount
of their contents. The method is as follows: Let the
heart rest upon the palm of the left hand, with the
thumb upon the upper surface; turn the heart_ to-
ward the left; this will make prominent^ the right
auricle, and will bring into view the superior and in-
ferior cava? where they join the auricle. Make an
incision into the auricle at right angles to the cava?.
Next turn the heart back to its former position;
lift the thumb from the anterior surface and incise the
right ventricle by a cut parallel and close to its right
border, remembering not to carry the cut to the apex,
as this is formed by the left ventricle only. Open the
left ventricle by an incision along the left border a
little to the right of and parallel to the coronary
vessels. To open the left auricle, put the fore-
finger in the cut in the left ventricle and the thumb into
the cut in the right ventricle, then lift up the heart and
carry it toward the right of the body; in this way the
left auricle, with the two left pulmonary veins enter-
ing it, will be seen. Open the auricle by a crescentic
cut, beginning in the upper vein, thence into the
auricle, and outward into the lower vein. Introduce
one or more fingers into the incisions and note the
amount of the contents and their character. The
left ventricle is contracted and empty, unless the in-
dividual has died from paralysis of this part of the
heart, when it will be found distended with blood.
The right ventricle and both auricles are usually
distended with blood, which may be fluid, as in death
from suffocation, or more or less coagulated. In
every case of sudden death it is desirable to open the
pulmonary artery in situ, in order to determine the
presence or absence of emboli.
Now remove the heart from the body by lifting it
vertically upward, cutting across in succession the
inferior cava, superior cava, pulmonary veins, aorta,
and pulmonary artery.
After removal of the heart from the body it is to be
further examined with reference to its valves, cavities,
muscular substance, and blood-vessels. Remove all
clots from the pulmonary artery and aorta, hold the
heart vertically by seizing in turn the walls of each of
these vessels, and allow water to run into them from
above. Note whether each of these vessels "holds"
the water, or whether it escapes — if the former, the
valves are sufficient; if not, they are insufficient, and
an idea of the degree of insufficiency may be obtained
by noting the rapidity with which the water escapes.
The ventricles are now to be further opened — the
right by a cut beginning at the lower end of the
incision already made and carried upward to and
through the pulmonary artery; the left by continuing
the incision already made directly upward into the
aorta, between the left auricular appendage on the
right and the pulmonary artery on the left.
( Opportunity is now afforded for an examination of
the cusps of the aortic and pulmonic valves. Having
completed this, insert as many fingers as possible into
the mitral and tricuspid orifices. Normally the
mitral admits three, the tricuspid four. Nexl
examine the segments of these valves and their
chorda? tendineae.
Note the size and shape of the cavities of the
ventricles. Continue the incisions already made in
the auricles into the auricular appendages as far as
the tips, noting the size of the auricles and whether
thrombi are present in the appendages. Next
examine the muscular wall of the heart and the
papillary muscles with reference to thickness, color,
and consistency. Follow out the coronary arteries
as far as possible, with the probe-pointed scissors,
with reference to narrowing of lumen from end-
arteritis or to presence of emboli or thrombi. This
completes the examination of the heart.
The lungs and pleurce next deserve attention.
In the previous cursory examination of the pleural
cavities with reference to the presence of fluid, the
presence or absence of adhesions of the pleural sur-
faces, over a larger or smaller area, will also probably
have been noticed. If there be any adhesions they
should now be torn. If the two surfaces are so
adherent that they cannot be separated except at
the risk of injuring the lung, the costal pleura should
be removed with the parietal pleura and lung, by fir;-!;
cutting the pleura along the under surface of the
ribs near the anterior border, then inserting the
finger nails, and then the fingers, and tearing it away
from the costal wall.
The left lung is now removed by lifting it out of the
pleural cavity and supporting it with the left hand in
such a way that the primary bronchus comes in the
fork between the middle and ring fingers. The
bronchus should now be cut across, and the small
amount of connective tissue of the posterior medias-
tinum which supports the lung behind should be
divided with the knife, keeping close to the lung to
avoid injuring the esophagus, which lies beneath.
Remove the right lung in the same way. Note the
volume of the lungs, the density, whether crepitant
or whether in part or wholly solidified. Also note
whether or not there are false membranes upon the
pleura. The incision into the lung is to be made
by resting the organ on its base, then making a
sweeping cut from apex to base in the direction of
the bronchus, beginning on the convex surface and
carrying it sufficiently deep to open the bronchus.
This gives two large surfaces for examination. The
bronchi are now to be opened with the scissors, to the
smallest tubes in which the blade of the scissors will
go. If there be any evidence of embolism in the
lung the branches of the pulmonary artery should
also be followed out.
Next examine the bronchial lymph glands.
This completes the examination of the thoracic
cavity for the present, and attention should be turned
to the abdominal cavity. The method to be given
for its examination is the one to be followed out in
case there is no evidence of there having been an acute
peritonitis. The variation in the method in this
circumstance will be described later.
The spleen, is to be removed first. It should be
seized in the left hand and drawn outward and
upward from its position, then lifted upward above
the lower margin of the ribs. In this way the gastro-
splenic omentum is put upon the stretch and can be
readily divided, together with the splenic vessels at
the hilus. The organ is now free. Its size, shape,
color, and density, together with the appearance of
the capsule, should be noted. An incision is then to
be made into it parallel to its flat surface. The
follicles, trabecular, and pulp are the individual parts
in the cut surface that demand attention.
The intestines are now to be removed. Lift up the
omentum, examine it, then cut away its attachments
to the transverse colon. Next separate the trans-
verse colon from the stomach by dividing the two
folds of lesser omentum which unite them. Then
draw the small intestines over to the right; by so
doing the descending colon will be exposed. It
should be seized, lifted upward, and its mesocolon
divided close to the intestine. The sigmoid flexure
796
REFERENCE HANDBOOK OF THE MEDICAL SCH \< I -
Autopsy
|g to be freed next, and the rectum cul across a little
below the brim of the pelvis. The folds of small
tin.- are now carried over to the left half of the
abdominal cavity so as to uncover the ascending colon.
The dissection to remove this should be begun at the
hepatic flexure, freeing it from the surrounding parts,
using special care nut to injure the duodenum, which
in contact with the ascending colon in its upper
terior portion. Continue the di ection until the
cecum is reached, which can he removed with the
vermiform appendix by first cutting the peritoneum
that binds it down laterally, and later the loose
connective tissue that holds it down posteriorly.
The large intestine is now free.
The small intestine is to be freed from its mesentery
by cutting the latter close to its attachment to the
-tine. This is best accomplished by making
traction on the intestine, thereby rendering the
ritery tense, which can then be readily and
rapidly divided by a -cries of fiddle-bow-motion cuts
made 'with the large knife. The separation of the
intestine from the mesentery should be continued
until the point is reached where the jejunum passes
behind the peritoneum.
At tin- stage in the autopsy the duodenum is to be
Opened in situ by an incision made with the scissors
along the outer convex border. This is done that the
. ommon bile duct and its orifice may be examined —
a point of the first importance, in cases of jaundice,
for determining the cause. The orifice of the dint
forms a papilla situated on the pancreatic side of the
duodenum about the middle of the descending portion
and directly opposite the incision already made. The
bile duct, in the latter part of its course, lies beneath
the mucosa of the duodenum. This portion of the
duct should be pressed upon by the finger, and the
latter moved toward the orifice, which is to be watched
with reference to the expulsion from it of bile or a
plug of mucus. Pressure may now- be applied to the
gall bladder, and the appearance or non-appearance
of bile at the orifice be noted. If no bile flows, the
common duct should be opened with the fine, probe-
pointed scissors and the cause of the obstruction
sought. It may be a plug of mucus formed as the
result of an inflammatory process extending to the
duct in a case of gastroduodenal catarrh, or it may be
a biliary calculus.
The stomach, connected with the intestine, together
with the pancreas and mesentery, must now be
removed. To do this, the left lobe of the liver should
be lifted up; the diaphragm cut through its middle
as far down as the esophagus; the esophagus divided
transversely about two inches above the stomach;
the cut end compressed between the thumb and
forefinger of the left hand; the stomach lifted and
dissected away from the underlying tissues; the
pancreas and mesentery dissected from the aorta and
inferior cava, and the gastrohepatic and duodeno-
hepatic omenta divided. The whole gastrointestinal
tract, together with pancreas and mesentery, is now-
freed and can be removed from the body.
Although the examination of the intestines is
usually postponed until the last, to avoid soiling
others parts with its contents, yet the method will be
given here. The gastrointestinal tract should be
opened its entire length, either with an ordinary pair
of scissors or with an instrument which renders the
operation far easier, the enterotome (Fig. 534), the
hooked blade being introduced into the inside. The
stomach is to be opened along the greater curvature,
the reason being that the common lesions — ulcers —
are usually situated on the lesser curvature. The
small intestine should be opened along the mesenteric
attachment, for the reason that Peyer's patches, the
usual seat of typhoid and tuberculous processes, are
situated on the opposite side. The large intestine is
to be opened along one of the three teniae, or bands,
the object being to avoid getting the point of the
scissors caught in the pouches lying between the
bands.
.Much time can be saved by using the scissors, not in
the ordinary way by Opening and closing the blade-,
but by keeping the blades tmmo ; carrying
the scissors forward with the right band, at the same
time drawing the intestine backward with the left
hand.
The amount and character of the contents of the
various portions of the gastrointestinal tract should
be noted; the mucosa is to be freed of it- adhi
materia] either by water, when this can be obtained,
Or else by the linger-, and the mucosa of the entire
ti:ei is then to be carefully examined for evidi I
of inflammatory processes — ulcers, perforations, or
other lesions.
The stomach and intestines having been n moved
from the abdominal cavity, a view can I"- obtained
of the kidneys, ureters, and bladder in situ — a point
of value, as the illation of one to the others is often
needed in explaining the association of lesions. It is
the custom of the German pathological anatomists to
remove the kidneys before the intestine, hence at a
stage in the autopsy when it is impossible to get a
view of the urinary tract in its continuity. It seems
to the writer that nothing is gained by removing the
kidneys before the intestine, but that much ma\ be
lost; for if one finds, as the kidneys lie in situ, that
they present changes, it may be very advantageous
to remove them with the renal artery and aorta, on
the one hand, as in cases of atrophy, especially when
dependent upon a chronic interstitial nephritis, or,
on the other nand, with the ureters and bladder and
perhaps the penis, if there be hydronephrosis or
pyelonephritis.
Urinary Organs. — A general inspection of the urinary
tract having been made as the parts lie in situ, one
should then open the bladder by an incision from one to
two inches in length along its upper wall. The amount
and character of the contents, and especially the ap-
pearance of the mucous membrane, should be noted;
for if there be evidence of an inflammatory process it
will be desirable to remove the kidneys, ureters, and
bladder in a single mass, owing to the fact that in-
flammatory processes in the mucosa of the bladder may
extend upward through the ureters and involve the
pelves of the kidneys and the kidneys themselves.
If there be no evidence of a cystitis, no further ex-
amination of the bladder is now to be made, but atten-
tion is to be directed to the kidneys. Inasmuch as
these organs lie behind the peritoneum, it is necessary
to cut this in order to get at them. The incision
should be made just to the outside of the kidney
along its convex border. The fingers of the right
hand should now be introduced into the cut and the
kidney "shelled out'' of its perinephritic fat, lifted
upward, the blood-vessels at the hilus cut transversely
and traction made upon the kidney, which will strip
up the ureter as far as the brim of the pelvis, where it
may be divided. The suprarenal capsules may
either be removed with the kidney or may be left in
situ until a later stage of the examination. On the
right side it is less easy to remove the suprarenal
capsule with the kidney than on the left, owing to
its closer adhesion to the under surface of the liver.
The examination of the kidney consists in noting
its size, shape, color, and density; and in the removal
of the capsule, observing whether it comes off easily
or with difficulty, also whether portions of renal
substance adhere to it. An incision in the kidney is
made by holding the organ between the thumb and
fingers of the left hand, with the hilus resting upon the
palm, and cutting along the whole convex border
through the kidney to and into its pelvis. In the ex-
amination of the cut surface the ratio of cortex to pyra-
mids, as to thicknes>. should first be noted, and then
the cortex studied with reference to the appearance
presented by the glomeruli and the regions of convo-
797
Autopsy
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
luted and straight tubules. The degree of injection of
the vessels of the cortex and pyramids, as determined
by the color, is to be observed; then the mucous mem-
brane of the pelves is to be examined; finally, the
ureters are to be opened. If there be evidence of atro-
phy involving one or both kidneys, the corresponding
renal artery should be opened to the aorta to deter-
mine whether the lumen is narrowed from chronic
endarteritis.
The next step in the autopsy is the removal of the
pelvic organs, either with or without the external
genitals. In the female, the external genitals should
be removed with the internal genitals in cases of
death following puerperal fever or abortion; in the
male, when there is a suspicion of stricture or wound
of the urethra, or of a periurethral abscess.
In case it is not necessary to remove the external
genitals the method of procedure for removal of the
pelvic organs is as follows: Sweep the knife around the
true pelvis, keeping as close to the bony wall as pos-
sible; in this way the loose connective tissues will be
severed. Seize the bladder by its upper portion and
draw it backward, away from the pubes; cut its
attachments to the pubes, and then, while still
making strong backward traction, cut the vagina
and rectum transversely as far forward as possible.
In this way the vagina as far as the hymen may be
obtained. The same procedure, so far as the drawing
back of the bladder and cutting its attachments are
concerned, is to be carried out in the male, the pros-
tate and rectum being then divided transversely
as far forward as possible.
The removal of the external genitals connected with
the internal pelvic organs is accomplished in the
following way: The pelvic organs are freed from their
surroundings as already described; then incisions are
made on the outside, beginning at the lower end of
the primary incision, which had been carried to the
pubes, and carried to the outside of the labia majora
on both sides in the form of an ellipse, the two cuts
meeting again in the median line behind the anus at
the tip of the coccyx.
The vulva is now dissected away from the pubes
until the bony pubic arch is reached. The knife is
then to be inserted beneath the pubic arch with the
blade close to the bone, and then pushed into the
cavity of the pelvis so that its point can be seen.
With the knife held horizontal^, it is swept around
in the two curved incisions described above until the
coccyx is reached. This will free the attachments to
the pubic arch anteriorly and laterally, and to the
coccyx and lower part of the sacrum posteriorly.
The external genitals are now to be drawn under the
pubic arch into the cavity of the pelvis. This puts
the attachments to the sacrum on the stretch, and
gives a better view of the parts that still require
to be divided in order wholly to free the organs in
question.
In the male the penis may be removed with the
internal organs by drawing the dartos toward the
glans; cutting with the scissors the small amount of
connective tissue that holds the skin to the body of the
penis; then dividing the penis by a transverse cut just
behind the corona, unless it is thought desirable to
remove the glans also, in which case the dartos should
be cut circularly where it is reflected upon the glans,
i.e. in the corona. The attachments of the penis to
the pubic arch are divided by transfixion, as in the
female; the organ is drawn under the arch into the
cavity of the pelvis, and the adhesions to surrounding
parts divided.
If there be anything abnormal about the perineum,
it is desirable to remove with the penis and pelvic
organs an elliptical or lozenge-shaped portion of skin,
its anterior apex being just behind the scrotum,
having its posterior apex at the coccyx. This will
include perineum and anus. The removal is accom-
plished by transfixing with the knife held in a
798
horizontal position, the point being carried well into
the pelvic cavity.
The further examination of the male pelvic organs
consists in prolonging the incision, made in the
bladder while in situ, to the urethra through the
prostate with the scissors. If the penis has hern
removed, the incision should be continued along the
dorsum to the meatus. The interior of the bladder
and urethra can now be examined. Trans\
incisions are to be made in the prostate. The
vesiculae seminales and the prostatic and vesical
venous plexuses should next receive attention. The
plexuses are of importance, as likely to be the seat of
thrombi.
The rectum is now to be opened along its posterior
wall, and the mucous surface examined.
In the female the bladder and urethra are first to be
opened and examined. The vagina is then to be
exposed along its whole length by an incision along
its left lateral wall. In this way one avoids injuring
the bladder. When the cervix is reached, the incision
should be carried at right angles to its first direction,
and the anterior wall of the vagina be cut transversely
as far as the middle line of the uterus. The scissors
are then introduced through the os into the' cervical
canal, and the uterus opened by cutting in the middle
line anteriorly as far as the fundus. Counter incisions,
beginning at about the middle of the body, are now
to be made in the direction of the orifice of each
Fallopian tube.
If the tubes are enlarged they should be opened
with the probe-pointed scissors. In the normal tube
the canal is so small that it is almost impossible to
follow it out, and it is furthermore unnecessary.
The ovaries are to be opened by an incision begin-
ning on the free, convex border and continued to the
hilus, i.e. to the broad ligament. The vaginal and
uterine plexuses are then to be examined.
If death has occurred in the puerperal state or after
an abortion, the external genitals and vagina should
be examined carefully with reference to lacerations,
and numerous incisions be made in the vaginal wall,
extending into the perivaginal connective tissue, to
determine whether a purulent lymphangitis is pre
In the puerperal uterus the inner surface is to be
examined for evidence of an endometritis. The
uterine sinuses, the pampiniform plexuses, and the
ovarian veins ate to be examined for thrombi under-
going septic softening. The tubes are to be opened
to discover evidence of a purulent inflammation of
their mucosa (salpingitis purulenta). Numerous
incisions are to be made in the wall of the uterus for
evidence of suppurative lymphangitis.
The examination of the testicles can be readily
made, without injuring the scrotum, by pushing
them upward through the canal, so that they will
appear at the rings on either side. The peritoneum
and then the tunica vaginalis are to be divided, and
the testicle can be removed by severing the cord. It
should be opened by an incision parallel to its long
diameter, beginning on the side opposite the
epididymis.
The liver is removed by cutting the ligaments. In
noting the dimensions of this organ one should take
cognizance of the relations of the right to the left loin
as regards size. The shape, color, density, ami any
points relating to the capsule are to be observed.
The incision for examining the interior should he
made transversely, beginning at the left bonier and
ending at the right border. The appearances of the
single lobules are now to be studied; the relative
proportions of central and peripheral parts and the
color of each being the important points to be
observed.
The gall-bladder is to be opened by an incision
parallel to the long diameter.
The order in the examination of the organs of the
abdominal cavity is to be varied in case of acute
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Autopsy
eritonitis. In making an autopsy one should nol
1st satisfied in finding evidence of acute peritonitis,
,it should always search for the cause. Of the
mses, the most common arc extension of an inflam-
lation from the pelvic organs, this especially in the
■male; perforation of the vermiform appendix from
ppendicitis; and perforation of the gastrointestinal
aol at some part. In case of acute peritonitis, no
rgan should be removed until the probable source
as been made out. This is done by lifting and
■parating the folds of intestine, and observing in
hich part of the peritoneal cavity the inflammatory
rocess is farthest advanced. Then the parts may
e dissected away from this organ, whichever it
lay I"', and the al tempi made to find the perforation
i oilier lesion which is primary. The questionable
,ii may then be removed and further examined.
Po proceed with the method ordinarily carried out.
Liter the removal of the liver there remain in the
r.ity of the chest and abdomen the trachea and its
ifurcation, the greater part of the esophagus, the
orta, and the inferior cava. The aorta is to be
pened in situ, with the scissors, along the anterior
all from the arch to the bifurcation, and then the
iac arteries are to be opened to the groin. The
i'erior cava and the iliac veins are also to be opened.
hese vessels are opened in situ that no injury may
e done to thrombi if they be present wit Inn.
The aorta and as much of the trachea and esophagus
- possible are now to be removed by cutting the two
itter as high up in the neck as they can be reached,
nd dissecting them and the aorta from the vertebral
olumn, the aorta being attached to the vertebral
olumn by a small amount of connective tissue.
Tin- trachea is to be opened along its posterior wall
i he cartilaginous rings being interrupted at this part) ;
he esophagus along the anterior wall.
The larynx and tongue may be removed with the
lings, or simply with the trachea. The knife is
lassed upward under the skin of the neck and the
ttachments of the trachea and larynx to the anterior,
ateral, and posterior parts severed by sweeping cuts
tarting in the median line and carried to the side and
hen to the back. The attachments of the muscles
if the tongue to the lower jaw are divided, the knife
)eing carried up from below preferably to being
ntroduced through the mouth. The soft palate is
eparated from the hard palate, and the pillars of the
auces are cut laterally so as to include the tonsils.
The tongue is now seized with the fingers of the left
land passed upward through the neck and drawn
lownward, and the muscles and connective tissue
tolding the pharynx to the vertebral column are
iivided.
In this way the soft palate, tonsils, wall of pharynx,
arynx, and upper part of esophagus may be removed
ogether, and a good opportunity afforded for their
■xamination — a point of value in diphtheritic proc-
:sses and the like.
The larynx should always be opened anteriorly.
The cavity of the trunk is now empty and a good
ipport unity is afforded for the examination of the
todies of the vertebra?, if there be anything in the
iase which renders such an examination desirable.
Unless the brain or cord is to be removed, the
lamination is now completed. Before returning the
organs to the body cavity it should be sponged dry,
and the pelvis packed with pieces of old cotton cloth
to prevent leakage through the anus. After the
organs have been put back the sternum is to be
replaced and held by two stitches on either side,
taken through the intercostal muscles.
The flaps are next brought into apposition pre-
paratory to sewing them together. To do this take
a piece of stout twine one and a half times the length
of the incision; after threading it, take a stitch at the
extremity of the long incision and tie a hard knot in
the end of the string. For sewing, the glover's stitch
is to be used, i.e. from inside out. The Btitches
Bhould be about three-quarters of an inch apart and
three-eighths of an inch from the edge oi thi Bap,
taking up only the skin and subcutaneou ti ue,
but not the fat ii ue. When the seam Is finished a
double knot is made in the string and the end drawn
under the skin.
Certain final details will be considered after the
method of removal of the brain and cord oa bet □
explained.
Method of Removal and Examination of the Brain. —
Note the ratio of the head to the body, and of the
cranium to the face.
Make an incision in the scalp, beginning half an
inch behind the right ear, near its lower bonier, and
extending over the middle of the vertex to the cor-
responding point behind the left ear. In women the
hair should first be roughly parted, along the line
where the incision is to be made, with the handle of
the scalpel. After the incision li.-i been started by
cutting with the edge of the knife downward, it is
best to reverse the blade so that its back comes
against the bone and to cut upward. The incision is
to be carried to the bone except in the temporal
region, where it should be carried only to the apo-
neurosis covering the temporal muscle.
The anterior flap is first to be freed from the tem-
poral muscle on either side, leaving the muscle at-
tached to the bone, as it is through this that the
stitches will be taken later that are to hold the calva-
ria in place. The flap is now to be seized by the left
hand and strong forward traction made, while a
series of sweeping cuts through the pericranial con-
nective tissue are made with the scalpel held in the
right hand. This dissection should be continued
until the frontal eminences come into view. The
posterior flap of the scalp is now to be dissected from
the bone as far back as the occipital protuberance.
While the scalp is being removed the condition of the
loose pericranial tissues should be noticed with ref-
erence to evidence of edema, hemorrhage, or puru-
lent inflammation. The skull is now bare over the
vertex, and note should be made of any abnormalities
of its surface.
The next step is the removal of the calvaria. This
is sometimes done by sawing through the skull in a
circle; but this is bad practice, in that the calvaria
cannot be later held firmly in place when it is sewn up
— it will wobble. The best way is to saw along three
lines to be marked in the periosteum, as a guide, with
the scalpel. The first or anterior cut begins above
and behind the ear, and is carried directly over the
vertex to a corresponding point on the other side,
the line passing just behind the edge of the hair
above the forehead. The other two incisions in the
bone are to begin, one at each end of the cut just
described, and be carried backward to the median
line behind, the two lines meeting at an angle of
about one hundred and sixty degrees, well in front of
the occipital protuberance. Each of these two lines
just described should meet the anterior line at an
obtuse angle in the temporal region.
If the hair be long it should be wrapped up in a
towel, so as to form a ball, and the whole mass placed
beneath the nape of the neck. This is to prevent, the
sawdust getting into it.
The calvaria is now to be sawn along the lines
already marked, the head being steadied by placing
the left hand upon the calvaria; a towel placed be-
tween the hand and the bone prevents slipping.
The incision in the bone should be carried through
the outer table and diploe, and nearly through the in-
ner table. One can readily determine when the saw-
has reached the diploe by the red color of the sawdust
and the softer feel conveyed to the hand through the
saw blade. What remains unsawn can be readily
cracked with the chisel and hammer, placing the
chisel in the incision and striking with the hammer a
799
Autopsy
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
quick, sharp blow known as a recoil blow; this ob-
viates the danger of driving the chisel into the brain.
If there be a suspicion of fracture of the skull, the in-
cision with the saw should be carried through the
bone and no cracking whatever done with the chisel
and hammer.
The calvaria being now loosened, the wedge-
shaped end of the hammer head is to be introduced
in the middle of the anterior cut and pressed down-
ward with the left hand, while the handle is rotated
in the horizontal plane with the right hand. In this
way a powerful leverage is obtained, and the calvaria
can be forced backward sufficiently to introduce the
hook on the end of the hammer handle into the cut
in the bone. By pulling backward on the hammer
the calvaria may be separated from the dura and so
removed.
Generally the adhesion between the calvaria and
dura is not a firm one, but occasionally in adults the
separation requires the aid of the end of the enterotome,
introduced between the dura and the bone and the
two pried apart. Occasionally in old people, and
always in young children, the adhesion is so firm that
the dura has to be removed with the bone. This is
accomplished by incising the dura along the incision
in the bone and then cutting the attachment of the
falx to the crista galli in the superior longitudinal
fissure, when the calvaria may be drawn backward
and the falx cut posteriorly.
After the removal of the calvaria, its thickness, the
relation of diploe to tables, and the appearance of the
inner surface should be noticed.
The examination of the dura is now in order.
First observe whether the alternation of fissures and
convolutions, as darker and lighter areas lying be-
neath, can be determined through it. If so, the
dura has the normal degree of translucency, and is of
the normal thickness. If this alternation of dark and
light cannot be made out the dura is thicker than
normal. Next open the superior longitudinal sinus
and note its contents, whether fluid or coagulated
blood or a thrombus. With scissors and forceps
cut through the dura along the line of incision in the
bone; then reflect it toward the median iine so as to
expose its inner surface. The presence of hemor-
rhagic or pigmented false membranes or patches is
the important pathological condition to be looked for
here.
The knife is now to be introduced into the superior
longitudinal fissure, the dura drawn backward, and
the attachment of the falx to the crista galli severed.
The dura can now be drawn backward as far as the
posterior incision in the skull; it should not be cut
off, but should be allowed to hang down. The veins
of the pia, where they enter the superior longitudinal
sinus, offer slight resistance to the removal of the dura.
They may be divided with the knife or scissors or else
torn.
The greater portion of the convexities of the brain
is now in view. One should note, in connection with
the pia, the degree of fulness of its blood-vessels;
whether it is translucent or opaque; whether ab-
normally dry; whether its meshes contain clear serous
fluid, and, if so, the amount; also whether there be
fibrin or pus in its meshes. One should then note
whether the brain fills the cavity of the skull; also
the relation of the convolutions to the sulci as to
proportionate size.
The brain is now to be removed from the skull.
Insert the two forefingers between the dura and the
frontal lobes on either side of the median fissure and
hook them around these lobes; draw brackward on
the brain until the optic nerves can be seen; then
making slight traction backward on the brain by two
fingers of the left hand hooked around its tip, cut
across the cranial nerves and carotid arteries close to
their foramina until the tentorium is reached; cut
the latter close to its attachment to the petrous por-
tion of the temporal bone. Next divide the crania
nerves given off from the medulla oblongata. Thei
carry the knife as far down in the vertebral canal a
possible, and cut the cord by an inverted V-shape<
cut, starting in the median line, and cutting first t<
the right, then to the left. The vertebral arteries an
divided by the same stroke.
The brain is now readily removed by hooking tin
fingers of the right hand under the cerebellum, sun
porting the brain from behind with the left hand
and then lifting it out by the same turn employee
in delivering the aftercoming head in a breed
presentation.
The further examination of the brain is to b<
postponed until the basal portion of the crania
cavity has been looked at. The lateral sinuses an
to be opened and their contents noted. If there be ;
suspicion of a fracture the whole of the dura is to bi
stripped off, it being usually impossible to discover ;
fracture of the base while the dura is in situ.
The posterior part of the eye may be exposed and
removed by chipping away with the chisel the thii
orbital plate which forms the roof of the orbit and tin
greater part of the floor of the anterior fossa.
The middle ear can be exposed by chipping off its
roof, which lies in the middle of the petrous portion
of the temporal bone. If the inner ear is to be exam-
ined, the whole petrous bone must be sawn out by a
V-shaped incision in the squamous portion of the
temporal, the apex of the V extending below tin
external meatus.
The mastoid cells can be opened either from the
inside of the skull or from the outside.
An excellent view of the nares can be obtained by
removing those portions of the ethmoid and sphenoid
lying in the middle line, from the cribriform plate of
the ethmoid in front to the posterior clinoid proc-
esses behind.
By removing the basilar process of the sphenoid and
the sphenoidal process of the basilar, the so-called
clivus Blumbachii, an excellent view of the pharynx
and larynx can be obtained.
The examination of the brain is now to be resumed.
If it is desired to weigh it, this should be done before
it is incised. The brain is placed upon the convexi-
ties, the base uppermost. The pia of the base is to
be examined especially for evidence of inflammation
or tuberculosis. The blood-vessels should then re-
ceive careful attention — first the circle of Willis, then
the vertebrals and basilar, then the anterior cerebrals.
The fissure of Sylvius is now to be opened by cut-
ting the pia that forms a bridge across the fissure
from the frontal to the temporal lobes, and the
branches of the middle cerebrals followed out as far as
the island of Reil. These are the most important of
the cerebral vessels, owing to the liability of lodgment
of emboli in them and because they supply the larger
and most important part of the brain. Evidences of
endarteritis should be looked for, and the vessels
opened with the probe-pointed scissors. Emboli
or thrombi, if present, can now be readily discovered.
This examination completed, the brain should be
placed upon its base and the incisions made to o] eo
the lateral ventricles. This is a curved incision
following the direction of the ventricle, the convexity
being inward, the anterior end about the middle of
the frontal lobe, the posterior end near the middle
of the occipital lobe, the middle of the curve about a
quarter of an inch from the longitudinal fissure. The
hemisphere should be supported by placing the fingers
of the left hand under the base and the thumb of the
same hand in the longitudinal fissure, lifting the
hemisphere upward. This serves to separate the roof
from the floor of the ventricle.
The anterior portion of the cut should be deep,
made with the knife held at an angle of forty-five
degrees, point downward (to reach the anterior horn).
The middle portion of the cut should be less deep,
800
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Autopsy
na de with the knife held horizontally (so as not to
inure the floor of the ventricle). The posterior cut
hoiilc] be deep, made with the knife held at an angle
if forty-five degrees, handle downward (to reach the
„, -tenor horn).
line lateral ventricle having been opened, the
.rain is to be turned half around and the other lateral
, ■utricle opened in the same way. The knife is now
oduced in the foramen of Munro, and an incision
made vertically upward through the anterior
us of the fornix and the corpus callosum. The
terior portions of the fornix and corpus callosum
now drawn backward as far as possible. By
loing the velum interpositum and choroid plexuses
rr brought into view. These are also to be drawn
.ivard, thus exposing the third ventricle. The
posterior pillar of the fornix and the adjoining
lain substance are now cut transversely and carried
to the left. This procedure exposes the corpora
]uadrigemina. The fourth ventricle is now to be
.■.I by an incision made through the middle line
rebellum, from above downward, at the same
dividing the corpora quadrigemina and valve of
i sens by extending the median cut to the aque-
of Sylvius.
The whole ventricular tract is now exposed to view.
Vote should be taken of the size of the ventricles, the
racter and amount of their contents, and the con-
lit ion of the ependyma.
The hemispheres are next examined. In doing this
i is essential to expose as large an area of white and
*ray matter as possible, but without disturbing the
(ions of the parts. The first incision is a curved
jne just to the outside of the basal ganglia and follow-
ing the line of their outer borders. It should extend
near to the pia below. A series of cuts are now to be
made, each succeeding cut being made in the middle
of the preceding cut and extending to, or nearly to,
the pia. In this way the hemisphere is rolled out,
unfolded as it were, and a large surface or series of
surfaces is exposed to view. The pia is to be left
uninjured, serving as a binding to retain the parts in
their normal relation; so that, 2 a lesion be discovered
in the white or gray matter, the parts may be replaced
and the situation localized as to convolution.
The basal ganglia (corpora striata and thalami
optici) are now to be examined by means of a series
of transverse incisions, the cuts being about one-
twelfth of an inch apart. These are most readily
made by supporting the ganglia by one hand placed
underneath, while with the knife in the other hand
the cuts are made and the slices turned to one side so
as to expose the cut surface. The necessity of the
numerous incisions in the basal ganglia is owing to
the fact that lesions sufficient to lead to a fatal result
are often small, and might go unobserved were the
incisions made far apart.
The cerebellum is now to be examined by a primary
incision beginning in the middle of the cut made in it
in opening the fourth ventricle and extending through
the greatest breadth of the organ. This divides it into
two equal portions, exposing a large surface of gray
and white matter and the arbor vitce. A series of
radiating, fan-shaped incisions should then be made
in each of these lateral portions, the cuts extending
to the pia.
The pons is now to be lifted by the left hand placed
beneath it and a series of transverse incisions is to be
made, beginning anteriorly in the corpora quad-
rigemina and crura cerebri and extending through
pons and medulla to the spinal cord. As in the basal
ganglia, so here, the slices should be as thin as pos-
sible, that even a minute lesion may not escape
observation.
The remaining step in the examination of the brain
is to strip the pia from the convolutions of the organ,
especially on the convexities, and note whether it is
readily removed or whether it comes away with
difficulty and removes portions of brain substance
with it, leaving a worm-eaten appearance r,i the
cortex beneath. Such an adhesion indicates a men-
ingoencephalitis, common in dementia paralytica.
The examination of the brain being now completed,
the cavity of the cranium should be sponged dry and
tilled with a sand ban. made by taking a piece of
cotton cloth eighteen inches square and putting on it
as much house sand as corresponds, in the judgment
of the operator, to the capacity of the cranium; then
gathering the corners into a mass and tying them
together with a string. A sand bag serves the double
purpose of giving weight to the head and supporting
the calvaria. The calvaria is to be replaced and held
there by stitches taken through the temporal nm i le
on either side, care being taken to draw the twine
tight to prevent slipping of the calvaria. The two
Saps of the scalp are now drawn together and sewn,
alter the method described in connection with the
body. The seam requires a piece of twine twice the
length of the incision.
Examination of the Spinal Cord. — To remove the
cord the body should be placed face downward, with
a block under the thorax. An incision is made along
the ridge formed by the spinous processes of the verte-
bras from the occiput to the sacrum. The skin to-
gether with the muscles filling the vertebral grooves
should be dissected from the arches, leaving the
lamina? bare. The lamina} are now sawn nearly
through in a line with the roots of the transverse
process. By means of the straight chisel, or, better,
with the rachitome (Fig. 538) and the hammer the
arches are freed and then pried off. The arches of
the upper cervical vertebra? are best divided with the
costotome (Fig. 533).
The membranes and cord are now divided trans-
versely at the lower end; the dura is seized with the
forceps and the cord lifted upward, and the spinal
nerves are divided with the scalpel close to the for-
amina. When the atlas is reached the cord is held
only by the dura, where it is reflected on the margin
of the foramen magnum to become the periosteum of
the inner surface of the skull. This is divided by a
circular incision a little below the foramen magnum.
The cord is now free.
The dura of the cord is now incised anteriorly
and posteriorly throughout its entire length, and its
inner surface, as well as the pia of the cord, examined.
The cord is examined by a series of transverse
incisions half an inch apart, the pia on the anterior
surface being left intact to serve as a binding to hold
the parts together. The incision in the back is to
be sewn up in the same way as the one in front.
Cultures of bacteria from the blood are best made
from the right ventricle of the heart. The surface
of the right ventricle is sterilized by a case knife
heated in a Bunsen lamp, laying it flat on the surface
of the heart. An incision is made through the wall
with another knife sterilized in the same way, and the
platinum wire introduced through the cut and the
culture made.
Cultures from any of the solid organs may be made
in the same way.
The examination of the whole body being now com-
pleted, the soiled newspapers are to be removed and
burned in the furnace or kitchen fire. The operator
should himself attend to the emptying of the slop
pail, which will contain bloody fluid and more or less
intestinal contents; and should also see that all
utensils are thoroughly cleaned, that all spots of
blood are removed from the body, and that the body
is restored to the position it was in before the au-
topsy was begun.
Report of the Autopsy. — A word as to the report
of the autopsy. A proper report should consist of two
parts. The first, to consist of a description of what is
seen, should be purely objective, and should contain
Vol. I.— 51
SOI
Autopsy
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
no expression of opinion. The second part is to con-
tain the anatomical diagnosis; in other words, the in-
ferences drawn from the appearances presented by the
organs.
If the report consists (as unfortunately it so often
does) simply of the inferences of the operator, with-
out a description of the appearances upon which
those inferences are based, it is of little value to any
one else, and of no value as evidence.
Let the physician, then, in his report, describe to
the best of his ability what he sees, and if he is in
doubt as to what the meaning of the appearances is,
any specialist taking his report can give him much
more assistance than if the inferences only are stated.
W. W. Gannett.
Autopsy, Medicolegal Relations of the. — When death
is due other than natural causes, the data upon which
such a conclusion is based may become the subject of
legal inquiry. This article concerns itself with such
data as may be furnished by the performance of an
autopsy. The lesions found, the method of their
observation, and the deductions to be drawn there-
from are the subjects for discussion. (For signs of
death, rigor mortis, putrefaction, etc v subjects em-
braced in an external examination of the cadaver,
see Cadaver, Legal Status of.)
"Natural cause of death," is rather difficult to
define tersely. The importance of its full compre-
hension is apparent, not only to avoid error in reach-
ing such a conclusion, but also from the fact that an
effort to show the evidence, including data from the
autopsy, compatible with natural causes is frequently
made by the defence. "Senile changes or disease
unassociated with poisoning or traumatism," al-
though it might answer in the majority of cases, is
nevertheless faulty, as the following considerations
show. The acute infectious diseases accepted as
natural causes are all associated with poisoning from
the toxins produced by the bacteria. Even the acute
Infectious diseases may come under the category of
unnatural causes if the bacteria are accidentally
or deliberately inoculated.
If we adopt the above, with these restrictions, as
a working definition, it becomes necessary in exam-
ining lesions to differentiate between those produced
by disease and those produced by poisoning or trauma-
tism. Nor is this an easy matter, as might at first
appear. A lesion apparently traumatic may be due
to disease. Lesions apparently due to disease alone
may prove to be dependent upon trauma primarily,
as when infection follows a wound. Again, a diseased
condition (as cerebral arteriosclerosis, or pachy-
meningitis luemorrhagica) may be an important
contributing cause (vertigo) of an accident in which
traumatism is sustained, causing death; or disease
may directly predispose to a result (fatal hemorrhage)
out of proportion to the comparatively slight trauma-
tism. Finally, traumatism and disease not depend-
ent in causation upon one another may both con-
tribute more or less equally in causing death. The
lesions of disease may so closely resemble the effects
of poison (in the toxicological sense) that their differ-
entiation by gross examination is almost impossible,
chemical and bacteriological examinations being
necessary to clear up the case.
Technique. — The method of observation includes
the technique employed in the performance of the
autopsy. Not only the data and the deductions
drawn therefrom, but the way in which these data
were acquired may be subjected to searching investi-
gation in court. By faulty methods incorrect data
may be obtained. Direct mistakes in observation
are not here referred to, but unintentional and unob-
served artifacts, and their diagnosis as lesions. It
is absolutely necessary to be fully cognizant of all
methods and manipulations by which such artifacts
may be produced, not only to avoid them, but also
to be able to testify to that effect. In considering
the technique of medicolegal autopsies, only these
points will be dwelt upon here, the reader being
referred to the preceding article for a detailed descrip-
tion of the technique ordinarily employed when no
medicolegal considerations are involved.
Head. — In removing the vertex the bone should
be sawed through completely. The wedge, or chisel
and mallet, had better not be used. Although the
physician may be certain that a fracture was pro-
duced during life and not post mortem by the use of
chisel and mallet, yet if their use is admitted a reason-
able doubt may be cast upon his testimony. The
brain should be removed with special care, raising
the frontal lobes sufficiently to cut nerves and vessels
close to the foramina of exit and, raising the temporal
lobes, to sever thoroughly the anterior and lateral
attachments of the tentorium, first on one then on the
other side, and divide the remaining nerves and
vessels below, in doing which the brain should not
be raised from the base of the skull more than neces-
sary. After division of the tentorium the brain
should be supported, as the final division of nerves,
vessels, and spinal cord proceeds, lest by its own
weight dragging upon these structures, it cau-
ait ifieial lacerations. The brain should be perfectly
free before its removal is attempted, and should be
allowed to slide backward, the convex surface resting
in the palm of the hand.
Spinal Cord. — To avoid artifacts a complete divi-
sion of the lamina? on either side, one centimeter from
the spinous process, should be made with a straight
saw curved on the end, the serrations extending a
short distance upon the curve. Chisel and mallet
had better be avoided. Test the complete division In-
pressing each spinous process from side to side. If
free, the lamina? and spinous processes can readily be
removed together from below upward, by grasping
the lowest and using the knife alone. After the
attachment of the dura spinalis to the foramen ovale
within the skull has been severed, the spinal cord
should be removed together with its dural sheath, the
spinal nerves being cut close to the intervertebral for-
amina on either side from below upward. The dura
should be opened in the median line anteriorly and
posteriorly after the removal.
Mouth and Neck. — The examination of the fauces
and aditus laryngis is of importance, more especially
in infants, great care being required to prevent occur-
rence of artifacts. The tongue, anterior and pos-
terior pillars of fauces, tonsils, soft palate, pharynx,
esophagus, larynx, and trachea may be removed
together. The incision is extended to the chin, or,
after the thorax has been opened, they may be re-
moved, without extending the incision over two
inches above the episternal notch, by separating t he
skin from the clavicle and working up from the
thorax, separating the unincised skin from larynx,
hyoid bone, and muscles of the floor of mouth. Re-
traction of the skin by hooks or a finger of an assist-
ant on either side in an upward direction gives ample
room if the sternum and costal cartilages have been
removed; and the space may be still further increased
by partial incision of the sternocleidomastoid muscle
near, or at its insertion into the clavicle. With a sharp-
pointed knife the floor of the mouth is punctured in
the median line close to the inferior maxilla, and the
muscles and mucosa cut through along the body of the
bone to the angle on both sides. The tongue is drawn
down through the incision, and with the knife passed
over the dorsum of the tongue, an incision is made
through the soft palate close to the bone from the
median Hue outward, then anteriorly to the anterior
pillar of the fauces, downward to the incision through
the floor of the mouth on both sides. The loose
areolar tissue on either side of the trachea and larynx,
802
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Auio|i-\, Medicolegal
Bclatlona
esophagus and pharynx, and posterior to the latter,
is separated well up to the occipital bone, where the
attachment of the pharynx is cut across. The sty-
loid muscles arc cut and the organs drawn gently
downward, care being taken to observe whether
there are any points at which attachments still re-
quire to be divided. It is possible for the stomach
(•(intents to reach the larynx or the aditus laryngis
posi mortem, either in moving the cadaver about or
during the performance of the autopsy. During the
removal of the stomach its contents may be forced
into the esophagus and pharynx and larynx. To
guard against this a ligature should be applied to the
cardiac end of the esophagus before dissecting out
the stomach.
Abdomen. — The abdomen should invariably be
ned before the thorax, the skin and muscles of
the latter being dissected off to give more room for
inspection. The height of the vault of the diaphragm
in the mammillary line on either side should be deter-
mined. The organs should be examined as far as
possible in situ and the contents of the peritoneal cav-
ity, if any, their character, amount, and distribution
ii 'ted. In cases of injury special care is to be taken
in the removal of organs, the incisions necessary
being deliberately and cleanly made and laceration
of tissue avoided. In cases of bullet and stab wounds
their site should be accurately determined and their
measurements carefully made so that the direction
of the course of the bullet or knife may be determined.
The abdominal organs may be removed together
with the thoracic organs and diaphragm, in order
to determine more accurately the relations of certain
traumatisms. The esophagus, aorta, vena cava, and
ligaments of the liver are not divided. An incision
is made through the parietal peritoneum on the right
side external to the right kidney and ascending colon,
on the left side external to the left kidney, descending
colon, and sigmoid flexure. The loose connective
tissue between the organs and the posterior abdominal
wall is readily separated by blunt dissection, the
lumbar branches of the aorta and the common iliac
vessels requiring the knife.
Pelvis. — The pelvic organs may also be removed to-
gether, the connection of ureters with bladder and the
sigmoid with rectum remaining intact. The female
genital organs, after examination in situ, should be
removed together. A circular incision is made
through the peritoneum around the margin of the
true pelvis, the loose areolar tissue stripped up with
the fingers down to the levator ani et vaginae, and an-
teriorly well down behind the symphysis pubis. With
a few sections of the knife the ostium vaginae to-
gether with the urethra, the bladder, vagina, uterus
and appendages, and rectum are removed. After
examination of the rectum, bladder, urethra, and the
appendages, especially the ovaries for a corpus luteum
of pregnancy, the vagina is laid open with knife or scis-
sors. The cavity of the uterus should not be opened
by thrusting the blade of the scissors or knife into
it. A clean incision should be made in the median
line posteriorly until the cavity is reached so as to
avoid all chances for the occurrence of artificial lacera-
tion or puncture.
Thorax. — In cases of hemorrhage, great care should
be exercised so that its origin may be accurately
determined, and its cause, whether traumatic or due
to disease or possibly to both conditions, determined.
The examination of the organs in situ should be made.
To determine the presence of pulmonary thrombosis
the pulmonary artery should be opened with organs
in situ. If the examination is unsatisfactory, the
organs of the thorax may be taken out together
with those of the neck and mouth if necessary. Pleu-
ral adhesions are then separated, or if they are too dense
(rather than risk an artificial laceration of the lung),
the costal pleura having been stripped off, the attach-
ments of the diaphragm are cut away from the ribs,
and its pillai • i red, an incision is made through the
parietal pleura along the vertebral column external
and posterior to I he aoi ta on i he ; il ide, t he lung
being brought forward for tha i po i and the lefl
subclavian vessels, common cat iticf, and jugulat
cut. < In tin- righl side the ini i ion i made e ternal
and posterior to the vena cava superior, right auricle,
and vena cava inferior, and the innominate arter; < 1
vein are cut across. '|i phagu neat the cardia
is ligated and cut above the Ligature. The aorta,
inferior vena cava, and suspensory Ligament ol the
Liver are then severed. By this technique injuries
may he clearly demonstrated which by the usual
technique might escape ob ervation, or, if observed,
their origin or relations might be doubtful.
Cases op Poisoning. — Cases of suspected poison-
ing require special consideration. The presence of
the chemist at the autopsy and his direct reception
of the organs for examination from the pathologist
simplify matters considerably. If this plan cannot
be followed, it devolves upon the pathologist to re-
move such organs and fluids in which the suspected
poison may be detected, in such a manner as to a\ oid
contamination, and to place them in possession of the
chemist with the least possible delay and by as direct
means as circumstances will allow. It "should be
remembered that every step from the performance of
the autopsy to the reception of the material for exami-
nation by the chemist may be made the subject of a
searching examination in court, namely, how the
organs were removed, what instruments were used
and what condition they were in, what receptacles
the material was placed in for transportation, how
these receptacles were treated before and after the
material was placed in them, whether any preserva-
tive fluid was used, were they properly sealed, and
what means were employed in transporting them to
the chemist. These points may appear trivial, yet
too much attention cannot be paid to the minutest
detail. Carelessness in this regard may nullify the
entire work of the chemist and cause a break in an
otherwise intact chain of evidence. On the other
hand, such carelessness may be the means of unwitt-
ingly convicting an innocent person. Glass jars
that have been used for no other purpose, carefully
cleaned with soap and water, rinsed with water,
then with alcohol, closed preferably with a ground
glass stopper or clean, well-fitting cork, should be
used. Stomach or intestinal contents, urine, and
blood should be placed in separate jars. When the
determination of the amount of poison in individual
viscera is of importance they should be placed in
separate jars. The condition of preservation or
decay of the material should be noted. If the mate-
rial cannot be placed in the hands of the chemist di-
rectly, a sufficient amount of strong alcohol should be
added to cover the organs in the jars, in order to
check decomposition and prevent breakage by the
gases of decomposition. If this is done a portion of
the same alcohol that was used in the jars should be
sent to the chemist also. Finally all jars should be
separately tied with tape, properly sealed and labelled.
By this means, although the material may have neces-
sarily passed through several hands, provided it
reaches the chemist with intact seal, the chain of
evidence, so far as the examination of the organs,
fluids, etc., is concerned, remains unbroken.
The evidence already at hand before the perform-
ance of an autopsy may point to a given poison as the
cause of death, either from the clinical history of the
case, or from the discovery of the empty poison bottle
or package, or of some of the poison suspected to
have been given to or taken by the deceased. This
evidence, although a valuable guide, cannot be en-
tirely relied upon and should not bias the judgment of
the pathologist. Cases occur in which an entirely
different poison is found to have been the cause of
803
Autopsy, Medicolegal
Relations
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
death, and some in which the presumptive evidence
appeared very strong have proved to be deaths from
natural causes, or the alterations found have turned
out to be merely postmortem changes. Cases occur
in which there is no suspicion whatever, and yet
poisoning is proved by autopsy and chemical examina-
tion. Such are not merely cases of sudden death
without any clinical history, but often enough cases
that have been ill for some time and treated for
disease by a physician, competent enough compara-
tively, who may have filed a death certificate giving
the disease diagnosed by him as the cause of death.
In fact, it is well known that the results of some
poisons may so closely resemble disease clinically and
even pathologically that mistakes can easily be made.
The only safe way to avoid error is for the clinician
to insist upon an autopsy before signing the death
certificate, and for the pathologist to employ chem-
ical and bacteriological aid. In the performance of
autopsies, whether poisoning is suspected or the cause
of death is unknown or doubtful, a complete exami-
nation of the body should be made; and the pathol-
ogist should be ever mindful of those conditions,
which although often resembling the results of dis-
eases such as cholera, dysentery, nephritis, malig-
nant jaundice, or acute yellow atrophy of the liver,
may nevertheless be the results of poisons such as
arsenic, mercury, potassium chlorate, or phosphorus.
Some poisons produce no characteristic changes in the
tissues of the body, so far as gross or even microscop-
ical examination is concerned; their presence cannot
be positively affirmed until chemical examination is
made. The pathologist may, however, be able to state
that no pathological condition of the organs due to dis-
ease or traumatism, and sufficient to cause death, has
been found. When the organs are found in a normal
condition it may be easy enough to reach this conclu-
sion. When, however, pathological changes are pres-
ent, it is often very difficult to estimate their impor-
tance in the causation of death. Although our knowl-
edge of the morphology of disease, and of the bacter-
iology of many of the infectious diseases, is extensive,
that of its chemistry is not nearly so well advanced.
Pathological conditions are found which in the absence
of any suspicious circumstances are assumed to be the
cause of death; yet we meet with cases in which
these conditions are present and may even be very pro-
nounced, but nevertheless death is the result of vio-
lence or of some other intercurrent disease. When
the circumstances of a death are suspicious, a chemical
examination is usually called for. There are cases,
however, of sudden death in which no suspicions are
entertained at the time, but in which, though a care-
ful autopsy is performed, a conscientious pathologist
cannot satisfy himself of the cause of death, even with
the aid of microscopical and bacteriological exami-
nations. In such cases a chemical examination alone
can affirm or exclude poisoning.
Other poisons do produce effects more or less
characteristic by their direct local action, by their
absorption, and by their excretion. The task in the
performance of the autopsy is to determine whether
the changes found may have been produced by a
poison, and if possible by what poison. Of course,
the positive proof in every case must be furnished by
chemical examination. The work of the patholo-
gist, however, is of importance, on the one hand to
obviate useless chemical examinations, on the other to
insist upon a chemical examination when necessary,
and to select such organs and fluids as are of impor-
tance forexamination. On this account it is impor-
tant to know what changes are characteristic of poison-
ing, and what are characteristic of special poisons.
Certain physical characteristics of poisons may
lead to the suspicion of their presence. A green
color may indicate the presence of acetoarsenite of cop-
per; yellow, potassium chromate or iodine; blue, sul-
phate of copper; or certain dyes, such as those used in
corrosive sublimate tablets, or in the heads of matches
may furnish an indication. The odor characteristic
of phosphorus, or of bitter almonds, of alcohol of
chloroform, of laudanum, or of carbolic acid may
furnish an indication. The granular or crystalline
appearance of the substance, its insolubility, may
furnish a clew. The chemical reaction, whether acid
or alkaline, is important, and the contents of stomach
and intestine should always be tested in this regard.
In the greatest number of poisoning cases, the
poison is introduced by way of the mouth; unusually,
by rectal, vaginal, intrauterine, or hypodermic in-
jection. Some poisons produce no effect upon the
mucous membrane; others are irritants and <>ause
effects varying in intensity from congestion and
ecchymoses to complete corrosion with production
of eschars. Those poisons which produce the corro-
sive effect upon the mucosa may act either by coagu-
lating its albuminous constituents — as happens in
the case of the mineral acids, oxalic acid and car-
bolic acid, and mercuric chloride — or by dissolving
them and causing a sw-elling and softening of the
mucosa — as is true of sodium, potassium, and ammo-
nium hydrate and potassium cyanide. Concentrated
sulphuric acid dissolves coagulated albumin; if
dropped on a mucous membrane a spot is formed that
is transparent in the center and white at the per-
iphery where the acid has been diluted by the fluid of
the tissue and the albumin precipitated. When the
caustic alkalies have acted upon a mucous membrane,
if neutralized or if the reaction is changed by addition
of acid, the albumin is precipitated and a grayish
eschar appears.
These effects may be further changed in appearance
by the action of the poison upon the blood with which
it comes in contact. If the poison separates hematin
from hemoglobin and dissolves it, the eschar or the
tissue may be discolored brown or brownish-black by
imbibition, as with sulphuric acid, hydrochloric acid,
oxalic acid, and the caustic alkalies. Carbolic acid
and corrosive sublimate coagulate blood but do not
cause a separation of hematin. Each, however,
produces a change of color in the coagulum, namely,
carbolic acid a bright brick red, and sublimate a
grayish-violet.
The effects may vary according to the amount of the
poison, its concentration, the duration of its action,
and the condition of fulness or emptiness of the stom-
ach and intestines. The lips and skin of the face and
neck may show corrosive action of the poison. The
mucous margin may present grayish-white or brown-
ish eschars. Crescentic streaks on either side of the
upper lip, extending upward from the corners of the
mouth, may be present when the poisonous fluid has
been imbibed from a tumbler; there may be streaks
from either corner of the mouth passing downward
over the cheek or chin, and down the neck, when the
poison has been spilled while drinking. Corrosion
of the lips and skin may be absent when the poison
has been swallowed from a bottle. The mucosa of
the mouth may show swelling and eschars, but from
short duration of contact these may not be well
marked. The mucosa of the esophagus may show
111 1 lc action from the short duration of contact and the
relatively slight amount of poison that remains in
contact.
The stomach usually shows the greatest amount
of change. This may affect its entire surface, or be
confined more especially to the region of the fundus,
greater curvature, and posterior surface. Excep-
tionally, the corrosive action may be confined to the
smaller curvature and anterior surface, the most
probable explanation being the ingestion of poison
upon a full stomach, which shortly thereafter has
emptied its contents into the duodenum, in which
case the duodenum and jejunum show the effects more
markedly. The summits of the folds in the mucosa
show more decided effect on account of greater ex-
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Autopsy, Medicolegal
Relations
oosure, tlie sulci being in part protected by contact
,f opposite surfaces. Thus the eschars in the stom-
ich Form longitudinal streaks separated sometimes by
intervening mucosa nol escharotic or less markedly
so. The corrosive action varies in depth and may
extend through the peritoneum, involving adjacent
ins such as the spleen, colon, pani rea . and liver,
without perforation of the stomach; or the stomach
have been perforated by the action of the poison,
contents having escaped into the peritoneal
1-avitv anil produced characteristic changes wherever
the poison has come in contact. Autodigestion
oi the stomach with perforation may occur without
the presence of corrosive poisons.
In the duodenum and jejunum the crests and
superior surfaces of the valvula- arc especially ex-
posed and show the greatest amount of corrosive
aiiion. usually more intense nearer the pylorus and
iming less severe further down. Exceptionally,
duodenum as well as the stomach may escape,
and a coil of jejunum further along show severe cor-
ion. The ileum rarely shows the effect of direct
local action, and the same may be said of the colon,
except in those cases in which the poison has been
introduced directly into the rectum. The caput coli
and first portion of the ascending colon may occasion-
ally show the effect of local action, probably from the
longer duration of contact of poisons that have passed
with greater rapidity through the small intestine.
The colon and lower part of the ileum ma}- show the
effects of poison by excretion. This is a character-
istic effect in bichloride of mercury poisoning, espe-
cially if a period of a week or two has elapsed after its
ingestion.
The effects upon the tissues from the absorption
of poisons is shown in the degenerative changes,
parenchymatous or fatty, in the functional epi-
thelial cells of the organs, as the stomach and liver: in
the muscle fiber of the heart and sometimes of the
voluntary muscles; and in the epithelium of the
kidney, more especially of the cortex, when excretion
of the poison has taken place.
Carbolic Acid Poisoning. — Eschars on the lips may
be white, grayish, or. when drying has occurred,
dark brown. The eschars on the cutaneous surfaces,
if any, are usually brown, dry, and leathery. The
mucosa of the tongue and mouth may be white or
grayish-white, or show no change. Pharynx and
hagus usually show grayish-white eschars. There
is generally more or less edema of the aryepiglottic
folds about the aditus laryngis and the loose sub-
mucous tissue over the arytenoids and anterior wall
of the pharynx.
The eschars in the stomach are usually longi-
tudinal, involving the crests of the folds, and of a
white or grayish color, while the intervening mucosa,
where not escharotic, will present a light red tint due
to the action of carbolic acid on the blood. The
entire wall has a dense leathery feel, and the stomach
may be markedly contracted. The action of car-
bolic acid may extend to the peritoneal coat and
even to the spleen and liver, the color usually being
pink, or light red, upon a grayish-white base.
The distribution of effects varies according to the
concentration and amount of the carbolic acid, and
the condition of the stomach, whether empty or full
when the acid was taken. The escharotic action may
extend to a variable distance down the small intes-
tine, the valvula? of the duodenum and jejunum per-
haps showing grayish-white eschars, while, further
along, the mucosa may present a pink discoloration
and marked swelling and softening. The other organs
show but little change, in the great majority of cases,
since death occurs within a few minutes. Passive
hyperemia is usually present. In cases of survival of
the ingestion of a smaller amount for some hours,
the characteristic phenol urine is found, with marked
parenchymatous degeneration of the kidneys.
Sulphuric Acid I'" The eschars on the lips
and -kin are usually brow n, leathery, and dry. The
mucous membrane of the mouth and esophagus
presents grayish-white eschars. The stomach wall is
thick and dense, the mucous membrane corroded,
the eschars brown or black from the imbibition of
dissolved hematin, Wherever the blood has been
acted upon, whether extravasated or in tl.
the coagulum is black, dry, and brittle. Either from
the action of the acid or from casting off of necrotic
portions of mucous membrane the surface may pre-
sent an irregular nodular appearance. The fundus
of the stomach may be perforated either during life
or post mortem, ami wherever the acid come- in eon-
tact with tissue a cloudy appearance is presented,
due to coagulation of albumin. The mucosa of the
small intestine may present a variegated appearance
of grayish-white eschars, where the acid ha- caused a
coagulation of the albumin of the tissue, with inter-
vening dark brown or black areas, where eeihyin
have occurred or where a previous eschar has ex-
foliated laying bare the submucosa stained with
hematin. The kidneys show parenchymatou
elation or nephritis. In prolonged cases thi
mucosa of the stomach and inte tine may be thrown
off, showing a hemorrhagic, edematous submucosa,
with more or less imbibition of hematin.
Hydrochloric Acid Poisoning.— Hydrochloric acid
produces no corrosive action on the skin. The eschars
are grayish-white when simple coagulation of albumin
has taken place, and dark brown or black when ecchy-
moses have occurred or when imbibition of dissolved
hematin has taken place. The effect is very much
like that of sulphuric acid, except that the drying
of the eschars and of the blood clot is less pronounced,
owing to the fact that hydrochloric acid has not so
strong an affinity for water.
Nitric Acid Poisoning. — The eschars present a
yellowish stain, due to the formation of xanthoproteic
acid; otherwise they are not markedly different from
those described above, except as regards the fact
that nitric acid does not separate and dissolve hem-
atin. The brown or black discoloration of the
eschars produced by both sulphuric and hydro-
chloric acids does not occur.
Concentrated Acetic Acid. — A case of poisoning
from this acid is on record; death was due to pneu-
monia, and a grayish-white corrosion of the mucous
membrane of the mouth and respiratory passages was
observed. A sponge saturated with concentrated
acetic acid was held at the mouth and nose.
Oxalic Acid and Oxalate of Potassium. — In concen-
tration they produce white or grayish corrosion of
the mucous membrane of the pharynx and esophagus.
The mucosa of the stomach is swollen, injected, and
escharotic, with imbibition of hematin; it is easily
removed by washing. The escharotic action, how-
ever, is never as great as with sulphuric acid. White
opacities (oxalate of lime) are found in the blood of
the corroded portions, also in the uriniferous tubules.
Perforation of the stomach may occur, with the re-
sulting effect of a local peritonitis, due to the escape
of the contents of the organ into the peritoneal cavity.
These perforations, however, are in most instances
a postmortem occurrence. Wherever the poison
acts upon the blood, black clots occur in which ox-
alate of lime crystals may be found.
Caustic Potash. Soda, mid Ammonia. — The mucosa
of the mouth may be swollen and red, the epithelium
partlj- exfoliated, partly still adherent in whitish
shreds. The esophagus may have lost its epithelium,
and may be swollen and hyperemic. its lower portion
being brownish and soft. The mucosa of the stom-
ach is thrown into thick folds, markedly swollen and
ecchymotic, with superficial losses of substance; it is
dark brown, from imbibition of hematin. The
submucous tissue is markedly edematous. Croupous
gastritis may follow the action of the caustic. Croup-
Ml.-,
Autopsy, Medicolegal
Relations
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
ous bronchitis and circumscribed areas of broncho-
pneumonia may result from aspiration of the caustic
soda or potash and may be the immediate cause of
death. In other cases the cicatricial tissue following
the exfoliation of the sloughs may finally, if not
relieved surgically, cause death by stricture of the
esophagus.
( drbon. Monoxide Poisoning. — The appearance of
the cadaver, in poisoning by carbon monoxide, is
very characteristic, more especially in the cases of
poisoning from illuminating gas. The postmortem
spots are of a pink hue, and give the cadaver an
almost life-like appearance. The blood is fluid and
cherry red in color. The mucous and serous mem-
branes are of a rosy tint, and the organs (especially
those containing much blood) present a cherry red
appearance. This is especially well marked where
the blood is seen upon a white background, as in the
brain. The color should be determined at once as
soon as the blood or organs are exposed to the air,
as after a longer exposure blood that does not contain
carbon monoxide hemoglobin may become light red
in color, the reduced hemoglobin changing to oxy-
hemoglobin, the oxygen being absorbed from the
atmosphere. The appearance of the blood in some
cases of carbon monoxide poisoning, although car-
bon monoxide hemoglobin is present, may present
a dark color from excess of reduced hemoglobin, from
carbon dioxide absorption. This occurs more com-
monly in poisoning from coal gas, and from inhala-
tion of smoke at conflagrations. The appearance of
the blood may also vary when several hours have
intervened between the cessation of inhalation of
carbon monoxide and death. Since vomiting is a
symptom of carbon monoxide poisoning, persons may
die, in an atmosphere of carbon monoxide, from
aspiration of vomit, the formation of carbon mon-
oxide hemoglobin being as yet insufficient in amount
to cause death.
Carbon monoxide hemoglobin is readily demon-
si rated by the spectroscope, producing two absorp-
tion bands near D and E like oxyhemoglobin, but not
reduced like the latter by addition of ammonium
sulphide. In doubtful cases, therefore, a specimen of
the blood should be saved for this examination.
II has been found that carbon monoxide hemoglobin
can be demonstrated in the blood of extravasations
and in muscle when its demonstration fails in the
blood taken from the heart. When persons have
died in an atmosphere of carbon monoxide, or shortly
after being removed therefrom, the blood resists
decomposition for a considerable time, and the
spectroscopic examination may be of value even
after the lapse of two or three months. Such blood
also keeps its bright red color. A note on the color
and condition of preservation of blood that is taken
for examination is of importance, since with decom-
position (especially if ammonia is present in abun-
dance) hematin is formed. Such blood is of dark
color and becomes cloudy when mixed with water.
The absorption bands are not clear, or there is only
a shading in the green. On addition of ammonium
sulphide two bands appear — i.e. the spectrum of
reduced hematin.
The differential diagnosis between illuminating-gas
and coal-gas poisoning may not be easy to make.
Cases of poisoning by illuminating gas present the
most characteristic appearances postmortem and on
spectroscopic analysis; those of poisoning by coal gas,
from the larger percentage of carbon dioxide, present
less characteristic appearances, and the spectroscope
may show the bands at D and E, after the addition
of ammonium sulphide, together with a more or
less deep intervening band between them. In cases
of death in conflagrations the effect of inhalation of
smoke, as shown by the presence of black, sooty
deposits upon the respiratory mucosa, is quite
characteristic.
Besides spectroscopic analysis there are a number
of chemical tests, very easy of application at the au-
topsy table, which prove of aid in doubtful cases.
The addition of a drop or two of a ten-per-cent.
sodium hydrate solution changes the color of other
blood to a dirty brown or brownish-green; carbon
monoxide blood remains bright red. Solution of a
copper salt changes the color of other blood to choco-
late brown; carbon monoxide blood remains red.
Tannin, ferrocyanide of potassium, and acetate of
lead form a brown precipitate with other blood, a red
one with carbon monoxide blood.
These tests, and also the spectroscopic test, may
produce recognizable results in some cases in which
death has occurred even sixty hours after exposure to
carbon monoxide; in other cases, however, the re-
action can barely be made out even when the interval
amounts to only two hours.
A certain number of lesions which sometimes occur
subsequently to carbon monoxide poisoning may aid
the examiner in reaching a diagnosis when from the
length of time between cessation of exposure and
death the above tests fail. Croupous inflammation
of the fauces has been noted where death followed
seventeen hours after coal-gas inhalation. In some
cases there are vasomotor and trophic disturbance 3
of the skin which predispose to necrosis from pres-
sure. A case with dermatitis bullosa on both hands
has been reported, death taking place five days after
exposure to coal gas. In another case death occurred
at the end of eight days. Symmetrical softening of
the anterior part of the inner capsule and adjoining
portion of the head of the caudate nucleus, also of the
inner part of the lenticular nucleus, has occurred
in a number of cases in which a day or more has
intervened. Its occurrence has been explained by
Kolisko on the ground of the peculiar course of the
arterial branch (the long anterior perforating branch
of the anterior cerebral) which supplies the part, its
course being in the reverse direction to that of the
artery from which it springs, so that with the de-
crease of pressure, which is the result of carbon
monoxide poisoning, a diminution in the flow of
blood or even stasis may occur.
Hydrocyanic Acid. — This acid, alone, produces
merely injection and ecchymoses of the mucosa of
the stomach, which may in part be explained by the
condition of asphyxia, death occurring rapidly there-
from. Besides the odor of bitter almonds there is
nothing characteristic.
Cyanide of Potassium. — The mucosa of the stomach
over its entire surface or at the fundus, or especially
upon the crests of the folds, is deep red in color, swollen
and softened, and presents sometimes almost a
translucent appearance; a thick mucus, which is tinged
a light red or brownish-red from blood, covers the
surface. The stomach contents are usually blood
tinged and stringy. The reaction is strongly alkaline.
The mucosa is soapy or slippery to the touch. The
characteristic odor of bitter almonds is present in the
stomach, and also in other organs, as the brain and
lungs. The odor of ammonia may be distinguished
cither from its presence in the cyanide, or through the
effects of decomposition in the stomach. The red-
ness and swelling of the mucous membrane an' due to
injection and ecchymoses, the primary effect of irri-
tation, and to the secondary action of solution of the
albuminous constituents of the tissue and imbibition
of the superficial layers with hematin due to the strong
alkaline action. The secondary effect, therefore, may
lie absent or poorly marked when the dose is small or
when its effects have been counteracted by the acid
■ ■.intents of the stomach. In such cases, unless a
characteristic odor is present, the diagnosis can be
made only by chemical examination.
The same effects may be apparent in the mucosa of
the duodenum, pharynx, esophagus, larynx, trachea,
and bronchi, especially if, during vomiting, some of
Mill
REFERENCE HANDBOOK OF THE MEDICAL M II AH -
Autopsy, Medicolegal
ftelatloiu
(he potassium cyanide has been aspirated. In some
cases the- crests of the folds in the mucous mem-
brane of the stomach may present a grayish-white
appearance.
Ilir blood usually presents the condition found in
asphyxia, i.e. it is dark and fluid. The spectrum is
tical with that of oxyhemoglobin and is reduced
by ammonium sulphide. Occasionally it is light red.
This color may be due, according to Hoffmann, to
the hyperalkalinity of the blood, which is easily and
quickly produced by the ammonia contained in cya-
nide of potassium, more especially in old samples.
ices of ammonia cause the appearance of a light
red color in blood solution, and clarify turbid solu-
tions. ( Ithers ascribe the light red color to the forma-
tion of a compound of cyanogen with methemoglobin
or hematin. If to a dilute solution of normal blood
ferricyanide of potassium be added, there is an imme-
diate change in color from red to brown, and in the
itroscope a methemoglobin band appears between
C and I>. A trace of hydrocyanic acid or of cya-
nide of potassium will change the solution to a red
color, and in the spectroscope there will appear in the
n a broad band which, after the addition of ammo-
nium sulphide, changes to two bands.
Xitrobenzol Poisoning. — The mucosa of the stom-
ach and small intestine is injected and ecchymotic.
The odor of bitter almonds in the stomach, brain,
and lungs is even more marked and persistent than
in hydrocyanic acid poisoning. The blood and mus-
cle are brownish in color. From the presence of
brownish methemoglobin in the uriniferous tubules.
especially in the pyramids, a resemblance to chlorate
of potassium poisoning is produced.
Arsenic. — Arsenous acid usually does not produce
corrosive effects upon the mucosa. These effects,
although they have been observed in several cases,
are evidently of rare occurrence. This poison, how-
ever, does produce an intense gastroenteritis. There
is nothing characteristic about the external appear-
ance of the cadaver, or about the condition of the
mouth, pharynx, or esophagus. The mucosa of the
stomach is intensely congested throughout or in
patches; it is edematous, swollen, and sometimes
ecchymotic. It is covered with blood-tinged mucus,
and scattered over its surface may be found granules
or crystals of arsenous acid. These are sometime-
large enough to be felt or even to be seen. The
small intestine is filled with thin fluid, almost watery,
with flocculi — the characteristic rice-water contents.
The mucosa is congested, markedly swollen, edema-
tous, and flaccid. In the lower portion of the small
intestine and in the large intestine, the mucosa may be
pale. There is marked parenchymatous or fatty
degeneration of the glands of the stomach and intes-
tine, of the epithelial cells of the kidney and liver,
and of the heart muscle. In some cases the stomach
may present few or no changes, but the changes in
the intestine are far more constant.
The appearance of yellowish streaks occasionally
Been on the stomach mucosa are due to the formation
of yellow sulphide of arsenic.
The colon may be covered with thick mucus con-
taining desquamated epithelial cells and many lym-
phocytes. There may be a croupous colitis. Themes-
enteric lymph nodes may be swollen. There maybe
ecchymoses in the pericardium and pleura, but
especially under the endocardium. The blood is
usually poorly coagulated, and in the peripheral vessels
may be thick and tarry, due to loss of water. In
some cases there is slight jaundice, and ecchymoses
may appear in the faucial mucous membrane and in
th ■ cellular tissue of the neck, but not in the muscle.
When ecchymoses appear in the pleura and mediasti-
num, and fatty degeneration of the heart, liver, and
kidney is present, the case may resemble phosphorus
poisoning. The hemorrhagic spots in the mucosa of
the stomach may become eroded by the gastric
contents, and this doubtless explains why a corrosive
action is ascribed to arsenic, which it most probably
does not possess.
Arsenic is more rapidly eliminated than other
metallic poison-, and it is conceivable that death may
occur from arsenic poisoning and yef quite small
amounts of arsenic be found. It is therefore of im-
portance to preserve for examination in suspected
cases not only the stomach and intestine arid their
contents separately, but also the heart, kidney, liver,
bone, and muscle, since in some cases arsenic has been
demonstrated in these organs, more especially in
the liver and bi.ne, when its demon I rat ion ha- failed
in the stomach and intestine or in their contents,
by reason of its having been already eliminated.
Much of the arsenic that has been taken internally
may have been got ten rid of by vomiting and diarrhea,
common with arsenic poisoning. In cases in which
examination is made after burial it is important not
only to take portions of every organ and tissue of the
body, inasmuch as it is well known that arsenic may
diffuse itself through the tissues post mortem, but
also to take samples of the objects surrounding the
cadaver, including wood of the casket and surround-
ing earth. In add it ion to t his it is also of importance
to take another sample of earth from another pari of
the cemetery. All organs should be carefully weighed
at the time of the autopsy, and if possible the entire
organ should be given to the chemist. If this cannot
be done, provided the weights of the organs are known,
a basis for calculation of the amount of arsenic is
furnished. It is both affirmed and denied that the
cadaver after arsenic poisoning resists decomposi-
tion for a considerable length of time. Mummifi-
cation has been described as a characteristic appear-
ance. This may, however, be due to other conditions,
such as burial in sandy soil, etc.
Aceto-Arsenite of Copper, Paris Green. — The appear-
ance of this substance, its characteristic color, its
insolubility, and the fact that it appears in the stom-
ach in pasty masses, loosely adherent to the mucosa,
which is swollen, edematous, congested, and ecchy-
motic beneath the attached mass, renders the diag-
nosis of this form of poisoning quite easy. The
small intestine shows the same appearance as in
poisoning by arsenous acid. The Paris green may be
covered by a brownish magma, the reduced iron
given as an antidote.
Phosphorus. — Red phosphorus is not poisonous;
the yellow variety is intensely so. Acute cases
(death in from four to eight hours) may show but
few pathological changes. The contents of the stom-
ach and intestines may smell of phosphorus and may
shine in the dark on being shaken; pieces of matches
may be found. The gastric mucosa, heart muscle,
and epithelial cells of liver and kidney may show
cloudy swelling. The subacute cases (death after
from three to seven days) commonly show character-
istic changes. The stomach is not corroded, ecchy-
moses and hemorrhagic erosions are common; the
gland cells, especially the adelomorphous cells, are
in marked fatty degeneration, so that the ducts are
marked by yellowish points (gastradenitis phosphor-
ica). The contents may be dark brown from the
presence of blood. Phosphorus may no longer be
demonstrated chemically in the stomach and its
contents, in the subacute cases. The lower part of
the small intestine and the colon are more likely to
contain phosphorus. Jaundice is regularly present
and marked. Ecchymoses, which are a character-
istic lesion in poisoning by phosphorus, are abun-
dantly present in the gastric and intestinal mucosa,
in all the serous membranes, especially the pleura
and the pericardium, in the adventitia of the aorta
and its branches, in the conjunctiva, in the subcu-
taneous areolar tissue, in the intermuscular tissue, and
in the mediastinum. Hemorrhages may occur from
the stomach and intestine, and from the uterus, in
807
Autopsy, Medicolegal
Relations
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
some cases causing death. The blood is fluid in
acute cases, poorly coagulated in subacute cases.
The red cells are disintegrated, the white cells may be
fatty. Fatty degeneration of the liver, kidney, mus-
cle of the heart, and arteries is very well marked.
The organs are bile-stained and the fecal masses in
the lower part of the small intestine and colon are
grayish. The jaundice, excessive fatty degenera-
tion, and hemorrhagic changes are so well marked
that the diagnosis usually presents no difficulty.
Acute yellow atrophy of the liver, and septicemia
with jaundice, ecchymoses, and fatty degeneration of
the viscera, may closely resemble phosphorus poison-
ing; this being specially true of the former. In
acute yellow atrophy, although a primary enlarge-
ment of the liver may take place, the characteristic
conditions are: marked diminution in size and con-
sistency, the occurrence of reddish softened areas
where the epithelial cells are disintegrated into a
granular detritus, and the appearance of round-celled
infiltration of the connective tissue. Many bacteria
have also been observed in acute yellow atrophy.
The liver in phosphorus poisoning is usually large,
and although of doughy consistency, it is atill firmer
than in acute yellow atrophy. Punctate hemor-
rhages may be present, but the reddish areas described
above are absent. In septicemia with jaundice
and ecchymoses, the fatty degeneration is usually
not so far advanced as in phosphorus poisoning.
The resemblance may, however, be so close as to
render a decision, simply from the gross appearances,
impossible, in which case the demonstration of phos-
phorus by chemical examination, or the demon-
stration of bacteria by bacteriological examination,
will clear up the diagnosis.
Bichloride of Mercury Poisoning. — In the acute
cases, in which death occurs in collapse after a few-
hours, the corrosive effect upon the mucosa of the
mouth, pharynx, esophagus, and especially the stom-
ach, is apparent in the presence of grayish-white
eschars. From the action of mercury upon the blood
the eschar may show a grayish-violet tinge. In
cases that have survived a few days the eschar may
in part have been cast off, presenting ulcers with
undermined edges, the submucous tissue being con-
gested and ecehymotic. Where the action has not
been sufficiently strong to cause corrosion, the mucosa
may be congested and ecehymotic. The upper por-
tion of the small intestine may also show the same
effects, which gradually become less marked as we
advance downward from the stomach in the course of
our examination. In subacute cases, these portions
of the alimentary tract may show no changes or
merely those of a diphtheritic inflammation. In
the lower portion of the ileum and in the large in-
testine, the characteristic changes are found, con-
sisting of an inflammation of an acute exudative
type with necrosis and the formation of a membrane,
affecting more especially the crests of the folds and the
areas in and about the lymphadenoid tissue. The
submucosa is considerably distended with serum and
infiltrated with pus cells. The gross appearances
closely resemble thosfe of dysentery. This effect is
not due to the local action of sublimate; it seems to be
due to the excretion of the poison, especially by the
large intestine, since it is equally well marked in cases
of mercury poisoning by inunction, by subcutaneous
injection, and by intrauterine injection. The kidneys
are enlarged, soft, and edematous. The cortex is
markedly swollen, and of a light yellow or grayish
color. The pyramids are dark and congested. These
changes are due to parenchymatous or fatty degenera-
tion of the epithelium of the uriniferous tubules,
especially in the cortex, and to an acute exudative
inflammation. A marked proliferation and des-
quamation of epithelium may occur. The stroma of
the kidney is infiltrated with serum.
Potassium Chlorate. — The oxyhemoglobin is re-
duced to methemoglobin, and in addition the red
blood cells are disintegrated. The blood presents
the appearance of thick chocolate or coffee grounds.
The postmortem spots are grayish or grayish-violet.
Jaundice may be present. The spleen may be en-
larged. The kidnej-s present a characteristic appear-
ance. An acute exudative nephritis of hemorrhagic
type is invariably present. It is characterized by
especially well-marked changes about the glomeruli,
tin' uriniferous tubules being filled with brown blood
clots which give the appearance of brownish stria-
tions more marked in the pyramids.
Opium anil Morphine. — If opium has been taken in
substance or in tincture, the characteristic odor may
be present. If a decoction of poppy heads has been
taken, particles of the plant may be discovered and
identified by the microscope. As far as the postmortem
appearances are concerned, there is nothing character-
istic upon which the diagnosis can be made positively.
Passive hyperemia of the brain and lungs may be
found. The blood in acute cases is usually fluid, in
others it is clotted. The appearance of the pupils is
of minor importance, since the marked contraction
may not be preserved post mortem.
Strychnine. — Early, intense, and persistent rigor
mortis has been noted, but this occurs in other con-
ditions. The blood is dark and fluid (asphyxia);
passive hyperemia of the brain and lungs and ecehy-
motic spots may be present.
Atropine and its group, digitalis, veratrine, aconite,
aloes, colocynth, jalap, scammony, savin, croton oil,
colchicum, hellebore, elaterium, may all produce the
effects of gastrointestinal irritation, depending upon
the amount of the drug — namely, hyperemia, ecchy-
moses, intense catarrhal or sometimes croupous
inflammation, or even necrosis.
Ptomaine Poisoning. — The postmortem appearance
is not characteristic; a more or less intense gastro-
enteritis may be the only lesion found. In addition,
parenchymatous degeneration of the liver, kidney,
and heart muscle, general passive hyperemia, ecchy-
moses, and dark fluid blood may be present.
Muscarine Poisoning (poisonous mushrooms). —
Cases have been described with jaundice, ecchymoses
in the cutis, acute fatty degeneration of the liver,
kidney, and heart muscle. The remains of the mush-
rooms in the gastrointestinal tract and their botanical
determination may lead to the diagnosis.
Chloroform. — Death from narcosis may leave no
characteristic signs except those of asphyxia. The
odor of chloroform may be present or absent in the
lungs, stomach, and brain. In some cases, the pres-
ence of chloroform may be demonstrated in the blood
or in the brain by chemical examination. If swallowed,
the odor of chloroform may be apparent in the
stomach contents, and the mucosa of the stomach may
present a soft grayish slough where the chloroform lias
come in contact. In one case in which death from
pneumonia occurred five days after swallowing
chloroform, extensive ulceration of the stomach and
jejunum was found; and similar lesions were observed
in another case in which death occurred after twenty-
seven hours. The blood is fluid or poorly clotted
according to the rapidity or slowness with which
death has set in. Decomposition after chloroform
poisoning takes place rapidly, and there will be gas
bubbles in the blood — a certain indication, as was
formerly believed, of chloroform poisoning. In < :a
in which death has occurred some time after chloro-
form narcosis, parenchymatous degeneration of the
heart, liver, and kidney has been found.
Chloral hydrate may produce merely a marked
hyperemia of the lungs, brain, and spinal cord. It
is" important to take a specimen of the urine for
chemical examination.
Ether. — Poisoning from ether narcosis may simply
show the signs of asphyxia, viz., fluid and dark-
colored blood and the occasional presence of ecchy-
808
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Aii(iii»n> , Medicolegal
ItHallons
loses. In recent cases the odor of ether may be
etected in the lungs, stomach, and brain. Poison-
ii; from ingestion of ether produces the effects of
itense gastrointestinal irritation.
It is of interest , and also of medicolegal importance,
, examine the lymphadenoid tissue throughout the
iody- namely, the nasopharynx, tonsils, dorsum of
he tongue posteriorly, solitary follicles of the stom-
ich and small and largo intestine, Payer's plaques
if the small intestine, the mesenteric and retro-
itoneal lymph nodes, the Malpighian bodies of the
leen, and the thymus gland. A hyperplasia of
hese structures — termed status lymphaticus — pre-
lisposes to the occurrence of sudden death from causes
hat otherwise appear insufficient. In a number of
ases of death following chloroform and ether nar-
nsis this condition has been found. In some of these
es very small amounts of etlier and chloroform hail
i given and had been very carefully administered.
Alcohol. — Concentrated alcohol coagulates albumin
mil extracts water, and may therefore produce a
direct corrosive action upon the gastrointestinal
mucosa. Numerous cases of sudden death follow-
ing ingestion of large amounts have occurred in adults,
comparatively small amounts have sufficed to
cause death in children. Post mortem there will be
found the signs of asphyxia, with alcoholic odor from
imach contents, lungs, and brain, and with intense
roenteritis. It is stated that in chronic alcoholics
intolerance of alcohol increases with the advancement
of the chronic pathological changes due to its long-
continued use, so that comparatively small amounts
may finally cause death.
Glass, if finely pulverized, is not poisonous, as is
commonly believed by the laity. If, however, the
particles are larger, an intense irritant effect on the
mucosa of the stomach and intestines may be mechan-
ically produced, and cases of death from this cause are
on record.
Trichinosis. — As deaths occasionally occur from an
invasion of Trichinella spiralis due to the ingestion of
diseased pork, the vender of such meat or sausage
might be held responsible. In such a case the con-
tents of the stomach and upper portion of the intes-
tinal tract should be examined for free trichinellae,
and the muscular tissue, especially of the diaphragm,
chest, and neck, for encapsulated trichinelke. At
the same time due consideration must be given to the
history of the case, and to such other points as may
throw light upon the source of the infection.
Anthrax. — Intestinal anthrax has occurred in a
number of cases in which an invasion of the bacillus
has been directly traced to infected meat. In some
cases the meat had been thoroughly cooked. This is
not surprising in view of the resistance of anthrax
spores to high temperatures.
Mortal Injuries. — The medicolegal questions
that arise are the following:
1. Differentiation between postmortem changes
and the effects of injury.
_'. Differentiation between injuries inflicted before
death and postmortem injuries.
3. The determination of the immediate cause of
death, whether directly due to the injury, and, in the
presence of more than one injury, the determination
of which one immediately caused death, or whether
more than one injury was necessarily fatal.
4. The determination, if possible, of the character
of the injury, and of the means and method of its
infliction; also whether the means and method alleged,
and the circumstances reported as having attended
the act, are compatible with the character of the
injury.
5. Whether the conditions found are compatible
or not with suicide, and, in the case of more than one
fatal injury, whether or not the injuries might have
been self-inflicted.
6. -Tlie determination of tin- ran e ol death where
id ease follows injury, and also the determination of
the question whether tin- disease i- the direct re ult
of tin' injury or not. When an injui OCI 11 in a
subject already diseased, it is important to learn
whether or n..i tin- di ea ed condition might have
predisposed to the occurrence of the accident in
which injury was sustained, or whether the outcome
of the injury was influenced for tin- worse by reason
of such preexist tng disease.
1. After deatli the blood remaining fluid in the
veins ami capillaries naturally Hows to the mo I
dependent pott inn of the cadaver, collecting especially
where the skin is not subjected to pressure. With
the occurrence of decomposition tile red blood cells
disintegrate, and the serum tinned with blood-coloring
matter may transude through the vessel wall and
infiltrate the surrounding loose areolar tissue. There-
fore the early postmortem spots may be entirely
obliterated by pressure. When, however, po t-
mortem transudation has occurred the spots are
permanent. When decomposition is advanced the
cutis, Milieu I a neons tissue, fascia, and even the muscle
may lie markedly infiltrated and succulent. I'nder
these conditions ordinary postmortem changes, unless
their character and the fact of decomposition having
taken place are noted, may be mistaken for contusions,
ecchymoses, or hematomata. Indeed, it is found that
after death, even without the presence of injuries,
when the veins and capillaries are distended with
blood from the parts being in a dependent position,
minute lacerations may occur and thus give rise to
the formation of ecchymoses. Such have been found,
for instance, in the conjunctiva on one side when the
head has been lying on that side, and in the skin of the
lower extremities when death has occurred by hang-
ing, the cadaver having been suspended for some days.
Where, however, such effusion of blood does occur
its extent is not usually equal to that following actual
contusion or that due to the formation of a hematoma
during life. When a contusion occurs or a hematoma
develops during life the effused blood usually clots;
if, however, decomposition is far advanced, the clot
may be partially disintegrated and some difficulty
may be experienced in determining the exact condition
of things. If we take into consideration all the above
points, and the fact that it is just this formation of
clot that hinders the further transudation into the
tissues, a conclusion can generally be reached.
2. Besides obvious mutilations of the cadaver,
embracing wounds, fractures, and lacerations of tissue,
] lost mortem injuries may be unknowingly produced
during the performance of an autopsy. A wound
sustained during life, however, will present certain
easily distinguishable characters. There will be some
inflammatory reaction about the wound, or granula-
tion tissue will be present, or the edges of the wound
will have become adherent. The effusion of blood in
the tissues about the wound, especially the clotting of
blood in these tissues, forms additional evidence.
Evidence of hemorrhage internally or externally is in
favor of injuries sustained during life. It is possible,
however, for blood to flow from a wound made after
death if the wound has been made in a dependent por-
tion of the body, if a large vein has been opened, or if
decomposition is somewhat advanced. Gaping of the
wound where the subcutaneous areolar tissue is loose
favors the idea that the injury was sustained during
life. Where, however, the skin is thick and the sub-
cutaneous tissue denser and more adherent, gaping
may not occur. Gaping of the wound or eversion
of its edges may occur when subcutaneous fat is pres-
ent in considerable amount, and when decomposition
has taken place. The sign, therefore, is not an abso-
lutely reliable one for or against, but may be of value
if these restrictions are taken into account. Frac-
tures may occur post mortem and may be unknow-
ingly produced, during the autopsy, especially in
809
Autopsy, Medicolegal
Relations
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
senile cases of osteoporosis, by overextension of- the
cervical vertebrae. The absence of hemorrhage and of
inflammatory reaction readily excludes the possibility
of a fracture having occurred during life. By the
same manipulation transverse laceration of the sterno-
cleidomastoid muscles may be produced. In de-
ciding the question of postmortem occurrence or of
infliction during life the same restrictions hold as were
discussed above.
Injuries may occur just before death in cases of
sudden death from disease or in cases of poisoning,
as the result of a fall. These may evidently be of
slight importance. In cases of cerebral hemorrhage
of this type it may be of considerable importance to
determine whether such hemorrhages are of this
character or have followed some primary lesion.
3. An injury may be sufficient of itself — if it should
seriously damage or destroy some vital organ — to
cause death. There are cases, however, in which the
decision that a given injury must necessarily have
been fatal is very hard to reach. This is due to the
fact that in rare cases the patient will recover from
injuries which are commonly looked upon as neces-
sarily fatal. Then again, even if he does not recover,
he may live for days or weeks after the infliction of
the injury.
Secondary mechanical effects following the injury
may be the immediate cause of death. Among these
may be mentioned compression of the brain by blood
clot, interference with heart action by hemorrhage
into the pericardial sac, pneumothorax from a pene-
trating wound of the chest wall or also of the lung
itself, and laceration of the lung by a fractured rib.
Hemorrhage, external or internal into one or
another body cavity, may be the immediate cause of
death. If it is internal, the actual amount of blood
lost to the circulation may be directly measured;
if it is external, and the evidence of the autopsy
alone is at hand, we must depend for our diagnosis
upon the anemia of the organs. If death is due to
hemorrhage, all the organs are pale and almost blood-
less; the heart and vessels contain much less blood
than normally and are contracted. This applies, of
course, to cases in which death immediately follows
the loss of blood. If some time has intervened be-
tween the occurrence of the hemorrhage and death,
there will be an anemic condition, an hydremia;
but the organs will not be found in the bloodless,
dry condition characteristic of those cases in which
death follows immediately after hemorrhage.
The immediate cause of death may be shock.
There is no positive postmortem evidence upon which
such a diagnosis could be based independently of
the history of the case. Multiplicity of injuries,
extent of injury, evidence of compression or con-
tusion of the abdomen as afforded by marked dilata-
tion of the abdominal veins, might all favor such a
conclusion. The clinical history, especially the time
intervening between injury and death, taken in con-
nection with the above data, is probably better evi-
dence. In this connection it should be remembered
that there are undoubted cases of death from shock
alone without the infliction of injury. In many, of
course, a neurotic predisposition may be presumed,
or the existence of heart lesions or disease of the
cerebral vessels may explain the cause of death,
the shock in such cases producing a nervous or
vascular effect determining the occurrence of syn-
cope and death.
In the presence of more than one injury, the effects
of each should be carefully weighed and its importance
in the causation of death determined. Each injury
should be separately considered and the probable
result, if such injury alone were present, determined.
This is a matter of considerable importance, as
the injuries may have been inflicted by different
individuals, or by the same individual under different
circumstances; as, for instance, when a first shot is
810
fired in self-defence and a second when the assailant
has turned in flight. The question might arise
whether one of the wounds might have been self-
inflicted, the other having been admittedly inflicted
by the defendant on trial. Such might possibly be
the case in a struggle, both the participants being
armed, or where an officer in pursuit of a fugitive
revolver in hand, is afterward found dead with two
bullet wounds. Even though there may be evi-
dence of his weapon having been recently dischan
this of course would not be conclusive of one wound
having been self-inflicted.
4. An accurate description of all injuries, their
character, location, tissues involved, measurements
direction, and external appearance, including that
of surrounding parts, not only of the body but also of
the clothing if possible, should be made in every case.
This is of the greatest importance, and may be the
only admissible evidence upon which a case can be
decided by the jury.
A contusion according to its severity indicates
more or less forcible contact with some flat or blunt
firm substance — i.e. either a blow or a fall. Which
is the case in a given instance may be impossible to
decide from the contusion alone. Its size may afford
some help; its location may be of more importance.
Such situations compatible with a fall will readily
suggest themselves, yet many of these contusions may
not be distinguishable from those which are the
result of a blow. If, however, the area of contusion
is smaller than the area which might readily have
come in contact with given surrounding objects, the
conclusion would be in favor of a blow.
Abrasions favor the conclusion of a glancing fall
or blow.
A hematoma may occupy the site of contact in a
blow or fall, or may be secondary to a fracture the
result of such blow or fall, and may occupy a position
near or at a distance from the immediate site of
contact.
Wounds are described as incised, contused, lacer-
ated, and punctured. These adjectives readily sug-
gest a cut or a thrust with a sharp, blunt, ragged, or
pointed instrument; or a fall upon such sharp, blunt,
ragged, or pointed object. It should be remembered,
however, that the appearance of an incised wound
may be simulated when such wound occurs over
projecting bony ridges, as the supraorbital ridge,
nose, margin of jaw, tibia, etc., although really pro-
duced by blunt objects either from a blow or from a
fall. Even a bullet wound may occasionally resemble
an incised or punctured wound from the splitting of
the skin over a bony surface.
Bullet Wounds. — The accurate description of their
special characteristics is of the greatest importance,
not only in proving the presence of a bullet wound
when the bullet cannot be found, but also in furnishing
data from which valuable conclusions may be drawn.
The points for examination and description are as
follows:
(a) The skin and surrounding parts externally.
(1) The solution of continuity in the skin.
(2) The immediate surrounding narrow zone of
contusion, abrasion, and lead staining. Both of these
are effects produced by the bullet.
(3) The stain or smudge which can readily be
wiped off or washed off, the effect of the smoke.
(4) The embedded powder particles, some of which
from their very superficial location can be washed
off, while others more deeply situated remain — tlie
effect of incomplete combustion of the powder.
(5) Burning of the surrounding skin and singeing
of the hair, the effect of the flame.
(G) The zone of contusion about the wound larger
than that produced by the bullet — the effect of con-
cussion of the explosive gases.
(b) Immediately beneath the wound in the skin
the following effects may be noted:
REFERENCE HANDBOOK OF THE MEDICAL SCIKXCF.S
Autopsy, Medicolegal
Relations
li Contusion and laceration of tissue by the
tplosh e gases.
(2) Staining by sinoko and by particles of powder
uchanged it incompletely burned.
Burning or charring by the flame, ignited
aider, or wad.
c) the track of the bullet and the tissue sur-
. muling it may present the above effects of lacera-
I'rom the explosive gases, charring from the flame,
ad blackening from embedded particles of powder;
nd in soft parts these effects may be even in. ire
larked than directly beneath the skin on account of
lie centrifugal distribution of these effects. In
.ullet wounds of the brain still other effects may be
iroduced; some of them being due to the fact thai
mailer or larger fragments of bone are carried in
projectiles, and others resulting from the fragmen-
m of the bullet, the result either of the composi-
l of the bullet or of the manner in which it has
truck the bone.
If we take these facts into account, it can readily
>e understood how these effects vary according to
he size, caliber, length, shape, consistence, and
tructure of the bullet; the kind, condition, and
imount of the powder charge; the character of the
veapon, whether a rifle, gun, pistol, or revolver; and
he range from which the shot was fired. Inter-
vening clothing and hair, depending upon its amount,
exture, and arrangement, may influence certain of
hese appearances, causing their absence in the wound
>r upon the skin when otherwise they would cer-
ainly have been present.
From experiments performed upon the cadaver
,vith different weapons of different caliber, at ranges
varying from contact onward, and upon different
parts, results have been produced which with cer-
tain minor limitations form a basis upon which,
when the effects produced in a wound are known and
the circumstances set forth above are taken into
account, the range at which the shot was fired can be
rmined with considerable accuracy. It is not
meant that the distance can always be determined
within an inch; nor is such determination always
called for. We can determine, however, that
certain effects could not have been produced beyond
a certain range, or within a certain range, and thereby
we shall be able to exclude suicide or to admit its
possibility. The effects produced in the wound may
then be the onty evidence upon which a decision can
be reached, or may prove strong corroborative
evidence, or may be the only means of preventing
an unjust conviction.
The wound in the skin may be round, its edges
roughened by contusion; or, by reason of small
lacerations of its margin, it may present the appear-
ance of a rosette. Again, it may be quite large and
may have a triangular or ovoid shape; or it may be
slit-like and resemble an incised wound, the bullet
having caused a splitting of the skin. Such a wound
may heal by primary union and obscure the character
of the injury. It is produced more frequently with
revolvers of smaller caliber and by pointed bullets.
Aberrations from the circular or round form of
wound may be produced by the bullet striking the
skin surface at a more acute angle. Larger lacera-
tions leading from the wound may in some cases be
explained by the effect of the explosive gases beneath
the skin. (For further details in regard to the
different characteristics of bullet wounds the reader
is referred to the article on Gunshot Wounds in a
later volume.)
The limit of the range beyond which grains of
powder cannot become embedded in the skin adjacent
to the wound varies, according to the caliber of the
weapon used and the amount of the charge of powder
from about one foot with a small revolver to three
feet and more with those of large caliber, six feet with
the old-style army pistol, and still greater distance
with a shotgun. Embedded powder grains are
found within these ranges f..r weapons cited. They
are few in number and scattered with tin- higher
range, and more concentrated and abundant as
contact is appi lied on account of their centrifu-
gal distribution. With contact they are usually
absent in the skin but present in larger amount in the
tissues beneath, f he depth depending upon the
caliber of the weapon ami the amount of powder in
the charge. With a revolver "i medium caliber the
deposit of powder grains in the wound diminishes
with increase of range to mere staining of the bullet
track, so that beyond one inch the effect of powder
grains in the wound cea i- to In cd. When the
muzzle is not held in immediate contact the powder
grains appear in the skin about the wound, and the
appearance varies with the distance as stated above.
At contact the effect of the explosive gases and the
staining and charring of the subcutaneous wound are
most marked, varying according to caliber and powder
charge. Laceration of tissue thus produced is almost
constant with 0.32 to 0.44 caliber, but is exceptional
with 0.22.
Burning of the hair is more extensive than burning
of the skin, and varies according to the caliber and
the range. With a 0.22 caliber it varies from con-
tact to three inches; with a 0.44 caliber, from con-
tact to fifteen inches. At contact there may be no
singeing of the hair at all, or if present it is confined
to a few hairs immediately about the wound. With
a revolver of medium caliber, at one-quarter of an
inch, singeing is invariably present but may be
limited to an area of one inch or less. At a range of
from three to five inches singeing is no longer constant.
Burning of the skin varies in the same way and
within narrower limits. At contact, with a revolver
of medium caliber, there may be charring of the edge
of the wound, but the greatest effect is produced
on the underlying tissues. At a distance of from one-
quarter of an inch to three inches charring is usual
but not constant; at. greater ranges it is absent.
With larger weapons it may occur at greater ranges.
To recapitulate, the effects will disappear in the
following order, as the range is increased from con-
tact to the maximum limit:
(1) Effect of explosive gases.
(2) Effect of smoke stain or smudge which can
be wiped or washed off.
(3) Effect of the flame in burning of the skin.
(4) Singeing of the hair.
(5) Embedded powder grains.
Protection of the part by clothing or hair will
explain the absence of some effects, namely, smoke
stain, embedded powder grains in the skin, or burning
of the skin at short range. In such cases we may
have the valuable sign of singeing of the hair to
guide us.
The track of the bullet, besides presenting effects
already noted, may be of importance in establishing
the direction from which a shot was fired or the
position of the body when the shot was fired. Care
should be taken in reaching conclusions, since it is
well known that the course of a bullet may be deflected
especially by bone, and that a bullet may wander
not only after being in the body a considerable time,
but also in fresh cases. The track is of importance
also as a guide to the location of a bullet. The track
may contain the wad, and in an interesting case in
literature such a wad served to convict. A game-
keeper was found dead in the forest; the wad was not
burned and proved to be part of a calendar in posses-
sion of a notorious poacher.
Although the bullet may be markedly deformed or
flattened, the rim at its base is usually sufficiently
intact to determine its caliber. Certain markings
upon the bullet may prove valuable evidence of its
having been fired from a given weapon. Moreover,
811
Autopsy, Medicolegal
Relations
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
its presentation to the jury is the best evidence that
the wound was really produced by a bullet.
Multiple wounds may be caused by the same bullet
passing through the upper extremity and thorax, or
lower extremity and abdomen, or through mamma
and thorax; three or more wounds being present in the
skin. It is necessary to distinguish wounds of en-
trance from wounds of exit. As far as the soft parts
are concerned, this has been discussed above. In the
calvarium the fracture produced is an excellent
criterion. The table upon which the bullet impinges
first is fractured to a less extent. Thus, in wounds
of entrance the outer table presents the smaller
opening, the inner the larger opening; the fracture
shelves inward. In wounds of exit the inner table
presents the smaller opening; the fracture shelves
outward.
The opening made by the bullet in passing through
bone is usually larger than the caliber of the bullet,
and in the case of bullet wounds of the brain the
canal of the bullet may also be considerably larger,
this effect being due in part to the flattening of the
bullet against the bone, and in part to the carrying in
of fragments of bone.
Where deflection has occurred and where, as in the
abdominal cavity, the bullet may traverse a consid-
erable distance without causing lesions, the track or
canal of the bullet may not lead directly to the bullet
itself. In one case the wound of entrance was located
in the right hypochondriac region and with it was
associated a wound of the transverse colon and its
mesentery. The direction of the track, up to this
point, was backward, inward, and slightly down-
ward, yet the bullet was found embedded beneath
the iliopsoas muscle on the left side of the fifth
lumbar vertebra. In another case the wound of
entrance was located on the anterior and inner aspect
of the left thigh, with perforation into the peritoneal
cavity below Poupart's ligament. The bullet, how-
ever, was found in the stomach, and there was a
wound in its posterior wall near the greater curvature,
with a second wound in the transverse mesocolon. In
bullet wounds of the brain the amount of deflection
may be considerable, so that the canal may pass
through the superficial part of the cortex, from one
side of the cranium to the other. The angle of deflec-
tion may be very acute. Thus in one case the wound
of entrance was located over the left parietal boss,
while the track passed downward and across the
median line through the brain to the right side of the
frontal bone, causing comminution at the junction of
the orbital plate and perpendicular portion. A
second canal was found in the right hemisphere
leading to the bullet; the latter being very much
flattened beneath the right parietal boss, which was
excessively comminuted.
The discharge of a weapon at contact, provided the
powder charge is sufficiently large, even though
there is no bullet and consequently no bullet wound
through the skin, may cause death. A case is re-
ported of laceration of the heart through such a dis-
charge at contact against the precordial region. The
skin presented the usual appearances with the
exception of a bullet wound, i.e. smoke stain,
burn, and embedded powder grains were visible.
Cases have occurred in which the mouth was
filled with powder, which was then ignited.
The extent of comminution of bone varies with the
character of the bullet, its soft or hard consistency,
its structure, its caliber, powder charge, and range;
in addition the thickness of bone must be taken into
account.
5. The decision whether a bullet wound was self-
inflicted may be difficult to reach when the wound
presents the appearance of a shot at contact, or wit h in
a range at which self-infliction is possible. Such
wounds may of course have been inflicted by another
individual. The wound in suicide, although usually
inflicted at or nearly at contact, need not of course
have been so inflicted. From the situation of the
wound of entrance, and the direction of the track
valuable conclusions may be drawn; but the possi-
bility of suicide should not be excluded except after
the most careful consideration, since peculiar methods
of handling the pistol may have been employed, such
as steadying the barrel with one hand against the
part and pulling the trigger with the other. From
the reflection of smoke and powder grains the ban
may become stained. Careful examination of both
hands with this end in view should be made, and
from the above it can easily be understood how the
stain may appear, not only upon the hand used to
discharge the weapon, but where the barrel has been
si radied with the other hand this may be stained, and
yet the stain be absent upon the hand that has pulled
the trigger. This will explain, for instance, the pres-
ence of a bullet wound on the right side of the head,
and a powder stain on the left hand. The palm and
flexor aspect of the thumb should be examined fur
scratches or contusions that might have been
produced by the recoil of the revolver. All attend-
ing circumstances should be noted. Of course, the
revolver still grasped in the hand of the deceased
does not necessarily prove suicide, as it is conceivable
that before rigor mortis has set in such a condition
may be directly produced post mortem.
The question of multiple self-inflicted wounds comes
up for decision in cases in which one or more were
necessarily fatal, and it may be important to decide
whether one was immediately fatal. The presump-
tion may arise that the second wound could not have
been inflicted after the infliction of the first.. Double
bullet wounds in the heart have been self-inflicted.
Whether a bullet wound of the brain necessarily
prevents a further voluntary action, is often hard to
decide. Of course, if a vital center has been lacer-
ated death must have occurred immediately there-
after. Still it is quite possible that laceration of the
brain, and sometimes quite considerable laceration,
may occur in uncommon cases without being imme-
diately fatal.
Bullet wounds together with other injuries may
occur in cases of suicide, all having been self-inflicted.
In addition, numerous cases have been reported of
poisoning and traumatism in the same individual.
6. The estimation of the relative importance of
disease and injury and of their dependence upon each
other is best considered regionally. Certain con-
siderations apply in all cases. Thus, for example, it
must be remembered that a wound infection — such
as septicemia, pyemia, erysipelas, and tetanus— may
follow an injury. Local tuberculous processes may
be secondary to traumatism. Pneumonia may
follow an injury and may prove fatal. When injuries
occur in a subject of chronic disease, the injury and
the disease should be separately considered, and the
attempt should be made to determine the part played
by each in the causation of death. Post mortem,
the differentiation between the results of disease and
those of traumatism should be made, and in this
connection the subject of hemorrhage is important,
as it may be the result of either. Mistakes may be
made in determining the origin of hemorrhage.
Brain. — In cases of concussion of the brain, external
signs of violence may be present, but cases may occur
of even fatal concussion with little or no evidence
of external violence. The brain is usually conge
and sometimes shows multiple and very fine contu-
sions over the entire surface. The floor of the fourth
ventricle is a spot where important evidence may In-
found in these cases, and it should be examined from
above, the brain having been laid on its base with the
cerebellum toward the observer. After section of the
cerebral hemisphere on either side, a median incision
is made through the cerebellum until the ventricle
is reached. Then the incision is to be extended
812
REFERENCE IIAXDHOOK OF THE MEDICAL SCIENCES
Autopsy, Medicolegal
Bela lions
nteriorly to the corpora quadrigemina and poste-
,,1-lv to the divergence of I lie restiform bodies. Fin-
||y the separation of the two halves of the cerebellum
ill bring into view the floor of the fourth ventricle.
n fatal concussion ecchymotic spots varying in
umber and extent are usually found here. Care
liould be taken not to confuse the prominent veins
sually found on either side of the anterior part of the
id of the fourth ventricle, with ecchynioses.
Contusion of the brain is practically a minute
face laceration of the cortex. It is marked by
ed spots that remain after pressure on the pia and
h on section prove to be a thin surface hemor-
bage beneath the pia in the brain substance.
Laceration of the brain is always a< mpanied by
aorrhage and may be due to violence or to the
•(fusion of blood from spontaneous rupture of a
eased vessel. In the latter case the typical loca-
.111 of the hemorrhage is in the lenticular nucleus,
he blood having come from a rupture of one or
ither of the anterior perforating arteries, most
lommonly the lenticulostriate. The hemorrhage
ind laceration may vary in extent; they may involve
inner capsule, the head of the caudate nucleus or
the optic thalamus, and sometimes they extend into
the ventricle; or the extension may take place in an
nut ward direction through the outer capsule, the
.laustrum, and the cortex of the island of Reil. Vio-
lence, however, may cause just such a hemorrhage,
although in such a case other lesions are likely to be
present in addition. As a general rule, multiplicity
of hemorrhages and lacerations point to violence.
A spontaneous hemorrhage may occur in the usual
site described above, and when the violence is due to
a fall upon the back of the head following loss of
consciousness multiple hemorrhages with laceration
of brain tissue may occur in the brain substance and
in the cortex. In laceration of the brain due to
violence, the lesions are usually most marked in the
cortex, on the surface, and they become less exten-
sive in the deeper portion of the brain tissue. Such
laceration may be due to a comminuted depressed
fracture of the skull, the actual tearing being caused
by fragments of bone; far more commonly, however,
the seat of laceration is directly opposite the point of
application of violence as indicated by a lacerated
scalp wound, contusion or hematoma of the scalp.
The brain is apparently capable of enduring
considerable compression without the occurrence
of laceration. Where, however, the brain tissue
is called upon to fill out an increased space, i.e.
where distention occurs, laceration results. When
violence is exerted upon one point of the cranium,
the convexity of the bone is suddenly reduced, while
at a point directly opposite the convexity is increased
by compensation. At the point of application,
therefore, the brain may be compressed without lacer-
ation, while at the opposite point the brain is dis-
tended and laceration results. With a blow or fall
upon the side of the head, with a hematoma in the
temporal or parietal region, the surface of the cau-
date nucleus and optic thalamus on the same side is
sometimes the seat of laceration, without laceration
of the temporal or parietal cortex on that side. Here,
again, the cortex has been compressed and an oppo-
site brain surface, though an internal one, has become
lacerated by distention. Laceration of the cortex,
although commonly occurring with fracture of the
skull, either at some point in the skull cap or at its
base, may also occur without fracture, the bone
having been sufficiently elastic to accommodate
itself, without breaking, to the sudden change in
shape due to the violence. With laceration of the
brain a blood clot, more or less extensive, may form
between dura and pia. When the laceration does not
involve the pia mater, blood may be infiltrated in the
meshes of the pia arachnoid and may infiltrate the
sulci beneath the pia mater.
Injuries to the <\r,h,,ii \, els. —Isolated laci
Hon of one or anothei cerebral vessel may be due to
violence either with or without fracture ol the skull.
The vessel may or may not have previously ben tin-
seat of fatty degeneration or of aneurysm. Iii such a
case the blood is usually poured OUl beneath the pia
mater, more commonly at the base of the brain;
it may infiltrate both fissures of Sylvius, and passing
beneath the velum interpositum, through the large
transverse fissure, may break through the single
layer of epithelium constituting the ependyma and
gain access to the ventricles. An accurate examina-
tion of all the cerebral vessels is a matter of consider-
able importance. In the case of an aneurysm, sponta-
neous rupture is quite possible; but when tin
are the seat, of tatty degeneration and atheroma,
spontaneous rupture is infrequent, if we except the
lenticulostriate and anterior perforating branche .
Atheroma will, however, account for conditions —
namely, vertigo and sudden loss of consciousness —
which in themselves may be responsible for the occur-
rence of traumatism.
Traumatic Meningitis. — Acute purulent or pro-
ductive meningitis may occur from traumatism, and
may be the immediate cause of death. Where a
wound, with or without fracture of the skull, has
opened the way for infection, or where fracture of t In-
base of the skull has permitted infection through
nasal, buccal, or aural orifices, the connection of a
purulent meningitis with the traumatism, although
indirect, is quite evident. Such a purulent menin-
gitis may not follow the traumatism directly, as infec-
tion may take place later and is possible as long as the
wound or fracture is not completely healed.
Where, however, a purulent or an acute productive
meningitis is found without an apparent avenue of
infection, but following a traumatism (as contusion
of some part of the head with concussion of the brain),
the connection between the meningitis and the trau-
matism is more difficult to establish. All other
causes of meningitis would have to be excluded.
In addition, the clinical history of onset of menin-
gitis within at least a few days from reception of the
traumatism, would be most important evidence.
The stage of the inflammatory process as found at the
autopsy is of great importance. Although it might
not be possible to determine absolutely the duration
of the disease, still it might be ascertained that the
duration was or was not longer than a given time,
namely, the date of the occurrence of the traumatism
in evidence.
The important bearing of an inflammatory process,
with invasion of pyogenic bacteria in some other
portion of the body adjacent or remote, should not be
forgotten as a possible source of infection.
The occurrence of acute exudative inflammations of
serous membranes in subjects of chronic interstitial or
diffuse nephritis without traumatism, would render
the acceptance of these diseases as predisposing
conditions of meningitis from traumatism quite
plausible.
Hemorrhagic meningitis is not necessarily trau-
matic. It may occur as a complication of typhoid
fever and other infectious diseases.
Acute pachymeningitis may be secondary to frac-
ture of the skull, from infection, or to an infected scalp
wound or erysipelas. The inflammation may affect
the external layer of the dura (usually in the form of a
purulent pachymeningitis) or the internal layer (in
the form of a fibrinous pachymeningitis), or both
layers may be inflamed.
Pachymeningitis interna hoemorrhagica may give
rise to a hemorrhage with formation of clot between
the dura and the pia. When one or more layers of
tissue result from attacks of this form of inflamma-
tion — layers which may be stripped off from the
dura — the diagnosis is readily made from a simple
macroscopic examination. An excessive hemor-
813
Autopsy, Medicolegal
Relations
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
rhage may, however, occur at an early stage when the
membrane is as yet very thin, and when microscopic
examination may be necessary to substantiate the
diagnosis. Pachymeningitis interna hemorrhagica
must be suspected whenever a blood clot is found
between the pia and the. dura, especially over the
convexity on one side, in the absence of laceration of the
brain. Such a clot might, however, result from lacera-
tion of the veins in the pia as they pass over to the
dura, to gain access to the longitudinal sinus. Pachy-
meningitis may at any time cause a spontaneous hem-
orrhage with compression of the brain and death. _ It
Is conceivable that violence, not necessarily excessive,
may at any time determine such a hemorrhage; it
should be remembered, however, that vertigo and
loss of consciousness (common symptoms of this
affection) may be responsible for the occurrence of
trauma, which in its turn may determine the
hemorrhage.
Meningeal Arteries. — Laceration is due to trauma-
tism, and occurs most commonly with fracture of the
skull (vertex or base), the site of laceration corre-
sponding to the point where the line of fracture
crosses the course of the artery. Laceration may
occur without fracture. The middle meningeal or
one of its branches is most exposed to laceration from
its course and its position in a deep groove, or even a
canal, of bone. The effusion of blood occurs between
dura and bone, unless the dura is completely lacerated
by a comminuted depressed fracture. Compression
of the brain by the resulting clot is usually sufficient,
if unrelieved, to cause death. However, when the
effusion of blood is not too excessive the compression
may not be sufficient to cause death. A clot three
inches in diameter and three-fourths of an inch in
thickness compressing the right frontal lobe, and due
to laceration of a branch of the anterior meningeal
artery, with stellate fracture of the right orbital
plate, was found in a case in which death was due to
pneumothorax from perforation of a tuberculous
focus. There was no history of cerebral symptoms.
The organization of the peripheral part of the clot
showed that it must have been present for several
weeks.
As regards fracture of the skull, vertex or base, as
a cause for death, it should be remembered that the
fracture in itself, except in so far as it may open the
way for infection, is of minor importance. The
lesions of the vessels and consequent hemorrhage,
the accompanying concussion, contusion, laceration,
and compression of the brain, are the important fac-
tors. The fracture is of importance, and its descrip-
tion should always be accurately made, as it may
indicate not only the degree of violence sustained,
but in addition may serve to indicate the character
of the weapon employed or the manner in which the
injury was sustained.
Neck. — The injuries produced by strangulation and
hanging are considered in the section on Asphyxia.
Contusion of the larynx may cause sudden death by
shock, by reflex paralysis of respiration, or by
spasm of the glottis. Fractures of the laryngeal or
tracheal cartilages, from the edema of the submucous
areolar tissue accompanying them, may cause occlu-
sion of the respiratory passage and asphyxia. Lacer-
ation of the mucosa accompanying such fractures or
occurring alone may be followed by cellular emphysema
and by asphyxia. A case in point has been observed
in which a laceration of the mucosa between the
larynx and the trachea, followed by cellular emphy-
sema of the neck, glottis, upper half of the thoracic
wall, and mediastinum, although tracheotomy had
been performed, caused death from asphyxia. The
laceration in this case was produced by sudden over-
extension of the neck, in a fall upon the chin.
Incised wounds of the neck, as in cases of suicide,
may cause death from hemorrhage; more commonly,
however, the larger vessels are not cut, but the inci-
sion passes between the hyoid bone and the larynx
through the larynx or trachea, into the respiratory
passage. Death in such cases may be due to a com-
plicating bronchopneumonia from aspiration of the
discharges from the wound.
Direct contusion of the posterior part of the neck
may be accompanied by contusion of the medulla and
spinal cord without fracture of the cervical vertebra.
Fracture and dislocation of the cervical vertebra
are more often due to a fall or blow upon the vertex
of the cranium than to direct violence upon the neck.
A wound of the jugular veins immediately above
the thorax may be followed by entrance of air into
the right heart and pulmonary circulation, causing
sudden death.
Thorax. — Simple fracture of the ribs is not usually
in itself a cause of death. If, however, an inter-
costal artery has been lacerated, or the lung or the
heart punctured, death may follow hemorrhage or
pneumothorax.
Compound fracture may be followed by cellular em-
physema, and, if perforation of the pleural sac has oc-
curred, by pneumothorax.
Contusion and laceration of the lung may accom-
pany fractured ribs, or there may be few or no signs of
violence in the thoracic wall. This is particularly
likely to be the case in children. These lesions may
produce ecchymoses, parenchymatous hemorrhages,
interstitial emphysema, or pneumothorax.
Pneumothorax may result from the perforation of
a tuberculous focus into the pleural sac.
Wounds of the lung may cause death by hemor-
rhage, pneumothorax, cellular emphysema, or by
complicating pneumonia.
Pneumonia may be secondary to cerebral injuries,
and to other injuries besides those of the respiratory
tract mentioned. Infection of wounds may explain
a secondary pneumonia in some cases; in others a
condition of passive hyperemia, followed by "hy-
postatic" pneumonia, may be due to the confinement
and enfeebled condition following such injuries, or
to the advanced age of the individual.
Rupture of the heart may be spontaneous and duo
to fatty degeneration or necrosis of a portion of its
wall from occlusion of the afferent branch of the
coronary artery. Such rupture usually occurs in
the anterior wall of the left ventricle. Contusion and
laceration of the heart may occur from direct con-
tusion, or from compression of the thorax. In the
latter case, laceration is far more likely to occur in the
wall of the right auricle. Laceration of the posterior
wall of the left ventricle, where it comes in relation
with the tendon of the diaphragm, was found in i
of fall from a height; the accompanying lesions in
this case being contusions, fractured ribs, and
lacerations of both lungs.
Stab and bullet wounds of the heart cause death
through the compression exerted upon the heart bj
the effused blood in the pericardial sac. This serves
to explain the fact that death in such cases is not
necessarily instantaneous. A few cases of recovi
from such wounds are on record. Depending ujion
the character of the wound and the rapidity or slow-
ness of the resulting hemorrhage, a shorter or longer
period may intervene between reception of the injury
and death. Voluntary action may occur ^ after a
wound of the heart has been received. Thus the
wounded person may run a short distance, or may
close the clasp knife with which the wound had been
inflicted. Multiple bullet wounds of the heart have
been self-inflicted, usually with weapons of small
caliber. Multiple self-inflicted stab wounds of the
heart and other organs are on record.
Fatty embolism of the pulmonary artery may follow
fractures of cancellous bone, especially if considerable
comminution occurs. Embolism of the pulmonary
arteries may also occur as a result of a primary per-
ipheral thrombophlebitis due to injury.
814
REFEHI'.XCK HANDBOOK or TIM-: Ml I'M \l -< [EXCF.S
Autopsy, Medicolegal
Relations
Aneurysms in this region may rupture spontane-
isly, or rupture may follow an injury of compara-
ble minor violence.
Abdomen. — Shock with comparatively slight evi-
ences of injury due to contusion of the abdomen or
f the solar plexus, may occur. Contusion, com-
- .j,,n. and laceration of organs without apparent
ijury of the abdominal wall, are not infrequent,
ration of an artery may occur alone from trau-
-iii, and without previous disease. In other
- the artery may be the scat of some disease like
neurysm or tuberculosis, and a spontaneous hema-
,ma or hemorrhage may occur, or such hemorrhage
iay be the result of an injury otherwise of insuffi-
: violence to cause rupture. Septic peritonitis
nay follow perforation of a hollow viscus due to
or perforation may have been immediately
irought about by injury. Hemorrhagic peritonitis,
orrhagic pancreatitis, with or without fat necro-
tic be mistaken for the results of injury. Hema-
oma of the suprarenal capsule due to excessive
lassive hyperemia, with or without rupture into the
eritoneai cavity, is another condition that may be
Mistaken for the result of violence.
Pelvis. — Spontaneous rupture of the bladder with-
lut disease may occur in subjects of hysteria. A
with fatal hemorrhage, in which traumatism was
ibsolutely excluded, has come to notice. Septicemia
nay follow infiltration of urine due to laceration by
■areless catheterization. Injury to the female
genitalia, not only in cases of criminal abortion but
ilso in non-pregnant cases, may be produced by
lirect violence, or during coitus. Such injuries are
•ommonly lacerations of various extent, either simply
involving the hymen or ostium vagina, or extending
upward into the vagina, or involving the fornix and
perforating into the peritoneal cavity. In such cases
death may be due to hemorrhage, or to septicemia,
or to septic peritonitis. Rupture of the pregnant
uterus may be the result of a fall or blow; on the other
hand it may occur spontaneously. In the latter case,
however, rupture occurs after labor pains — that is,
contractions of the uterus — have set in, and usually
after a more or less prolonged duration of labor due to
obstruction to delivery.
Abortion. — The questions for investigation are:
Has abortion occurred? If so, has it been induced?
Is it responsible for the death of the individual?
Abortion may be defined as the termination of
gestation before the viability of the fetus, this term
being accepted as about thirty weeks or seven cal-
endar months. The postmortem conditions upon
which the diagnosis of gestation that has been termi-
nated may be based, may readily be remembered by
recapitulating the changes produced in the uterus
and ovary by gestation. If in addition some por-
tion of the products of conception is still retained in
utero, its demonstration affords positive proof.
Nevertheless, if no such portion be found, the changes
produced in the uterus and ovary are. sufficiently
characteristic, provided too long a time has not
elapsed, to warrant a positive diagnosis.
If a portion of the fetus or its membranes, more
especially chorionic or placental villi, be demon-
strated, this alone is proof of gestation, but is not in
it-elf proof of criminal abortion. The signs so far
as the uterus and ovary are concerned may individ-
ually, at least in part, be produced by other condi-
tions. These signs are, in the first place, enlargement
of the uterus, especially its body, and enlargement
of its cavity; second, hypertrophy of the uterine
wall, a softer consistency and enlargement of its
veins with formation of sinuses, especially at the
placental site; third, thickening of the endometrium
with the characteristic change in its morphology —
namely, the production of the true decidua of preg-
nancy, and over the anterior or posterior wall at the
fundu-, where the chorionic villi become attached to
tin 1 decidua serotina, the formation of the placenta.
Even though all the chorionic portion of the placenta
has been -eparated, a raw surface i left, differing
from the otherwise smooth lining, which ran readily
be recognized, even from the gross appearand
the placental -ite.
The size of the uterus will vary, in the fir-t place,
according to the period i has been
reached, and, in the second place, according to the'
time elapsed between the cessation of gestation or
abortion and death. The i i tencj "I the uterus
will vary according to the period of gestation, the
presence or absence of metritis, and the advancement
of postmortem changes. The decidua will vary
according to the time at which gestation v. a- inter-
fered with, according to the time which has elapsed
between then and death, and also according to the
degree of inflammatory reaction that may have taken
place.
The ovary that has supplied the ovule which has
been fructified presents a change in its Graafian
follicle that is quite characteristic, especially in the
earlier periods of gestation, namely, .the true corpus
luteum. At the end of the third week this presents
a cyst of two centimeters in diameter with a wall
three millimeters in thickness and of a characteristic
yellow color, usually distended at this period. Shortly
thereafter this wall shows a slight convolution,
while the cavity is often filled with a clear, slightly
viscid fluid, sometimes blood-tinged, or entirely
bloody. From this period onward the change con-
sists in a gradual shrinkage of the entire cyst with
more marked convolution of its yellow wall, and with
absorption of its fluid contents, coincident with a
growth of connective tissue which occupies the place
of the fluid. The corpus luteum persists throughout
the entire period of gestation, and does not diminish
markedly in size until the end of four or five months.
Although in structure the corpus luteum of preg-
nancy does not differ from the normal corpus luteum
of menstruation, yet from its larger size, and its
persistence in size up to the fourth or fifth month,
together with the thickness of its yellow border, it
forms a valuable additional sign of gestation, espe-
cially during the period when criminal abortion is
more commonly committed. The corpus luteum of
menstruation under certain disease conditions — as,
for instance, when there are fibroid tumors of the
uterus, or cystic oophoritis — may reach one centi-
meter or even more in diameter. It is then filled
with clotted blood and has a yellow margin, some-
times convoluted, and measuring one or two milli-
meters in thickness; yet its appearance, when one has
become familiar with the true corpus luteum of preg-
nancy, is quite different. Moreover, a number of
such corpora lutea are usually found. The absence
of diseased conditions in which they occur would be
additional evidence in doubtful cases.
To recapitulate, the only positive evidences that a
fetus in utero has existed are these: The presence of
chorionic villi, which from their adhesion to the
placental site may be readily enough found, and the
demonstration of a true decidua of pregnancy, both
of which structures must have their true character
verified by microscopical examination. To these two,
perhaps, should be added a third, viz., the demonstra-
tion of a true corpus luteum in one or the other ovary.
All the other signs are not in themselves positive, but
taken together they may form sufficient evidence of
recent gestation.
Signs of Abortion having been Induced. — Induction
of abortion may under certain circumstances and
after consultation be perfectly justifiable. When
there is no lawful reason for the termination of gesta-
tion, induction of abortion is criminal. What signs
may we rely upon, in the postmortem examination,
to "conclude that abortion has been criminally in-
815.
Autopsy, Medicolegal
Relations
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
duced? In the first place, the examination of the
fornix of the vagina and cervical canal, especially at
and just below the internal os, for punctures and
lacerations, may furnish strong evidence of such
interference. A large number of cases of criminal
abortion are produced by mechanical means, employed
by persons lacking anatomical knowledge and surgical
skill. A stylet, sound, catheter, or syringe is intro-
duced, or the cervix is clumsily dilated with some in-
strument, all these procedures leaving a mark by rea-
son of their unskilful employment. Examination of
the fundus, the anterior wail or the posterior wall of
the uterus may show a partial or complete puncture
or laceration. The effect of certain corrosive fluids
may be quite noticeable upon the endometrium, for
these fluids — such as carbolic acid or bichloride of
mercury solutions — are sometimes used as intrauterine
injections for the production of abortion.
The effects of the mechanical means mentioned
above are to cause the uterus completely to empty
itself; and, provided the woman escape infection or
withstand it, death may not result. In many cases,
however, the abortion remains incomplete and hemor-
rhage from the partially separated placenta, or from
the actual lesions, lacerations or perforations, pro-
duced, may prove fatal. Or infection may take place
and death may result from a septic endometritis,
metritis, parametritis, and peritonitis.
Besides mechanical means for the induction of
abortion, there are numerous drugs and nostrums
which are taken internally for this purpose. The
danger in their use is twofold: in the first place they
may cause direct poisoning, since many of them in
increased doses are intense gastrointestinal irri-
tants; in the second place, the effect is usually partial,
the fetus being killed but not expelled, or its mem-
branes and the placenta are either incompletely
expelled, or they remain in the uterus and subsequently
lead to death from hemorrhage or from septic
infection.
Asphyxia. — Asphyxia may be due to mechan-
ical causes preventing the entrance of oxygen into
the lungs or interfering with the movements of
respiration; or it may be due to the presence of irrespir-
able gases or to causes acting upon the respiratory
center in the medulla. The following list includes
many of the different ways in which asphyxia may be
produced in a mechanical manner: Occlusion of the
mouth and nose, larynx, trachea, and bronchi,
either by foreign bodies or by intrinsic tumors;
occlusion of these same channels by pressure exerted
from the outside — as by an aneurysm, a new growth,
or an enlarged thyroid gland, or by an accumulation
of fluid or air in the pleural sac; compression of the
chest wall, direct compression of the trachea, or
more commonly the compression of the hyoid bone,
base of the tongue, and epiglottis, over the aditus
laryngis, as in strangulation; aspiration of stomach
contents in vomiting; entrance of pus from a tuber-
culous lymph node which in breaking down has
perforated the trachea or bronchus; submersion as in
drowning, or conditions in which the mouth and
nose alone become submerged below the level of the
fluid, as in some cases of death of the new-born, or of
intoxicated or unconscious persons.
(For information in regard to the various forms of
poisoning by carbonic acid gas, see the article entitled
Carbon, Oxides of.)
Asphyxia may be caused by inhalation of irrespir-
able gases such as chlorine, bromine, iodine, nitrous
acid, sulphurous acid, and sulphureted hydrogen.
In these cases death is usually caused immediately by
the shutting off of oxygen. There have been cases in
which death has occurred some time after such
exposure from bronchopneumonia. In regard to
sulphureted hydrogen, it has been thought that it
forms a compound with hemoglobin. If the gas is
passed through blood the latter becomes dirty green-
ish in color and shows a spectrum somewhat like
that of oxyhemoglobin, but with an absorption band
in the red. The blood in cases of death by asphyxia
from sulphureted hydrogen does not show this
spectrum. In animals killed by exposure to sul-
phureted hydrogen much less gas is required (one-
tenth to one-half per cent.l than is needed to cause
the appearance of the sulphureted hydrogen spec-
trum in their blood.
The respiratory center in the medulla may be the
seat of various pathological alterations: there may be
some gross injury, or a hemorrhage may have taken
place, either of traumatic origin or the result of
disease; or the medulla may be compressed by a new
growth, or it may be directly affected by the action of
drugs capable of causing a paralysis of respiration.
When respiration has been suddenly interfered
with by any of the foregoing causes, ecchymotic
spots, varying in size from one millimeter to one
centimeter in diameter, are usually found in the
visceral and parietal pleura, the mediastinal pleura,
the visceral pericardium, sometimes the parietal peri-
cardium, the endocardium, the meninges, and more
rarely the peritoneum. This sign is a valuable one,
although not in itself absolutely diagnostic of as-
phyxia. In cases of slow asphyxiation no ecchymoses
may be found.
Again, ecchymoses may be found in these sites in
conditions other than asphyxia, namely, in septicemia,
purpura hemorrhagic, nephritis, hemorrhagic pleu-
ritis, pericarditis and peritonitis, in many infectious
diseases, and in poisoning by phosphorus, arsenic,
and other poisons. When, however, these conditions
can be excluded the presence of ecchymoses indicates
asphyxia; their absence does not exclude asphyxia,
if otlier conditions are present upon which the diagno-
sis can be based. In some cases of sudden occlusion
of the larynx by a foreign body, as a piece of meat,
or by a laryngeal tumor, death occurs very suddenly,
apparently by reflex paralysis of respiration. The
same condition is sometimes met with in infants with
very large thymus glands, yet in these cases, in spite
of the sudden cessation of respiration, ecchymoses
may be entirely absent.
When death is due to occlusion by a foreign body,
by aspiration of vomit, or by the other conditions
described above, these will be apparent at the autopsy
and in most cases the ecchymotic spots will be present
also. The blood is usually fluid, very dark, from
reduced hemoglobin, and distends the right auricle
and ventricle, pulmonary artery, and vena cava.
The lips and the skin of the face and nfeck may be
cyanotic.
In death from smothering or overlying, the ecchy-
moses are almost invariably found. The lungs
and the bronchial mucosa are usually intensely con-
gested; there may be vesicular emphysema, more
especially of the anterior edges and external margins
at the base of the lung; in some places an actual
rupture of vesicles takes place, with suffusion of
air beneath the pleura, probably from spasmodic
expiratory efforts. The brain is intensely congested,
the face is usually markedly cyanotic, the lips almost
black. The internal organs are engorged with dark
fluid blood; the pulmonary artery, right auricle and
ventricle are distended with dark blood, mostly
fluid, rarely and then poorly clotted.
When death is due to strangulation by garroting or
to compression by the hands, scratch marks are
usually found over the neck and sometimes upon the
chin and cheeks. The hyoid bone and base of the
tongue with the epiglottis may be found pressed over
and occluding the aditus laryngis. There is usually
contusion of muscles and fascia and effusion of blood
into the loose areolar tissue. There may be fracture
of the hyoid bone, of the thyroid cartilage, or of
tracheal rings.
S16
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
A ii lops \ , Medicolegal
Relations
In asphyxia due to strangulation by hanging, tin-
nark of the cord or band is usually found about the
ieck forming a single or double furrow whose depth
, pale, ami whose margins are deeply congested,
11,1 under which in the connective tissue and muscle
he effects of contusion, laceration, and hemorrhage
re found. Laceration of the intima of the arteries
,1m' site of compression may occur. The course of
his furrow may vary, and according to the position
e knot or loop of the noose a con verge nee behind
me or the other ear. under the angle of the jaw on
her nh', under the chin, or under the occiput
:iv lie apparent. The trachea may be compressed
I some of its rings broken, the thyroid curtilage or
he hyoid bone may be fractured, or most commonly
hyoid bone with the base of the tongue and the
piglottis is pressed backward, occluding the opening
f the larynx.
The tongue may be pressed forward and clenched
men the teeth. Cyanosis of the head and neck
hove the furrow may be present. Fluidity ami
lark color of the blood, ecchymoses, and general
ive hyperemia, especially of the lungs and brain,
nay all be present.
It is possible that death may be caused by com-
sion of the vagi, with sudden paralysis of respira-
ion and heart action, in which case cyanosis, exces-
sive hyperemia, and ecchymoses may be absent or
xiorly marked.
In some cases of hanging, with the loop or knot
placed behind the ear, and with sudden tension of the
>ody weight upon the noose, fracture or dislocation
if the atlas upon the axis, with crushing of the medulla
by the odontoid process, occurs, and death is instanta-
neous. The signs mentioned above might then be
'■nt.
In asphyxia by submersion, as in drowning, or
where mouth and nose are alone submerged, the lungs
are increased in size and weight, and congested, the
bronchi are filled with a frothy fluid, and on section a
msiderable amount of fluid escapes. The condition
- quite different from an ordinary edema, even though
very excessive. It is not possible to diagnose sub-
mersion with certainty from chemical examination
of the fluid in the lung, as one might at first think.
If specific substances are contained in the fluid, such,
for instance as portions of vegetable matter, such a
diagnosis might be positively made by microscopical
examination. In addition to the water in the lungs,
which is very probably aspirated in the last moments
of life, there is usually in the stomach a considerable
amount of fluid that has been swallowed. The ques-
tion may arise as to whether or not in a given case in
which a body has been removed from the water, death
was due to drowning. If the above signs are present
the cause of death would be asphyxia by submersion,
since if life is extinct water cannot gain access to the
lungs or stomach. On the other hand, if these signs
are absent it might not be safe to reason that life
was extinct before the body entered the water, since
it is conceivable that in an unconscious condition
there might be no struggle, no dyspnea, and conse-
quently no swallowing or aspiration of water.
Infanticide. — The following points should be
determined:
1. The viability of the fetus; that is, whether it can
be assumed that the fetus was capable of sustaining
life.
2. Was the child born alive, or in a state of sus-
pended animation?
3. The immediate cause of death.
The accepted period of uterogestation, upon the
termination of which the fetus is" viable and capable
of sustaining life under favorable conditions, is reck-
oned as thirty weeks. Some cases have been reported
in which the infant was born alive at twenty weeks,
Vol. I. — 52
ami some even at twenty-live vvei cap-
able of sustaining life foi B lon» I 01 tei time.
At thirty week - t he fetu i forty centimeti i
length. Its weight varies from 1,500 to 2,000 grams.
The skin is covered with fine hair, tin- finger nails
reach the tips of the linger-, the pupillary mem-
brane is either absent or only a vestige remain-, the
te i icle i ha e de i ended or at l< b I eii e Id I hi canal,
the center of ossification in the os calcis is live milli-
meters in diametei thai in the astragalus half thai
size. There are no centers of ossification in
epiphyses at the knee.
The presence of air in pulmonary vesicles, provided
decomposition or direct mechanical inflation can be
excluded, is plain evidence that the child has breathed,
although it is not necessarily evidence thai complete
birth alive has occurred. [nspiratory movements
anil aspiration of air may even occur in utero iluiing
obstetrical manipulations or operations, ami it is
conceivable thai after birth of the head inspiration
may occur and through delay asphyxia may take
place. Again, it is well known that a child may be
born in a condition of apnea, anil even after it has
remained for hours in a condition almost resembling
death, with an occasional heart beat, it may finally
be resuscitated by artificial respiration. In such
cases, although the child is born alive, it may never
have breathed, and consequently the lungs will be
found in a condition of fetal atelectasis. In some of
these cases the presence of air in the stomach or
intestine, provided decomposition can be excluded,
may be the only sign of this condition. In other
cases aeration of the lungs of the fetus may be inter-
fered with by the presence of some pathological
condition of the lungs, namely hepatization, due to
desquamation and fatty degeneration of respira-
tory epithelium (forming whitish areas), by the pres-
ence of an interstitial pneumonia, or by compression
of the lungs by the abdominal organs (either from
partial absence of the diaphragm or from a large
cystic kidney). Again, by the aspiration of liquor
amnii or blood, or by the membranes being unrup-
tured, or, though ruptured, by a portion thereof occlud-
ing mouth and nose, the lungs may fail to become
aerated although the child was born alive.
The differential diagnosis between atelectasis
and aeration of the lung from inspiration is practic-
ally and readily made even from a gross examination,
provided decomposition is not excessive; in fact,
it can be made even though decomposition be
considerably advanced. The atelectatic lung is
smaller, and therefore the vault of the diaphragm is
higher (at the third rib or intercostal space). When
inspiration has occurred the lung is increased in
volume, and the vault of the diaphragm is found
at the level of the sixth rib. Atelectatic lung
is denser and darker in color, its edges are sharper,
it does not crepitate, and it cuts like liver, differing
from hepatization due to inflammation in the absence
of a granular surface on section, and in the absence
of pleuritis. The consistence of aerated lung is
softer, it crepitates on pressure, is light red in color,
and presents on the surface and on section a character-
istic mottled appearance due to the occurrence of
aerated vesicles between areas of blood-vessels.
Magnified by an ordinary hand lens the aeration is
seen to be distributed throughout all the vesicles in
the area. In this it differs from the appearance
presented by vesicles which are filled with gas due to
decomposition, for this gas is never distributed in
such a regular manner. Aerated lung may become
dark from congestion, and often enough post mortem
the posterior portions are found congested and dark,
while the anterior or upper portions are quite light.
Such hypostatic congestion is not at all a marked
feature in atelectatic lungs when respiration has not
taken place. Moreover, in the aerated lung, on
scraping the section frothy blood is found; while in
817
Autopsy, Medicolegal
Belations
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
the atelectatic lung, from which air is absent,
blood if present in any amount is fluid.
The specific gravity of the lung tissue itself being
rather low, when any air is present in its meshes it
readily floats. This is called the hydrostatic test,
and is quite reliable under certain limitations. It
must be remembered that if a lung or portion of a
lung floats, it simply means that it contains air or
gas, which may be the air of inspiration or the gas of
decomposition. Therefore, if decomposition can be
excluded and the lung floats, it is a positive evidence
of aeration. Even though decomposition be present,
it may still be possible to determine the fact that the
lung is aerated; for the gas is never as finely dis-
tributed throughout the air vesicles as is the air in an
aerated lung, but occurs in larger bubbles throughout
the tissue. If after these are pricked and the piece
of lung is squeezed, it still floats, it is highly probable
that the lung is aerated, since it is difficult entirely to
squeeze out all the air from aerated lung tissue.
Another point in regard to decomposition depends
upon the fact that this process develops earlierin the
liver and spleen than in the lung. If portions of
spleen or liver float, and the lung does not, it is posi-
tive evidence of atelectasis.
All the other tests are not as reliable as the exami-
nation of the lung and the demonstration, under the
restrictions given above, that air is or is not present
in the stomach and intestines. In uncommon cases
a child may breath for a number of hours, or even
days, and then die with atelectasis, usually partial
and only rarely complete.
It may be necessary to determine if possible the
length of time that the child lived. The appearance
of the umbilical cord with attached placenta, or of
only a portion of the cord, in a moist and white con-
dition, is a very reliable sign of a recently born infant.
The same may be said of the presence in abundance
of the vernix caseosa. If, however, the umbilical
cord is dry and mummified this does not neces-
sarily mean that the child has lived a number of days,
since the same drying may occur post mortem. A
better criterion is found in the retrogressive changes
of atrophy in the umbilical arteries, and later in the
umbilical vein. The appearance of the umbilicus,
if the cord has come away, may not be a reliable
criterion, inasmuch as it may have been torn out in
the fresh state, or may have dried off, or have been
torn off post mortem. If, however, some granula-
tion tissue is present, this might be of help in approxi-
mately determining the age — for the cord usually
separates after the lapse of from four to seven days.
The so-called fetal vessels, besides the umbilical
arteries — namely, the umbilical vein, the ductus
arteriovenosus, and the foramen ovale — may remain
patent for a week or two, so that this does not help us
in absolutely determining the age within the first
week. The presence of food in the stomach is of
course a valuable sign that the child has lived. The
caput succedaneum is a reliable sign of a recently born
child, and should not be mistaken for an ordinary
hematoma.
In determining the immediate cause of death special
care is necessary to avoid mistaking normal fissures
and divisions of the cranial bones for fractures, and
also not to misinterpret the peculiar rachitic growth
of bone both in the skull and in the long bones for
fractures. In cases of passive hyperemia with patent
ductus arteriovenosus, a hematoma may form in the
medulla of the suprarenal gland and may even rup-
ture into the peritoneal cavity, thus simulating a
traumatism. In cases of melena neonatorum an
effusion of blood may occur in the stomach or in
the intestine, or in the loose areolar tissue about the
kidney and behind the peritoneum.
Special care should be used to avoid the production
of artifacts in the removal of the tongue, fauces, soft
palate, pharynx, larynx, etc., together, as already
described, and a careful search should be made for
evidences of injury or lodgment of foreign particles
or lacerations which ma}' have been produced by the
finger having been passed into the pharynx to cut off
respiration. What has been said about other causes
of death, both traumatism and poisons, applies of
course to infants as well.
Death from Electric Shock. — The medicolegal
importance of death from lightning stroke is slight.
Postmortem appearances may be negative or the
cadaver may present peculiar arborescent markings
of the skin, probably due to vasomotor paral
and subsequent decomposition. Internally, lac
tions of various organs have been described and even
fractures, but the conditions are not constant.
Death from currents of high electromotive force
(fifteen hundred to two thousand volts). — The skin and
subcutaneous tissues may be burned even down to
the bone, in parts that have come in contact with the
wire or other charged object, or, as has sometimes
been observed, the cadaver may show no external
signs whatever. The postmortem conditions are
not sufficiently characteristic, unless such burns are
present, to base a diagnosis of death from electric
current upon them. They are practically the signs
that are seen in other conditions producing asphyxia.
The blood is fluid, the right side of the heart being
filled and dilated. The left ventricle may be con-
tracted. There may be ecchymoses in the endocard-
ium, in the pericardium, in the pleura, and rarely in
the peritoneum. There may be minute hemorrhages
in the floor of the fourth ventricle. The blood is
dark in color.
Death from Burns and Scalds. — Deaths in
conflagrations are more commonly than is generally
believed due to asphyxia from inhalation of smoke,
or to actual burns of the respiratory passages and
acute edema of the glottis from the inhalation of
hot air or flame. Postmortem appearances in such
conditions are discussed in the section on Asphyxia.
When death occurs from actual burns — as may happen,
for example, as a result of a conflagration — it will
be found that the extent of cutaneous surface burned
is a more serious factor than the mere depth of the
burn. Although recovery has occurred in cases in
which a greater area has been involved, if one-third
of the surface of the cutis is burned the individual
usually dies. The cause of death in these cases may
be shock, or it may be due, judging from postmor-
tem appearances, to the action of some poisonous
substance either absorbed from the wound surface
(namely, some ptomaine-like product,) or from the
invasion of bacteria, or from an autointoxication due
to suspension of function of the skin involved.
The heart muscle and the epithelial cells of the liver
and kidney present the appearances of parenchy-
matous degeneration, or, if death occurs somewhat
later, of fatty degeneration. It has been reported
that round ulcer of the duodenum is a frequent accom-
paniment of extensive burns. It is supposed to be
due to ecchymosis of the mucous membrane and
subsequent erosion. In many cases of fatal burns,
however, such ulcers are not found.
The external appearances of the burns vary with
the degree. A burn that during life has merely pro-
duced erythema may, by reason of the postmortem
distribution of the blood, escape attention after
death. If the burn is intense the spot may remain,
and forms good evidence of the burn having been
produced during life. Even though redness may have
vanished, the epidermis may show some change.
In burns of the second degree vesicles are produced,
serum exuding in the lower layers of the epidermis,
and lifting up the horny layer. These vesicles may
be small or large, and after death they may remain
unbroken, and may be surrounded by an area of
hyperemia, or the latter appearance may be absent.
818
REFF.RFNCF. HANDBOOK OF TIIF. MKDIt'AL SCIENCES
Avrrroi's
f the vesicle has been broken, and if this lias recently
iccurred, the denuded corium underneath is moist
uul light in color, ami the shrivelled epidermis may
,ill be partlj- attached. If, however, the part has
ieen exposed to air for a longer time the denuded
orium becomes dry, hard, yellowish or yellowish
irown, or dark brown in color, and like leather or
larchment in consistence. In burns of the third
ree involving the corium down to the subcutane-
ius tissue, if recently produced by scalding, the ti tie
nay be white or grayish white, as if cooked, from
-illation necrosis, or, if produced by a burn, may
ent the appearance of having been roasted. The
le filled with serum is a fairly good indication of
burn having occurred during life. Although some
claimed to have been able to produce such
les post mortem, in most of the experiments
performed on the cadaver such vesicles contain gas.
but not serum. When burns of the third degree
e occurred during life, the blood in the vessels is
immediately coagulated. If a burn is produced posl
mortem, unless possibly in a dependent portion of the
adaver, the coagulated blood will be found only in
the veins and capillaries, and not in the arteries
as well. Histological examination of such tissue
may, under these circumstances, prove of value.
It is said that the network presented post
mortem by leathery, dried-out burns, is due to the
coagulation of blood in the vessels, and if the burn
been produced during life such a network is
very much finer than if the burn is produced after
death.
Where complete charring of the skin has been pro-
duced in conflagrations spontaneous rupture may
occur, its usual site being the flexor aspects of joints
and the perineum. Such spontaneous lacerations
have been mistaken for wounds. They present,
however, no reaction, no hemorrhage, and through
adipose tissue from one surface of the laceration to
the other, vessels and nerves may pass. With the
charring of the skin, rupture not having as yet occurred,
a contraction and shrivelling of the tissue be-
neath may take place. The charred skin protects
the underlying parts from further charring. On this
account complete incineration at conflagrations
3 not usually occur. Besides a bursting of the
scalp, fracture of the bone or the formation of holes
in the bone with exfoliation of burned bone after
charring, or in addition a diastasis of the sutures or
an actual fracture of the skull, produced by the vapor
from the tissues within the cranium being subjected
to a high degree of heat, may occur. Such conditions
may be mistaken for the results of inflicted violence.
If injury has been sustained during life hemorrhage
occurs, or the tissues may become infiltrated with
blood as already discussed. If evidence of such
reaction is found the injury must have occurred
during life. Another valuable criterion is the exami-
nation for carbon monoxide hemoglobin in the blood
that has not been exposed externally. The demon-
stration of carbon monoxide in the blood in
internal parts that could not have come in con-
tact with carbon monoxide after death clearly
proves that carbon monoxide was inhaled. This
tesl may be of value in determining whether life
was extinct or not when the individual was exposed
to the smoke.
The question may arise as to the time which must
have elapsed before the effects found in charring of the
body could have been produced. It has been found
that an hour's exposure to flame will cause a com-
plete charring of the soft tissues, and a further hour's
exposure to the heat of glowing embers will cause
calcining of the bones of a newly born child. At
conflagrations the result is probably produced after
a much longer exposure. The exact time might be
very difficult to determine.
The identification of charred bodies or portions
thereof may present great difficulties. The mat I
shrinkage of the tissues (with the exception I
due to prolonged exposure to heat, should !»■ remem-
bered. \ ca e is reported in which a part found con-
i ted of a pelvis, clearly that of a male adult, which
was embedded in a mass about the size of a man's
head. In it were also found the heart, liver, coils
Of intestine, and tl \teinal genitalia which
very small. The organs presented an ap] ' 1 1:1 1
would have led one to estimate the age of the sub
as between four and six years. The I ■ although
completely charred, may -till sufficiently sustain
their form to be a valuable guide in determining
probable age, or, at least, height of the subject, and
the pelvis may aid in determining the sex after
puberty.
Death from Exposure to Cold. Appearances
due to frosl bite may or may not be present. Light
red spots of postmortem decomposition are supposed
to be characteristic by some and are denied by
others. The heart, and central veins have been
described as abnormally filled with blood, this
being supposed to be due to contracture of the per-
ipheral part of the vascular system. The diagnosis
must be made by exclusion, and from the circum-
stances of the case.
Death from Starvation-. — The proof of this
may be of medicolegal importance, more especially in
cases of children who have been subjected to cruel
and inhuman treatment. The blood is markedly
anemic and clotted, and may be quite thick in cases
in which the subject has in addition been deprived of
water. The heart may be small, soft, and flabby.
The liver, spleen, and kidneys may be smaller than
is natural, from atrophy. Stomach and small intes-
tine may be empty, and there is a marked diminution
of subcutaneous fat and also of internal fat, namely,
in the omentum, mesentery, perinephritic tissue,
and subpericardial tissue. Fat, however, is never
entirely absent. The external appearance of the
cadaver presents the characteristic appearance of
marked emaciation. Otto H. Schultze.
Avens. — Under this name are known various spe-
cies of the genus Geinn L. (Fain. Rosacea), of which
there are some thirty or forty, distributed through
both temperate zones, especially the northern. By
Avens is generally understood the rhizome and root
of G. urbanumLi., while that of G. riralc L. is known
as Purple Avens, in allusion to the purple flowers of
the plant. G. virginianum L. and some others are
known as White Avens. None of them is much used
at present, but they were formerly largely employed,
both in domestic and in professional practice, as
astringents and tonics. They contain volatile oils,
amaroids, and much tannin. The oil quickly disap-
pears from them during and after drying. The
combination of tannin and volatile oil (when fresh or
recently dried) gives them a much better control of
summer diarrheas than do drugs which are astrin-
gent merely, and this is their proper field of usefulness.
They are given in doses of gr. xv. to ,~i.(1.0 to 4.0).
II. II. Busby.
Averroes. — Born in Cordova, Spain, in the early
part of the twelfth century; died in Morrocco, Dec.
12, 1198. His true name was Abul Walid Mohammed
ben Ahmed ibn Roshd, and he came of a distin-
guished Moorish family. Averroes himself acquired
considerable celebrity, but rather as a philosopher
than as a physician. The following remark is attrib-
uted to him: "An honest man may derive pleasure
from the study of the theory of the medical art,
819
Averroes
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
but the practice of this art should cause him to trem-
ble; for, no matter how well equipped with medical
knowledge he may be, it will never be possible for
him to ascertain the true relationship existing between
the patient's temperament, the real degree of severity
of his malady, and the remedy which may advan-
tageously be administered." From which remark
it may easily be inferred that his published works on
Fig. 539. — Averroes.
medicine contain a much larger proportion of theory
than of actual observation. However, we find in
them for the first time the statement that one cannot
have smallpox twice. A. H. B.
Aviation. — A fundamental distinction between the
animal and the vegetable world lies in the power of
locomotion which the former somehow developed in
the process of evolution. The earliest locomotion
was aqueous, since all life was in the beginning marine.
The lazy, plastic movements of the ameba and the
jellyfish were replaced by the more purposeful wrig-
gling of the squid and then progressively to the
perfect and always attractive swimming of the fish.
Next came the pelagic reptile which could swim more
vigorously than the fish and could, by reason of
improved respiratory apparatus, lift its head above
the water and breathe in the animal sense.
The recession of the waters from the drying land
tempted the reptile upon the latter. Some reptiles
continued to crawl on their bellies — snake fashion.
Others developed fins into feet, and vestiges of this
are evident to-day in the web-fingered, web-footed
individuals that occasionally turn up in dispensaries.
Certain reptiles now finding the land pretty fully
occupied (and that with belligerent neighbors) by
endless patient and cunning adaptation succeeded
in flapping clumsily into the air, these first ptero-
dactyls being the first aviators among animals; from
them developed all bird-life with its wonderful adapta-
tions to the conditions of aerodynamics.
Space does not permit a notice of the development
of man from the simian state to his fashioning of
weapons; his capture and use of the horse, his making
beasts of burden of this and other creatures; of his
achieving a boat and making even the winds of
heaven his servants; of his discovery of the uses of
steam by which the whole modern field of mechan-
ics was developed. The discovery of the uses of
electricity and of gasoline, and the development of
the motor, have made possible aviation, the latest
step in cosmic evolution, at least in so far as the
earth and its inhabitants are concerned.
Man's assured conquest of the air by means of the
aeroplane and the dirigible has been and is contin-
gent upon the recognition of, and the adaption to,
conditions unfamiliar to the race previous to our
generation. And the situation has developed aspects
most important for the physician to consider.
The aviator must accustom himself to an alto-
gether unusual environment. He must maintain
himself in a medium compared with which water is
solidity itself — the inconstant air with her fitful
winds, her dreadful vacua, or rather variation of
pressure, and her insidious currents (the study of
which, from the bird-man's viewpoint, has hardly
as yet begun). We marvel at the rapid flight of the
aeroplane; it has to be at least as swift as the fastest
express train, if it is to keep in the air.
Aviation again requires three dimensional steering.
All other vehicles (automobiles and the rest) move in
a single plane; except perhaps the bicycle which
must be both balanced and guided, but the balancing
gives no difficulty after the start, upon the princi-
ple of the gyroscope. "The aviator can make mis-
takes all around the sphere." He must be constantly
on the watch lest disaster befall him — lest a side-
way gust suddenly overtake him, or lest he drop all of
a sudden thousands of feet, as in vacuo, like a shot
fowl. He must listen anxiously to every sound from
a complicated motor; lie must manipulate one rudder
for up and down, another for right and left, and two
more at the ends of the wings; and all these intricate
movements must be coordinated. And the tyro,
equally with the expert, must at once attain and
maintain, so long as he remains in the air, a complex
interrelation of mind and muscle, of psychism and
corporeal engine, never before the present genera-
tion demanded of the human species. Is it not
indeed true that aviation is developing a type of
superman?
Consider only this among the many thrilling experi-
ences which have been detailed: Morane — he of
the French temperament — decided "to go up as
high as possible. When I was up 1,000 meters I
began to feel cold, but kept facing the sun as much as
possible to keep warm. At 2,000 meters my motor
began to work more feebly; at 2,600 meters the motor
became weaker and weaker and I felt I must descend.
On cutting off the ignition I slid through the air for
500 meters, when I felt sick and heard a buzzing in
my ears. I started the motor again and after a few-
seconds repose I again cut off the ignition and recom-
menced planing. All went well, but the speed was
too fast. At 1,500 meters I again pressed the contact
button; but the motor refused to start properly.
There were some explosions, but many misfires.
My apparatus underwent extraordinaiy twistings.
I was thrown over, sometimes on the right wing, and
sometimes on the left. This lasted for perhaps forty
seconds, which I truly thought were the last forty
of my life. When the propellor finally came to a
complete stop I was again master of the machine.
I planed down in an enormous circle. The landing
was perfect; but you can assure the world that I
am not in a hurry to complete the experiment."
And certainly once was enough for any man to have
ascended in a heavier-than-air vehicle one and three-
fifths miles into the ether (8,472 feet); 10,000 feet
has since been achieved.
What wonder is it then that a new disease —
aviation sickness — has developed. Seasickness is
a terror to most who venture upon the ocean; should
aviation gain many votaries, air sickness is like to he
an even worse phenomenon. Many feel unpleasant
even in an elevator, or in a swing. Almost everyone
has realized Poe's meaning in The Imp of the Pern rst ,
everyone who has dared to stand upon the edge of a
precipice and to look down into the chasm below—
the resulting giddiness and the fear of falling, due to
a sense of jeopardized equilibrium. People speak
glibly of the probability of aero-traffic being an
accomplished fact in the near future. If so the physi-
cian will have to know about aviation sickness, which,
820
REFERENCE HANDBOOK OF Till: MEDICAL SCIENCES
\\ on sulphur Springs
•athcr than any defect in the mechanism of the
leroplane, lias probably been the cause of most of
lie all-too-frequent deaths among bird-men. To bi
;tricken in this way is to lose control of the machine
["here is nausea, with a swimming sensation in the
id, frontal headache and a desire to sleep, perhaps
i lapse into unconsciousness. The turning of sharp
■ircles while descending would tend i" dizziness,
chel and Monlinier (" Le .Mai des Aviateurs,"
i, pliysiol. 1 1 1 inches)
of mercury and the maximum pressure eighteen cent i-
meters (7. OS inches) as measured on a Pachon sphyg-
ueter. The pulse was seventy. After a twenty-
minute flight, during which, at the twentieth
minute, a height of 1,100 meters (3,009 feet) was
reached, the constant pressure was twelve centi-
meters (4.72 inches) of mercury and the maximum
nineteen (7.4S inches) ; the pulse had risen to eighty.
The aviators were athletes in full training. The rise
in pressure was less marked in fatigued aviators;
but these showed cardiac palpitation and marked
pulse acceleration (108). In one case after a flight
of an hour, in which 1,000 meters was reached, the
aviator manifested tachycardia — functional cardiac
insufficiency with vertigo. Xo rise in blood pressure
noted in aviators who flew at altitudes less than
500 feet. The cause of the blood pressure rise is
probably the sudden descent to earth, in four to five
minutes, from heights of 1,000 to 2,000 meters — in
one-fourth or one-fifth the time required in ascending.
At 2,000 meters elevation the atmospheric pressure
i- 591 millimeters (23.3 inches) of mercury as against
760 millimeters (29.9 inches) at sea level. The
circulatory system does not have time to become
adapted to the change of pressure when a swift descent
is made. There is also the dangerous fatigue of the
circulator}' apparatus caused by high flying, which
provokes increased and irregular heart action. A
sound heart and supple arteries are absolutely essen-
tial to aviation. It is considered that safety lies in
height because the aviator, in case of accident, has
time in which to get control of his machine: yet a
sudden plunge from a height of several thousand
fret is liable to strike the aviator helpless if not uncon-
scious, and therefore to seal his doom. An examina-
tion of the body of Maloney, in California in 190"),
showed no broken bones or bruises sufficient to have
caused death; evidently he was stricken with heart
failure and died during his descent.
Other manifestations of vial des aviateurs are
sensation of intense cold; desire to urinate; irregu-
larity in the movements of voluntary muscles and
reflex aberrations — probably the expression of the
combined effects of cold, accelerated heart beat,
nervous tension, and fatigue. On landing there is an
intense sensation of warmth over the surface of the
body; the face is flushed; the eyes "sting." There
is an almost invincible desire to sleep. Some of the
symptoms noted in caisson workers find a counterpart
in those reported by aviators.
Of course only fit men should take to the air.
Flights call for continuous effort, both physical and
intellectual, under conditions to which the human
organism is not as yet primarily adjusted. By way
of prevention of all-too-frequent deaths some system
of automatic stability should be invented (if such a
thing were possible) so that an aeroplane may not
dive to earth should an aviator become stricken
while in flight. The aviator should, moreover, always
carry a parachute, or wear a parachute garment so
i hal he may jump or i umbl it aa end to
earth in a iuld hi- machim !„ come unman-
ageable. \\ here the mai : than
250 feel he had best bi I rapped in, a in B
ground the mosl danger is from collisions or
hoi i di\ is, from u hidi the a\ iator is like ■
uninjured h he cannot be flung oul when the crash
comes, or even before, as was Moisanl <
"'leans, Johm B. Ill
A\icenna. — Abou Ali Ben AbdaUah Ebn Sina, better
known to the Western World, thi ransmuta-
tion oi the last two components of this name, as
A\ icenna, was born in Bokhara, Turkestan, in August,
980 of the present era. He studied medicine and phil-
osophy in Bagdad, and in dui time was looked upon
by the Arabs a md Galen; they went so far,
in fact, as to bestow upon him the appellation of
I
Fio, 540. — Aviceuna.
Prince of Physicians. His "Canon Medicinse," a
Latin translation of which was first printed in Padua,
Italy, in 1470, was, for several centuries, the standard
work on medicine. As a result of his luxurious habits
and frequent excesses Avicenna contracted a dysentery
that carried him off at Hamadon, Persia, in the year
1038, at the comparatively early age of fifty-eight
A. H. B.
Avon Sulphur Springs.
York.
-Livingston County, New
Post-office. — Avon. Hotels.
Access. — There are four railroad outlets. The town,
located on two branches of the Erie Railroad, is made
accessible from all points. Avon is in direct commu-
nication with New York, 36j miles distant, Rochester
twenty miles, and Buffalo, sixty-six miles. Man}'
fine state roads emanate in four directions from the
village.
The village has a surpassingly beautiful location,
nestled as it is in the charming and picturesque valley
of the Genesee. The springs are on a somewhat lower
level, about three-quarters of a mile from the village.
The surrounding country is delightfully interspersed
with charming lakes and streams. The Avon Mineral
Springs were known to the Indians who resorted to
them for the cure of skin diseases and so-called wast-
ing disorders. The use of the Avon Springs for medic-
inal purposes by white men dates from 1792. Those
found to possess the greatest efficacy are known as the
"Upper" and the " Lower" spring. The " Congress "
and the " Magnesia" springs are also used to some ex-
tent, the latter being the favorite for drinking. The
following analyses show the chemical ingredients in
one United States gallon of three of the springs:
821
Avon Sulphur Springs
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Solids
Upper spring,
J. Hadley,
analyst
drains.
Lower spring.
Dr. Samuel
Salisbury,
analyst.
Grains.
Ci ingress
Hall spring,
11. M. Baker,
analyst.
Grains.
Calcium carbonate. . . .
Sodium sulphate
Magnesium sulphate.
S tdium chloride
8.00
16.00
84.00
10 00
IS. 40
29.33
13 73
57 I-'
49 61
9 25
21 02
27 61
19.07
29 . 1 1
8.41
Trace.
Sodium sulphide. . . . 1
Calcium sulphide. . . )
99.55
Total.
158.50
_'ll.-, .11
Gases.
Sulphureted hydrogen
Carbonic acid
Oxygen
Nitrogen
Cubic inches. Cubic inches. Cubic inches.
12.00
5.60
Total.
10.02
3.92
. 56
5.42
19.92
27.63
22 H4
0.97
3.88
54.52
The well or New Bath Spring was discovered by
R. K. Hickok in 1S35, while digging for pure water.
The soil through which the excavation was made is
hard blue clay, having a strong sulphurous odor.
The temperature of this water is 46° F.
Long's Spring has been in use since 1833. It
rises from the surface of an alluvial deposit through
the center of which passes what is termed Black
Creek, a small stream having its rise some miles to
the south. It is about a mile southwesterly from the
upper spring.
Following are the analyses of these two springs:
New Bath spring, Long's spring,
Dr. L. C. Beck, Dr. J. R. Chilton,
analyst. analyst.
Grains. Grains.
8.08
3.52
3S.72
13.10
109.05
3.27
19.31
5. 68
57.89
27.09
26.96
2.45
.81
Total
82.96
232.97
Gases.
Cubic inches.
Cubic inches.
Sulphureted hydrogen
31.28
43.58
5.87
These waters are of the saline-calcic, sulphocar-
bonated variety. The chemical constituents of the
magnesia spring are believed to be quite similar to
those of the lower spring, with, however, a greater
proportion of magnesium sulphate. In consequence
of the considerable proportion of this ingredient the
latter two springs have valuable laxative and pur-
gative properties. They thus become useful in dis-
orders of the gastrointestinal tract accompanied by
torpor of the liver and constipation. The water also
produces an increased activity of the functions of the
skin, and free diaphoresis often ensues. The water
also possesses antacid properties and has been found
of special benefit in cases of dyspepsia attended bv
flatulence, heart-burn, and gastric catarrh. Both
internally and in the form of baths, these waters have
been found beneficial in cases of obstinate rheuma-
tism, diseases of the urinary tract, and in various skin
disorders. Facilities for all kinds of hot. cold, and
electric baths are supplied. Emma E. Walker.
Axilla. — See Shoulder.
Azedarach. — Pride of China or India. China-
berry Tree; China-tree. The bark of the root of Melia
azedarach L. (fam. Meliaceoe). This is a fine, medium-
sized, ornamental tree from India, but long cul-
tivated in all the warmer parts of the world.
It has delicate, twice pinnated leaves, fragrant
clusters of lilac-colored flowers, and yellow globose
fruits of the size of small grapes. Azedarach has been
occasionally used for one or another purpose in various
countries where it grows, and, in deference to a slight
reputation in the Southern States was some time
ago admitted to the Pharmacopoeia. It is now,
however, excepting as an extemporary country
medicine, nearly obsolete. The bark of the roi
thus described: "Incurved pieces or quills, varying in
size and thickness; outer surface red brown, with
irregular, blackish, longitudinal ridges; inner surface
whitish or brownish; longitudinally striate; fracture
more or less fibrous: upon transverse section tangen-
tially striate, with yellowish bast fibers; almost in-
odorous, sweetish, afterward bitter and nauseous."
It contains a whitish-yellow resin, which is claimed
to be the active principle.
Azedarach disturbs the digestive tract, causing, in
large doses, vomiting and diarrhea. It is a fatal nar-
cotic poison in still larger ones, but its qualities are not
well known. It is usually given, however, for intesti-
nal worms in decoction, or in syrup of the fresh root.
Dose, four to eight grams oi. to ij.(4.0 to 8.0).
Birds become stupefied by eating the berries, and
fatal cases of poisoning by the seeds have occurred in
India. H. H. Rusby.
Azores. — The Azores or Western Islands lie about
2,000 miles from Boston, 1,400 miles from the Lizard
Point, in England, and 800 from the coast of Portugal,
of which they are a possession. The islands are nine
in number and are divided into three distinct groups,
about one hundred miles apart: Santa Maria and San
Miguel forming the southeastern portion, Flores and
Corvo the northwestern, and the remaining five the
central division. The total area of the islands is
about 1,000 square miles, and the population is esti-
mated at 300,000. San Miguel is the largest island,
being forty miles long and ten broad. Fayal and
San Miguel are the two islands which are generally
visited and with which there is the best communica-
tion. One can reach them by steamers from New
York and Portugal, and from Boston. The whole
system of islands is of volcanic origin, and their out-
lines in consequence are rugged and picturesque.
The coast line is precipitous, and the central portion
of each island rises in mountain peaks, which vary in
height from 1.SS9 feet (San Miguel) to 7,613 feet
(island of Pico). There are no natural harbors, and
vessels lie in the open roadstead off the principal ports.
A breakwater has been under construction for a long
time at San Miguel, but it is not yet completed.
The vegetation is rich and luxuriant, and both
tropical and subtropical fruits — the fig, orange,
banana, loquot, pineapple, prickly pear, guava, pome-
granate, and lemon — grow in the open air. Flowers
bloom in nearly infinite variety, and the gardens of
San Miguel and Fayal contain an almost endless
822
REFERENCE HANDBOOK OF Till" Ml DI( \l. S( [ENCES
Back, Diseases and injuries <>f
iversity of tree, flower, and fruit. There an- no
•wer than forty plants peculiar to the islands. Be-
- these there are about 100 species which are
iund in Europe, and 340 which are not found in
ipe, but are common to Madeira, the Canary
Is, and the Azores ( Roundell).
The climate is a mild and moist marine one, and
cry equable at all seasons of the year. The mean
niiual temperature is ti'2 J F. The extremes are
; to be Sti° and 45° F. The range between win-
in, I summer is from 10° to 15°. The night tem-
■ uro is generally not more than four degrees
■■ than the day. The summer is enervating at
, and one is drenched with perspiration on the
lightest exertion. The mean temperature for winter
58 for spring 61°, for summer 68 . and for autumn
1 . The three coldest months are usually Janu-
nv. February, and March. In winter it sometimes
chilly and damp, and one seldom leaves home
without an umbrella. The humidity is so great that
rail-paper will not adhere, and the veneering of fur-
liture strips off. The mean annual relative humidity
cinv— ix per cent, and for winter it is seventy-
n per cent. The mean animal rainfall is 38.5
5. The wind blows with great force at timi s
ind there are frequent storms.
Ponta Delgada, in San Miguel, is the largest city of
islands. It has a population of 25,000 inhabi-
-. There are a good theater, a public library,
lers of fine gardens, ancient churches and govern-
ment buildings, public markets, etc. There are
fortable accommodations here as well as at Horta.
principal town of Fayal, and the food is generally
Twenty-seven miles from Ponta Delgada by
triage road, through beautiful and wild scenery,
le Valle das Furnas, where are hot sulphur springs
temperature of from 56° to 212° F. All contain
sulphur, iron, alum, and silica in varying proportions.
Besides the public bath houses, built by the Govern-
ment and free to all, there are also private baths.
The bath tubs are cut out of solid limestone or lava
reck, and have taps for hot and cold water, the hot
coming from the sulphur spring, and the cold from
the water impregnated with iron. The bathing
in begins in June and lasts for six months, dur-
ing which time a large number of people frequent Las
Furnas. The general custom is to hire lodgings and
to take meals at the hotels. The various diseases for
which these springs are beneficial are chronic rheuma-
tism, which is almost invariably 7 benefited; paralysis,
syphilis, skin diseases (especially eczema), dyspepsia,
and internal troubles.
Las Furnas itself is situated in the valley of the
Furnas, which is the bottom of a vast crater of an
extinct volcano. In this valley are the various boil-
ing springs, with masses of white vapor hanging over
them. A roaring noise is heard, as the hot gases
le from the earth. The Caldeira Grande supplies
the sulphur water to the baths, and is enclosed by a
wall some six feet in height. The water in this tank-
like enclosure boils in a most furious manner and with
a great noise. It furnishes nineteen gallons per
minute (Roundell). The ground about is covered
with patches of white sulphur and alum, streaked
with orange and red. In another part of the valley is
the Boca do Inferno, or " Mouth of Hell," a dark pit of
unknown depth filled with boiling mud, constantly-
thrown up with a great smoke and noise. This mud
is collected by the people and used as an external
application in skin diseases. All the geysers or
springs are said to boil most furiously when the wind
is east.
So far as the climate in general of these islands is
concerned it is applicable to such cases as require a
mild, equable, moist climate. It is therefore suitable
for patients who are suffering from neurasthenia,
from Bright's disease, from nervous affections, from
hay fever, etc., and for those who are convalescing
from the grippe and from other acute
The water supply is from springs, wells, and
and i^ generally good.
From a personal visil to Fayal and Pico, the writer
can testify to the charm and fascination of these
strange islands with their ancii and primit
uis, beautiful scenerj . and I ful and ever-
varied walks, drives, and excut ioi -in hardly
conceive of a more entrancing place for the lover of
nature, or one more restful and refreshing for the
weary and overworked. The only drawback is the
long journey there, which is almost prohibitory to a
sufferer from sea-sickness.
I ■>!■ a very interesting and extended account of
these islands the reader is referred to Mi . Charles
Roundell's "A Visil to the Vzores, " and also to the
two papers by Canfield and Junkin on " The Azores as
a Health Resort." Edward O. Otis.
Azule Springs. — Santa Clara County, California.
Location, twelve miles wesl of San JosI, in the foot-
hills of the Santa Cruz Range of mountains, 900
feet above sea level.
Access. — Electric cars run from San Jos<5 to '
gress Springs, one and one-half miles from there to
Azule. Trains on the Southern Pacific Railroad
from San Francisco to Santa Cruz stop on signal at
Azule Station, two and one-fourth miles from Azule.
The following analysis was made some years since
by James Howden, State Chemist:
One Gallon- of "Water Contains:
Grains.
Sodium chloride 90 ss
nesium chloride 18 18
Potassium chloride r_' 14
Magnesium carbonate 77 20
Sodium carbonate 50 ^
< :t Uium carbonate 9.00
Free carbonic oxide 152.24
Total 431 . 12
This is a natural seltzer water. The water pos-
sesses antacid, aperient, diuretic, and tonic properties.
There are cottages for rent, and camping privileges.
Emma E. Walker.
Babesia. — Pyroplasma, Pirnplasma. A pathogenic
genus of Sporozoa, order Hiemosporida. B. hominis
causes Rocky Mountain tick fever, "spotted fever. "
or " piroplasmosis hominis" in man This disease
appears to be local in distribution, occurring in
spring and early- summer in the mountains of
Montana and Idaho, and may be transmitted to
man, rabbits, guinea-pigs, and monkeys by ticks.
The Texas cattle fever is caused by B. biaeminum
a sporozoan carried by the tick, Boophilus bovis. In
this case some of the blood sucked by the mother is
enclosed with the eggs she lays so that young are
born with the fever infection if the blood contained
it. East Coast fey r er is caused by a similar sporozoan.
See Protozoa. A. S. Peakse.
Bacillus. — A genus of the family Baeteriacea?, com-
prising cylindrical rod-shaped or oval forms, with
peritrichal flagella, often with endospores. Division
occurs in the transverse plane and the individual cells
may remain attached, forming chains or threads of
varying lengths. The term bacilli is often incorrectly
used to denote the Schizomycetes, or fission-fungi, in
general.
Back, Diseases and Injuries of the. — In wounds
and injuries of the back, as in those of the chest and
abdomen, we have to consider first, the injury inflicted
upon the superficial tissues, and secondly, that
sustained by the subjacent organs. The wounds of
the superficial structures present no characteristics
823
Back, Diseases and Injnri.- of
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
peculiar to this region. The back is, however, by
reason of its numerous articulations, very liable to
sprains. These may vary greatly in degree, and
since it is impossible always to determine at the
moment how serious the injury may have been, a
sprain of the back should never be neglected, but
should be watched and treated as though it were an
important affair until its true nature is ascertained.
The spinal ligaments may be simply strained, or they
may be ruptured; or an injury of the back, which
may at first seem of comparatively slight moment,
may be accompanied with fracture or dislocation of a
vertebra, with con-
sequent compres-
sion or concussion
of the cord; or
compression may
be caused by hem-
orrhage within the
canal. The loca-
tion of the sprain
may be indicated
by a swelling, or
there may be no
external evidence
whatever of in-
jury. Sprains in
the lumbar region
are not infre-
quently followed
by hematuria, but
this symptom, al-
though apparently
so serious, is usu-
ally of little mo-
ment and disap-
pears without any
further complica-
tion. The treat-
ment of simple
sprains, without
injury to the cord,
is essentially rest
in bed with, later,
coun terirritation
over the affected
region.
Neuroses of
varied character
are very liable to
follow concussion
or other violence applied to the spine. The fre-
quency with which nervous symptoms follow spinal
injuries received in railway accidents led Erichsen to
apply the term "railway spine" to such conditions.
Whether the resultant neurosis is spinal or mental
in essence is still sometimes a matter of dispute, with
the weight of opinion inclining to the latter. (See
Neuroses, Traumatic.)
Penetrating wounds of the back are serious because
of the injury inflicted upon the internal organs. In
determining what organs may have suffered in any
particular case, if we leave out of consideration for
the moment the direct evidence afforded by the symp-
toms, it is necessary to ascertain the nature of the
wounding object, whether a knife, a bullet, etc., and
also the direction of the wound. If a knife or other
sharp instrument have been used, it should, if possi-
ble, be ascertained how deeply it has penetrated, and
whether the blow was struck from above, from
below, or laterally; and if it be a gunshot wound,
whether the weapon was discharged at close quarters,
or whether the ball was nearly spent before pene-
trating the back. It must not be forgotten also that
the course of a bullet is often very erratic, and that,
while it has seemingly penetrated the abdominal or
thoracic cavity, it may, in reality, have glanced along
a rib and be lodged in the muscles on the other side of
Fig. 541.— The Relations of the Thor-
acic and Abdominal Viscera, as seen from
Behind. The stars indicate the location
of the spinous processes of the seventh
cervical, fourth and ninth thoracic, and
third, and fi.th lumbar vertebne. (Modi-
fied from Quain.)
the back, or anteriorly. The position of the person
at the time the injury was received is also to be con-
sidered, since, when he is in the recumbent position or
when stooping, the liver and some of the other organs
are higher than when the person is sitting or standing
erect. And another point to be determined in certain
cases is the time at which the wound was received,
whether after a hearty meal or while the individual
was fasting. Fig. 541 represents diagrammaticaJly
the ordinary position of the thoracic and abdominal
viscera, but of course only in a very general way.
The movements of the back are chiefly in an
anteroposterior and lateral direction, though a slight
amount of rotation is also possible. In the upper
portion but little motion of any character takes place,
and it is in the lumbar region chiefly that flexibility
exists. A "'stiff back" may be due to chronic
rheumatic arthritis of the spine, to Pott's disease, to
spinal ankylosis, to inflammation or rheumatism of
of the spinal or abdominal msucles, to psoitis, or to a
sprain.
Pain in the back is a common symptom, and may
be due to any one of a variety of conditions, as 6.3.
neurasthenia, muscular rheumatism, rhachialgia,
Pott's disease, nephritis, cystitis, renal or vesical
calculi, an accumulation of gas in the intestines,
uterine disease, myositis, or hysteria. (See Lumb
and Spine, Diseases of the.)
The back is frequently the seat of tumors and other
swellings, the nature of which it is important, while
at the same time not always easy, to determine. V, e
have, in the first place, the ordinary fatty and fibrous
tumors, naBvi, epitheliomata, and sarcomatous and
sebaceous tumors (the last two rarely), the diagnosis
of which offers nothing peculiar in this region. Spi
bifida is a not very uncommon affection, and is usually
not difficult of diagnosis. (See Spina Bifida.) Ab-
scesses of the back are by no means rare. They
be idiopathic, or the result of traumatism, or the pue
from an empyema may point posteriorly. It should
not be forgotten that an abscess, pointing in the
back or elsewhere, may be referable to spondylitis
even though there be no angular curvature visi
The kyphos of Pott's disease can hardly be mistaken
for anything else, but in lateral curvature with so-
called rotation, the resulting prominence of the
muscles on the side of the convexity might, if ci
lessly inspected, be taken for a tumor. Sometimes
this apparent tumor is at some distance from the
spine, and is the expression of a secondary deformity
and bulging of the ribs.
The back is the ordinary seat of bed-sores, whether
occurring from pressure or of neurotic origin. There
is no other condition with which a bed-sore is liable
to be confounded, though it is not always an easy
matter to discriminate between the different varic
of this distressing affection. (See Decubitus.)
Diseases of the skin and muscles of the back do not
differ in any essential points from similar affections in
other parts of the body, and their consideration
need not therefore be entered upon here.
T. L. S.
Bacon, Francis. — Born at New Haven, Connec-
ticut, October, 6, 1831. His father was a distin-
guished theologian, Rev. Dr. Leonard Bacon. He
studied medicine at the Yale Medical School, and
received the degree of Doctor of Medicine from that
institution in June, 1S52. Very soon after the
termination of his medical course he went to Galves-
ton, Texas, where he had charge of the hospital of
that city. He remained there for several years,
until the outbreak of the Civil war.
During the Civil War he served first as Assistant
Surgeon, and afterward as Surgeon, in one of the
Connecticut regiments. He was then appointed
Medical Inspector in the Department of the Potomac,
824
REFERENCE II. WDM < < U- Till: MLDICAL scl i:\TES
Bacteria
and, still later, Medical Director of the Department
of the Gulf, with headquarters at New Orleans.
\t the close of the war he resigned his commission
: i id returned to New Haven, having been invited to
fill the Chair of Surgery in the Vale Medical School,
upon the retirement of Dr. Jonathan Knight. In 1906
University conferred upon liim the hono
title of Doctor of Science. He died in New Haven
on Vpril 26, 1912.
Dr. Bacon made very few contributions to medical
literature. He was not fond of writing, and his very
large surgical practice left him scarcely enough time
for needed rest and recreation. The various official
positions, however, which he held — first during the
Civil war and afterward during his life in Nev
Haven — testify sufficiently to his ureal ability as an
executive officer and as a surgeon, and to the high
esteem in which he was held by his professional
brethren and by his fellow citizens.
Bacon, Francis, Baron Verulam, Viscount of
Saint Albans. — Born in London, January 22, 1561.
His lather, a celebrated jurist and one of the most
influential advisers of Queen Elizabeth, gave him
every possible educational advantage. From his
earliest childhood young Bacon manifested unmis-
takable evidences of possessing a mind of a superior
order. During his course of studies at the University
of Cambridge he made astonishing progress in all the
departments of learning. Already at the early age of
sixteen he displayed remarkable independence of
character, as evidenced by the fact that, in complete
disregard of the philosophical views held at that time,
he did not hesitate to begin laying the foundal
of a new general system of philosophy — the one,
namely, which subsequently brought him imperish-
able fame. After completing his university career
in 1576, he visited Paris in company with Sir Amyas
Paulet, Queen Elizabeth's ambassador at the Court
of Trance, remaining there until the death of his father
in 1579. While he
was still in Paris, be-
ing then not nineteen
y.ars of age, Bacon
began writing his
essay On Life and
Death, " Historia vitae
et mortis" (not pub-
lished, however, until
1623 in London)—
that one of his treat-
ises which touches
more especially on
purely medical science
than does any other
of his writings. The
Dictionnaire Histor-
ique de la Medecine
makes the following
analysis of this essay:
"In animated bodies
there exists, as Bacon
assumes, a spirit which is purer than air and less ener-
getic than fire, and which is held fast in the tissues by
substances of a viscous nature. This spirit (or prin-
ciple of life) gradually, in the course of time, consumes
the bonds which hold it fast and is thus eventually and
Completely set free — this is the direct cause of natural
death. One may hope to prolong life by moderating
all vital activities, by avoiding the different impressions
made by the air, by restoring the humors of the body
to their normal state, by bringing back to the viscera
the vital spirit which they may have lost, and by
closing the pores or channels through which it tends
to make its escape. These ends may be attained by
a proper degree of repose, by a somewhat debilitating
regimen or diet, and by the use of the two drugs —
Fig. 542. — Francis Bacon.
and opium. I bi ii Bacon cites, in Bupporl of
I heory, mi tances of m
great longer ity. He also i ntion
to thi fact that the longest duration of
in those animals which have a long period ol ge 'at ion
and which are alow in attaining their full growth.
I i' illy, he describes t he < Mil. Is oi life, and
i xplains the phenomena of death.
The most important of Bacon's works wire, in
addition to those j tioned, "The '■
on hi of Learning." 1605; "Novum Organum,
indicia vera de interpretatione," 1620; and "De
Augmentis Scientiarum," L624, the latter being an
id ami revised Latin translation of the earlier
work mi "The Advance nt of Learning."
Bacon died April 9, 1626. A. II. B.
Bacteria, Pathogenic. — The Schizomycetes or Bac-
teria are among the smallest and at the same time the
most int cresting of all known living organisms. \\ hile
most bacteria are harmless — some of them, indeed,
being of the greatest use in ll 'otiomy of nature,
by producing the decomposition of dead animal and
vegetable matter, without which life on the earth would
be impossible — others are the cause of various infec-
tious diseases in man and animals. Bacteria are
very widely distributed in nature, and are present
in the air, water, soil, and also in the food and
bodies of animals.
Historical Review of the Development of
Bacteriologt. — Although most of the important
discoveries of bacteria in their relation to disease are
of comparatively recent date, from the earliest days
of medicine, and long before these microorganisms
were known to exist, minute living germs were thought
to be concerned in the production of many disea
Before entering, therefore, into a detailed considera-
tion of pathogenic bacteria, it may be interesting and
instructive to review briefly the more important
-tips which lead up to the development of bacterio-
logy as a science.
The first authentic observations of living micro-
organisms of which there is any record are those of
Athanasius Kircher, a Jesuit priest, in 1659. The
compound microscope dates from 1590, but this
observer was the first to find in putrid meat, milk,
vinegar, cheese, etc., minute living organisms or
"worms," invisible to the naked eye, which he con-
cluded must be the cause of putrefaction. Kircher,
however, did not describe the form or character of
these "little worms," and with the microscopes in
use in his day he probably did not see bacteria, as we
now understand them. Nevertheless, his observa-
tions seemed to substantiate the view- that infective
diseases might be caused by .substances which,
introduced into the body, give rise at first to no symp-
but increase till they bring about disease; the
opinion held at that time by many physicians being
that if putrefaction is produced by living organisms
outside the body, when these organisms are found
in the blood, etc., they must necessarily cause putre-
faction there also.
Not long after this, in 1675, Anthony van Leeuwen-
hoek, a citizen of Delft, Holland, a linen draper by
trade, who practised the art of grinding and polishing
lenses, constructed a microscope with which he was
able to observe in rain water, in putrid infusions, in
human saliva, in intestinal evacuations of man and
animals, and in the scrapings between the teeth,
numbers of living "animalculae" as he called them,
varying in form and size and in the character of their
motion. Of these he gave descriptions and drawings
which are remarkable for their accuracy, considering
the imperfect optical instruments at his command,
and there is little doubt that he really saw some of the
larger species of bacteria, probably spirilla. Leeu-
825
Bacteria
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
wenhoek made no attempt to assign any importance
to these organisms regarding the role they might
play in relation to disease, his work being conspicuous
for its purely objective and unspeeulative nature.
But his contemporaries and those who immediately
succeeded him seized upon the idea of these animal-
cules causing a great number of diseases, even in
cases in which they were not found, reasoning from
analogy that they must be present, until there arose a
veritable craze of the germ theory of disease or
contagium animatum. Then later followed a reaction,
and the idea for a time was ridiculed out of existence.
And so throughout the history of medicine this
theory continued to be often asserted and as often
again denied, on speculative grounds, until well into
the present century, when the question was finally
settled by actual observation and experiment.
Among those who at this early date (the end of the
sixteenth and beginning of the seventeenth century)
held to the doctrine of contagium animatum were
Lange and Hauptmann, who shortly after Leeuwen-
hoek's investigations advanced the opinion that
puerperal fever, measles, smallpox, typhus, ple-
urisy, epilepsy, gout, and many other diseases were
due to animal contagion. And in 1701 Andry and
Linne assumed the same origin for syphilis, and
Lancisi (1718) for malaria. Antonius Plenciz, a
physician of Vienna, who published his deductions in
1762, maintained that not only were all infectious
diseases due to microorganisms, but that the infective
material could be nothing else than living animals or
plants. On these grounds he endeavored to explain
the variations in the incubation period of different
diseases. He insisted also that special germs were
concerned in the production of each infectious disease.
Plenciz believed, moreover, that these microor-
ganisms were capable of multiplication in the
body, and suggested the possibility of their being
conveyed from place to place through the air, etc.
Besides these deductions he also made original in-
vestigations into the processes of putrefaction and
fermentation, and having found animalcules in all
decomposing material, he became so thoroughly
convinced of their causative relation to these processes
that he formulated the law tha.t decomposition of
animal and vegetable matter takes place only by
means of and through the increase of living organisms.
Still all this was entirely a matter of speculation
only, unproved by direct experiment; but the theory
advanced was so plausible and the arguments used
in its support were so logical and convincing, that in
spite of great opposition and ridicule it continued to
gain ground, and in many instances the conclusions
reached by these early philosophers have since been
shown to be correct.
Meanwhile the question which most attracted the
interest of all investigators into the cause of in-
fectious diseases was: What is the source of the
microorganisms which are supposed to produce these
processes? Are they the result of vegetative changes
in the substances in which they are found — the
theory of generatio oequivoca, or spontaneous genera-
tion; or are they reproduced from similar preexisting
organisms — the vitalistic theory? This question is
intimately connected with the investigations into the
origin and nature of fermentation and putrefaction,
for it was in these experiments that the theory of
spontaneous generation was overthrown and the
germ theory established.
Of those who most vigorously advocated the idea of
generatio oequivoca was Needham, who, in 1749, at-
tempted to prove experimentally the truth of his
opinions. He placed a grain of barley in a watch
glass containing water, covered it carefully, and
allowed it to germinate. On later examination he
found living microorganisms present which he main-
tained were the effect, not the cause, of the decompo-
sition and due to vegetative changes in the grain itself.
Again, he boiled meat infusions and kept them in
tightly corked flasks; in these also living organisms
developed. As all life must have been destroyed
by the boiling, and the closed flasks shut out appar-
ently everything from without, Needham concluded
that the organisms present could have been pro-
duced only from the dead material by spontaneous
generation.
This conclusion seemed indeed irrefutable at the
time, but Bonnet, in 1702, suggested that possibly
there were certain germs which were able to resist the
boiling temperature, or that the flasks were not so
tightly closed that no germs could enter. Then in
1769 Lazarus and Spallanzani showed experimentally
the falseness of Needham's results, by demonstrating
that if putrescible infusions of organic matter were
placed in hermetically sealed flasks and boiled for an
hour the infusions remained sterile; neither were living
organisms found in the liquids, nor did they decom-
pose. It was objected to these experiments that the
high temperature to which the liquids were subjected
so altered them that spontaneous generation could not
occur. Spallanzani then simply cracked one of the
flasks a little and allowed air to enter, when organisms
and decomposition again appeared in the boiled solu-
tions. Again it was objected that in excluding the
oxygen of the air by hermetically sealing the flasks the
essential condition for the development of putrefaction,
which required the free admission of this gas, was
interfered with. This objection was met by Schultze
in 1836, who showed that the air could have access to
sterilized infusions without causing putrefaction, if it
were first freed from germs by passing it through
strung sulphuric acid. Schwann effected the same
thing in 1837 by passing the air through red-hot tubes;
and Helmholtz in 1843 repeated and confirmed these
experiments with calcined air. Again the point was
raised that the heating of the air had perhaps brought
about some chemical change which prevented the
production of putrefaction. Schroeder and von
Dusch then showed, in 18.54, that if the air was fil-
tered through cotton wool, by simply placing stoppers
of this material in the mouths of the flasks before
boiling — a device which has since proved of inestim-
able value in bacteriological work — the contained
liquid was incapable of producing putrefaction.
Similar results were obtained by Hoffmann in 1860,
and by Chevreul and Pasteur in 1861, without a cotton
filter, by drawing out the neck of the flask and bending
it downward, the mouth being left open. Here the
force of gravity prevents the suspended bacteria in the
air from ascending, and there is no current to carry
them upward into the liquid. Tyndall later (1876)
showed by his investigations upon the floating
substances in the air that in a closed chamber in
which the air is not disturbed by currents, all sus-
pended particles settle to the bottom, the super-
incumbent air being optically pure. He demonstrated
beyond all doubt that the presence of living organisms
in decomposing fluids was always to be explained
either by the preexistence of similar living forms in
the fluid or upon the walls of the vessels containing it,
or by the liquid being exposed to air which was con-
taminated by organisms.
But still another matter required explanation.
A certain percentage of the experiments with infu-
sions, which had been boiled for a considerable time
and carefully protected from subsequent contamina-
tion, would now and then fail despite every precaution.
Bonnet in 1762 had suggested the explanation of this,
on the assumption that some organisms were perhaps
capable of withstanding the boiling temperature,
and still grow when the infusion cooled. Then Past-
eur found that he could sterilize milk only at a tem-
perature of 110° C, and later (1865) showed that the
organisms which resist boiling temperature are re-
productive bodies, now known as spores. But it
was not until 1876 that the nature of spores was care-
826
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Bacteria
fully studied and explained by Cohn, and afterward
confirmed by Koch. These investigators proved thai
certain rod-shaped bacteria possess the power of
passing into a resting or spore stage under peculiai
conditions of growth, and thai when in this stage
they are much less susceptible to the injurious
action of higher temperatures and other deleterious
influences than when in their normal vegetative con-
dition.
With this discovery the question of spontaneous
generation was finally settled in the negative and the
germ theory established. If living microorganisms,
ie of them capable of producing the more resistant
res, were present in the air, soil, water, etc., it was
easy enough to understand how irregularities occurred
in previous experiments; nor eon 1.1 1 here longer beany
doubt that bacteria were the cause, not the effect, of
fermentation and putrefaction, and possibly also of
iase.
But, in the mean time, little or nothing had been
accomplished in the systematic classification of bacte-
ria, although their forms were zealously studied tniero-
scopically as matters of curiosity. The first attempt
at classification was made by Midler, of Copenhagen,
in 17SH, who divided microorganisms into two main
divisions — monas and vibrio. But he, like all the
earlier naturalists, owing to lack of sufficiently power-
lid microscopes and inadequate knowledge of the
biology of bacteria, fell into grave errors of classifica-
tion. Thus various motile organisms, which are now
ignized to be of vegetable origin, were commonly
included among the infusorians or unicellular animal
organisms. Even Ehrenberg, in 1838, and Dujardin,
in 1841, though their work shows considerable pro-
gress in this direction, failed to arrive at a satisfactory
classification of bacteria; these authors dividing
bacteria into four orders — bacterium, vibrio, spirillum,
and spirochete — and including them with the in-
fusorians. Perty, in 18.52, was the first apparently to
draw attention to the vegetable origin of bacteria; and
Robin, in 1S53, then suggested their relationship to
the alga*. But it remained for Cohn in 1S54, and
Naegelt in 1S.57, to bring anything like system into the
confusion which had previously existed regarding the
classification of bacteria. It was Naegeli who estab-
lished their resemblance to the fungi, in that they were
chlorophyll-free plants, and gave them the name of
Bchizomycetes or fission fungi to indicate their mode of
reproduction; and Cohn confirmed and emphasized
this relation of bacterial species to the vegetable
kingdom, and first employed the term bacteria for the
entire class of these microorganisms, studying their
various groups more carefully.
At the same time, the physiological properties of
bacteria were studied, with as much, if not more,
success than their morphology and classification.
Stimulated by the discovery of the microbic origin
of the processes of fermentation and putrefaction —
the specific cause of one form of which, alcoholic
fermentation, was found by Latour and Schwann, in
1837, to be the yeast plant (Saccharomyc.es cerevisice) —
the study of the causal relation of microorganisms to
disease was again taken up with renewed vigor. So
far the bacterial source of infectious diseases was
founded only on hypothesis, and although belief in this
theory was much strengthened by the foregoing
experiments, it had not yet been proved. It was not
long, however, before the necessary proof was forth-
coming at least for one disease, for in the same year as
Schwann's discovery of the yeast plant, Bassi dis-
covered that a fatal infectious malady of silkworms
was due to a parasitic microorganism; and later a
similar origin was found for various infectious dis-
eases in grains, potatoes, etc. Just about this time,
too (1S40), Henle published his "Pathological In-
vestigations," in which he described the relation of
bacteria to disease with remarkable clearness and
precision, the weight of the opinion of this great
authority contributing much to i interest i
doctrine of infection. Although Henle failed to
organisms in 111.' 1 1 ue in various infect
this did not lead him to change his opinion, for he con-
tended rightly that there were no means at that time
of distinguishing between tissue cells and bacteria.
Nor did he consider the presence of microorganisms
alone sufficient proof of their etioloi ition,
but postulated the conditions later confirmed to the
letter by Koch, which must be fulfilled to dec
that a disease is due to a specific microorganism.
These conditions were constant presence in the dis-
ease, isolation, and evidence of tne infectious nature
of the isolated germ by inoculation. Similar con-
clusions were also reached by Mitchell, independently,
reasoning by deduction.
Very soon after this it. was shown experimentally
that microorganisms were thi causi "f various skin
diseases in man, as favus and ringworm. About this
time also. Pollender (1849) Observed certain rod-
shaped bacteria in the blood of animals dying from
anthrax or splenic fever, and he was followed by
Davaine (1850); but the e observers attached no
special significance to their discovery until Pasteur
made public his researches in regard to fermentation
and the role played by bacteria in the economy of
nature. Then Davaine resumed his studies, and in
1S63 e-tabli.-hed by inoculation experiments the
bacterial origin of anthrax — which was later con-
firmed by Pasteur, Koch, and others.
Schwann had already shown the connection be-
tween certain organisms and alcoholic fermentation,
but Pasteur, in 1857, deserves the credit of finally
establishing the fact that the various kinds of fermen-
tation — lactic acid, butyric acid, acetic acid fermen-
tation, etc. — are all caused by microorganisms, which
not only differ in physiological action, but are charac-
terized by morphological and biological peculiarities.
In this connection Pasteur also made the discovery of
certain bacteria which were incapable of growth in
free oxygen, assigning to them the name of anaerobes
to distinguish them from the aerobes, or those re-
quiring the presence of free oxygen. Others, again,
he found were capable of growth, either with or with-
out free oxygen, and these he called facultative
anaerobes. Pasteur's investigations demonstrated
the fact that since bacteria are the cause of fermenta-
tion and putrefaction, they are necessary for the life
of plants and animals, for without their agency the
higher plants, incapable of feeding upon the complex
substances of dead animals and plants, would die if
these substances did not undergo decomposition
into their elements through the instrumentality
of bacteria; and thus the earth would be unin-
habitable.
The next important discoveries related to the cause
of infection in wounds. Lemaire, following up the
experiments of Pasteur, had observed that when car-
bolic acid was added to putrescible substances fer-
mentation was prevented, and he came to the conclu-
sion that the carbolic acid destroyed the germs which
produced fermentation. The processes of fermenta-
tion and suppuration he believed to be analogous.
If the addition of carbolic acid solution inhibited
fermentation, why should it not be applicable to the
prevention of suppuration in wounds?
Upon these suggestions Lister now (1863-70)
instituted his famous antiseptic treatment of wounds,
which has led to such brilliant results in modern
operative surgery. The publication of Lister's work
exerted a powerful influence upon the general recog-
nition of the germ theory of infectious diseases, and
had much to do in lessening the number of its oppo-
nents. Then Rindfleisch, in 1S66, and Waldeyer
and von Recklinghausen, in 1871, drew attention to
the constant occurrence of microorganisms in pyemic
processes resulting from wound infection — observa-
tions which have since been amply corroborated by
827
Bacteria
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
others for all suppurative processes under whatever
condition produced.
From this time on followed, in comparatively rapid
succession, the discoveries of a number of microorgan-
isms as the cause of various infectious diseases. In
1S73, Obermeier announced having found in the blood
of patients suffering from relapsing fever a minute
spiral, motile organism — the Spirochete obermeieri —
which is now recognized as the specific infective agent
in this disease. In 1S78, Koch published his im-
portant work on traumatic diseases. In 1879
Hansen reported the discovery of bacilli in the cells of
leprous tubercles, which, from subsequent investiga-
tions, are believed to be the cause of leprosy. Neisser,
in the same year (1879), discovered the "gonococcus"
in gonorrheal pus. In 1880, Eberth and Koch,
independently, observed the typhoid bacillus, which
Gaffky, in 1884, proved to be the cause of typhoid
fever. In the same year Pasteur published his
discovery of the bacillus of fowl cholera and his
investigations upon protective inoculation against
this disease and anthrax. Sternberg and Pasteur, also
in the same year, independently observed a patho-
genic microorganism in human saliva, which was subse-
quently (1885) proved by Fraenkel and others to be
the organism most commonly associated with acute
lobar pneumonia and now recognized as the usual
cause of that disease — the Diplococcus pneumonice.
In 1881, Koch made his fundamental researches upon
pathogenic bacteria, which form the basis of our
modern bacteriology. He introduced solid culture
media and the "plate method" for obtaining pure
cultures, and showed how different organisms could
be isolated, cultivated artificially, and by inoculation
of pure cultures into susceptible animals made, in
many cases, to reproduce the specific disease of which
they were the cause — thus carrying out Henle's
suggestions. It was also in the course of this work
that the Abbe system of substage condensing appara-
tus on the microscope, and the Ehrlich-Weigert
method of staining bacteria for microscopical prepara-
tions were first generally used. In 1882, Koch
published the discovery of the tubercle bacillus. The
same year Pasteur made his investigations upon hog
erysipelas; in this year also his communication upon
rabies appeared. In 1S82 also Loeffler and Schiitz
discovered the bacillus of glanders. In 1884 Koch
discovered the spirillum of Asiatic cholera, the "comma
bacillus." This year, too, Klebs and Loeffler dis-
covered the diphtheria bacillus. Rosenbach also, by
the application of Koch's methods, fixed definitely
the characters of the various pus-producing organisms.
And the same year Nicolaier discovered the tetanus
bacillus which Carl and Rattone afterw-ard showed to
bs the true cause of the disease, and Kitasato obtained
in pure culture. In 1892, Pfeiffer discovered the
bacillus of influenza; and finally, in 1S94, Kitasato
discovered the bacillus of bubonic plague.
This closes our brief historical sketch of the develop-
ment of bacteriology, including all the more important
facts which are of special interest to physicians.
But no review of the progress which has been made in
this branch of science would be complete without
reference to the recent discoveries of antitoxins in the
treatment of diphtheria and tetanus, the protective
inoculations against rabies, cholera, the plague, etc.,
and the peculiar reactions of the blood serum of per-
sons ill with infectious diseases. These discoveries,
in which the names of Pasteur, Koch, Behring,
Kitasato, Roux, Pfeiffer, Gruber, and Widal are the
most prominent, not only mark an epoch in the
history of bacteriology in relation to medicine, but
have served to establish beyond all doubt the
microbic origin of many diseases, the cause of which
was until then in dispute. Attention has, moreover,
been directed of late to the group of animal micro-
parasites, the protozoa — to which class belong the
Plasmodium malaria and the Amoeba coli, the cause
828
of malaria and epidemic dysentery, respectively
which may prove to be the source of infection in many
affections the origin of which is still unknown, as the
exanthemata. And quite recently interest has been
awakened in the possible pathogenic properties of
certain of the fungi, among which it is suggested may
be found the cause of other unexplainable diseases
as cancer, smallpox, scarlet fever, measles, and rabi
Several bacteria also not mentioned in this list hj
created considerable discussion of late; but tl
organisms have not yet been positively shown to be
the specific cause of the diseases with which they
are found associated, and hence have been omitted.
General Characteristics op Bacteria. — Clax-
sification and Definition. — Under the general term
"microorganism" may be included all the minute
lower forms of life which are of biological or hygienic
interest, and which are the cause of fermentation
putrefaction, and disease. They are both of the
vegetable and of the animal kingdom; among the latter
of these are the protozoa, and among the former the
fungi and bacteria. Bacteria are classed among
plants from the fact that they are able to derive their
nourishment both from organic and inorganic mater-
ials. They are of the class of cryptogamons plant*,
that is, plants which, having no seeds or flowers, are
reproduced by means of spores, such as the fungi,
lichens, and algae. Of these they are most nearly
allied to the alga?, but differ from them in that they are
without chlorophyll, the green coloring matter by
means of which the higher plants, under the influence
of sunlight, decompose carbon dioxide, ammonia, and
sulphurated hydrogen into their elementary con-
stituents. In many respects bacteria resemble the
mycetes or fungi, which are also without chlorophyll;
but they differ from these again in their mode" of
reproduction, being reproduced by division or
simple fission. Hence bacteria have been called
schizomycetes or fission fungi. A few varieties of
unicellular organisms have also been found resembling
bacteria in all points, except that they possess chloro-
phyll or some pigment substance similar to it. Other
organisms, again, have been observed which, though
they are without chlorophyll, are able to build up
organic compounds synthetically and even in the
absence of light. Some bacteria, moreover, especially
the motile forms, are closely allied to certain micro-
organisms belonging to the animal kingdom. It is
therefore difficult to classify or define bacteria
scientifically, under our existing knowdedge of them.
Excluding the microorganisms, however, which
contain chlorophyll, bacteria may be defined ac-
curately enough for all practical purposes as ex-
tremely minute living vegetable organisms, without
chlorophyll, which arc reproduced by division, con-
sisting of single spherical, rod-shaped, or corkscrew-
like cells or aggregation of such alls, between irliose
protoplasm and nucleus it has not been possible to
differentiate with certainty.
Bacteria, then, belong to the family of mycetes or
fungi, of which there are four groups:
1. Hyphomycetcs, or mould fungi.
2. Blastomyci U a, or yeast fungi.
3. Streptothrices.
4. Schizomycetes or bacteria.
But besides this classification of bacteria it becomes
necessary to divide them into saprophytes or refuse-
eaters, and parasites. Saprophytic microorganisms
are such as commonly exist independently of a living
host, obtaining their supply of nutriment from soluble
food stuffs in dead organic matter. Parasitic micro-
organisms, on the contrary, live on or in some other
living organism, from which they derive their nourish-
ment for the whole or a part of their existence.
Those microorganisms which depend entirely upon
a living host for their existence are known as strict or
REFERENCE HANDBOOK OF THi: MEDICAL SCIENCES
Bacteria
>bligatory parasites; those which can lead a saprophytic
istence, bul also thrive within the body o
animal, arc called facuttatir, . The sapro-
phytes strictly so called, which represent the larger
number of microorganisms, are not only harmli
but perform the useful function of the destruction of
dead organic matter through fermentation and
putrefaction. The parasites, on the other hand,
though Mime of them may multiply in the secretions
or on the surface of the body without injury to the
animal upon which they exist, are usually harmful
iders, giving rise, through the lesions brought
about in the body by their growth and products, to
various acute and chronic infectious diseases.
Numerous attempts have been made by various
authors to classify bacteria systematically, but
usually with the proviso that the system was only a
temporary one. As a rule, the genera are based upon
morphological characters and the species upon
biochemical, physiological, or pathogenic properties.
While the form, size, and method of division are the
most permanent characteristics of microorganisms,
and so are naturally utilized for classifications,
nevertheless on this basis of arrangement there are
ided difficulties. Thus while the form and size
of bacteria are fairly constant under the same condi-
tions, they are in many quite different under diverse
conditions. Another serious drawback is that I
morphological characteristics give no indication
whatever of the relation of bacteria to disease, etc. —
the very characteristics for which as physicians we
study them. < Ither properties of bacteria which are
fairly constant under uniform conditions are those of
spore formation, motility, reaction to staining agent-,
relation to temperature, to oxygen or other food
materials, and finally their relation to disease, fermen-
tation, and pigmentation (pathogenic, zymogenic, and
chromogenic bacteria).
Taking any one of these properties of bacteria as a
basis, we can classify them; but even here there will be
groups which under certain conditions would be placed
in one class and under other conditions in another.
Thus the power to produce spores 11133- be totally lost
or held in abeyance for a time. The relation to oxy-
gen may be gradually altered, so that an anaerobic
species grows in the presence of oxygen. Parasitic
bacteria ma3' be so cultivated as to become saprophy-
tic varieties, and those which have no power to grow-
in the living body given pathogenic properties. The
possibility of making any thoroughly satisfactory clas-
sification is rendered still more difficult by the fact
that many necessarily imperfect attempts have already
been made, so that there is a great deal of confusion,
which is steadily increased as new varieties are found
or old ones reinvestigated and classified differently in
the various systems. We shall, therefore, simply use
the commonly accepted nomenclature, without any
attempt at classification, except to consider together
as far as practicable certain groups of bacteria whose
members are closely allied to one another in some one
or more important features.
Morphology. — There are three basic forms of the
individual bacterial cells: the sphere, the rod, and
the segment of a spiral. Although under different
conditions the form of any one species may vary
considerably, yet these three main divisions under
similar conditions are permanent; and so far as we
know, it is never possible by any means to bring
about changes in the organisms that will result in the
conversion of the morphology of the members of one
group into that of another — that is, cocci always,
under suitable conditions, produce cocci, bacilli pro-
duce bacilli, and spirilla produce spirilla.
The form of the bacterial cells at their stage of com-
plete development must be distinguished from that
which they possess just after or before they have
divided. As the spherical cell develops preparatory
to its division into two cells, it becomes elongated
ami appears as a -hort oval rod at thi of its
division; on the contrary, the tran verse diameter of
each of its two halvi ater than their long di-
ameter. A shorl rod becomes in the same way, al the
"-tit of its divi 1 1 cells, the long diameter
"i each of which may he even a trifle less than its
shorl diameter, and thus they appear on superficial
e lamination as spheres.
As bacteria multiply the cells produced from the
parent cell hai ea 1 ncy to remain
at taihed. In some varieties this tendency is ex-
tremely marked, in others it is slight. This union
may appear simply as an aggregation of separate
bacteria or so close that the group present-
appearance of a single cell. According to the method
ot the cell division and the tenacity with which
cells h,,i ( i together we get different grouping
bacteria, which aid us in their identification and
differentiation. Thus whether the bacteria] cell
divides in one, two, or three plane-, we get forms
built in on.-, two, or three dimensions. If we gi
bacteria according to the characteristic forms of the
cells, and then subdivide according to the manner of
their division in reproduction and the tenacity with
which the newly developed cells cling to one another,
we -hall have the following varieties:
1. Coccus or Micrococcus. — Spherical or sub-
spherical forms.
(a) Single coccus, grouped irregularly.
(b) I ■ is, forming pairs.
(c) Streptococcus, forming chains, often showing
paired cocci.
T< tracoccus, forming fours by division through
two planes of space.
■ Sarcina, forming packets of eight by division
through three planes of space.
(J) Staphylococcus, forming irregularly shaped,
grape-like bunches by division apparently in any axis.
2. Bacillus. — Oblong or cylindrical forms, having
one dimension greater than any other, more or less
straight, and never forming spirals, dividing only in
one plane perpendicular to its long axis.
(a) Single bacillus.
(b) LHplobacillus and streptobacillus, forming twos
or longer chains, the bacilli attached end to end.
(c) Filaments or thread-like growths, in which
division into bacilli of the normal length are not
apparent, or occur irregularly and transversely to
the long axis of the growth.
3. Spirillum. — Cylindrical and curved forms, con-
stituting complete spirals or portions of spirals.
Spirilla. like bacilli, divide only in one direction. A
single cell, a pair, or the union of two or more elements
may thus present the appearance of a short segment
of a spiral or a comma-shaped form, an S-shaped
form, or a complete spiral or corkscrew-like form.
The term bacterium has also been used by some
authors for bacilli or rod-shaped organisms; while to
spirilla the terms vibrio and spirochcete have some-
times been applied. But as there is no uniformity
among bacteriologists as to the exact meaning of
these terms, we shall employ only the terms bacillus
and spirillum to denote these different groups.
Structure of Bacterial Cells. — A bacterial cell con-
-i-t- of protoplasm enveloped in a cell membrane;
the cells as a rule being homogeneous and without
visible nucleus. The cell is generally colorless,
though in some species it contains chlorophyll or
other similar coloring matter. The protoplasm may
at times also contain minute granules of sulphur and
1 iccasionally refractive oily particles or colorless spaces
in stained specimens, which have been mistaken for
spores, but are supposed to be due to the shrinkage
of the protoplasm with partial dissolution of the cell
wall caused by abstraction of water, known as
plasmolysis. In many species of bacteria, as in the
diphtheria bacillus, there is observed in the interior
829
Bacteria
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
of the cells on suitable staining, a peculiar granular
appearance, to which has been given the names
metachromatic bodies or sporogenous granules. The
cell membrane is sometimes colored, and sometimes
surrounded by a gelatinous envelope or capsule,
which can be occasionally brought out by staining.
The demonstration of this capsule may be of assist-
ance in differentiating between certain bacteria, as,
for example, some forms of the streptococcus and
pneumococcus. A peculiarity of the capsule bacteria
is that, except very rarely, they exhibit this envelope
only when grown in the animal body or in special
culture media, such as liquid blood serum, bronchial
mucus, etc. The outer surface of bacteria when
occurring in the form of spheres and short rods is
almost always smooth and devoid of appendages;
but the larger rods and spirals are usually provided
with fine hair-like cilia or flagella, which are their
organs of motility. These flagella, either singly or
in numbers, are sometimes distributed over the
entire body of the cell, or they may form a tuft at one
end of the rod, or only one polar flageltum is found.
The polar flagella appear in the cells shortly before
division. They are believed to be formed of proto-
plasmic material, which penetrates the cell mem-
brane, and probably to have the property of pro-
trusion and retraction; but their nature is imperfectly
understood. So far as we know, the flagella are the
only means of locomotion of bacteria. They are not
readily stained, special mordants being required for
this purpose. Bacteria may lose their power of
producing flagella for several generations, whether
permanently or not is not known.
Vegetative Reproduction. — The process of vegetative
reproduction of bacteria, which is to be distinguished
from spore formation, takes place by division, and
may go on, under favorable conditions, indefinitely.
When development is in progress a single cell will be
seen to elongate in one direction. Over the center of
the long axis thus formed there appears a slight
indentation in the outer envelope of the cell; this
indentation increases until there exist two distinct
cells. As a rule, the cells separate soon after division,
but occasionally they remain together for a time,
forming pairs and chains, or under certain conditions
of nutrition long threads or filaments which break
up into fragments, however, when placed under
other conditions. Although elongation in one direc-
tion and transverse division is the rule for most
bacteria, there are certain groups (as the sarcina,
for example) which divide more or less regularly in
three directions. Division in two directions results,
as already mentioned, in the formation of tetrads;
while division irregularly in all directions produces
grape-like clusters. Bacilli and spirilla, as far as
we know, never divide longitudinally.
Spore Formation. — This is the process by which
bacteria are enabled to enter a stage in which they
resist deleterious influences to a much higher degree
than is possible for them in the growing or vegetative
condition. It is not a process of multiplication of
bacteria, but only one of reproduction for the preser-
vation of the species under conditions unfavorable
to their growth, and occurs when the organism has
nearly exhausted its supply of nutrition or poisoned
it with products of its growth, etc. The fungi, on
the other hand, form spores under the most favorable
conditions, even requiring an abundant supply of
nutrition for their production, the life history of the
fungi, indeed, being incomplete without the formation
of spores. But in bacteria the process is compara-
tively rare, and all the conditions which tend to bring
it about are not yet known.
Two kinds of spores have been described in bacteria:
1. Endospores, which are strongly refractile and
glistening in appearance, oval or round in shape,
and developed within the interior of the cell. They
830
are characterized by the power of resisting to a
considerable extent the injurious influences of heat,
desiccation, and chemical disinfectants, which would
kill vegetative cells. 2. Artitrospores or jointed
spores, developed, not within the cell, but as a sprout-
like projection from one of its extremities. These
jointed bodies are believed by Hueppe to have also
more or less power of resistance to desiccation, etc.,
than the ordinary cells, though less than endospori
but they have been but little studied, and their exist-
ence in bacteria is still an open question. In describ-
ing the biological characters, therefore, of the varioi
species, whenever their property of spore formation
is mentioned it will be understood that endogenous
spores are meant.
The production of endospores in the different
bacterial species, though not identical, is very similar.
Spores represent a state of suspended activity, and
motile organisms always come to a state of rest or
immobility previous to spore formation. The fol-
lowing description of the method of spore form i-
tion in the anthrax bacillus may serve as an illustra-
tion of the process: Under suitable conditions of
temperature, moisture, etc., the cell is elongated and
at first the protoplasm is clear and homogeneous, but
after a time it becomes turbid and finely granular.
These fine granules are then replaced by a smaller
number of coarser granules, which are finally amal-
gamated into a spherical or ovoid refractile body.
This is the spore. As soon as the process is completed
there appears between two spores a delicate partition
wall. For a time the spores are retained in a linear
position by the cell membrane of the rod, but this
later is dissolved or disintegrated and the spores are
set free.
The following types have been observed: (n)
Spores lying in the interior of a short, undistended cell;
(b) spores lying in the interior of a short, undistended
cell, forming one of the elements of a long filament;
(c) the spores lying at the extremity of an undistended
cell much enlarged at that end — the so-called "head
spores"; and (d) the spores lying in the interior of a
much enlarged cell in its central portion, giving it a
spindle shape.
The germination of spores takes place as follows:
By the absorption of water the spores become swollen
and paler in color, losing their shining, refractile
appearance. Later a little protuberance is seen to
project from one side or at the extremity of the spore;
this rapidly grows out to form a new rod, which
consists of soft protoplasm enclosed in a membrane
formed of the inner layer of the cellular envelope, or
endosporum. The outer envelope, or exosporum, is
then cast off, and may often be seen in the vicinity of
the newly formed rod. In some species the vegetative
cell emerges from one end of the oval spore, and in
other species the exosporum is ruptured and the
bacillus emerges from the side.
Involution Foryns. — In old cultures of bacteria in
which deleterious substances have been produced or
the supply of nutriment has been exhausted, there air
frequently found irregular or distorted forms, which
are thought to be due to abnormal development of the
bacterial cells under unfavorable conditions. These
are generally spoken of as involution or degenerated
forms, though sometimes the terms pleomorphism and
polymorphism are applied to them. Placed under
suitable conditions these irregular or deformed cells
again produce normally shaped organisms.
Chemical Composition. — Qualitatively considered,
bacterial cells consist of carbon, hydrogen, oxygen,
and nitrogen, for the most part in the form of water,
salts, fats, and albuminous substances. There are
also present, in smaller quantities, extractive sub-
stances soluble in alcohol. Glucose has not been
found in any bacteria, but many species contain
starchy substances which give a reaction with iodine.
REl'ERKXCi: IIANDHooK uF Till'. MI'.llK'AI, Si II WES
Bacteria
Cellulose has also been detected in certain species, as
i he Bacillus subtilis, some of the colon group, and
the tubercle bacillus. The nuclein bases, xanthin,
guanin, ami adenin, moreover, have been found in
considerable amounts. There is also a group of bac-
teria, l lie Bcggiatoa, which contain sulphur, and
another group, the Cladothrix, has the power of sepa-
rating ferric oxide from water containing iron, as in
iron and sulphur springs. Hut very little is known
about the chemical composition of bacteria quanti-
tatively, only a few species having been completely
analyzed; but the percentage composition would
appear to depend largely upon the character and
constituents of the culture media in which they are
grown.
Conditions of Growth. — Although there are some
pathogenic bacteria which grow only in I In' bodies of
Uving animals and plants, and are therefore apparently
strict parasites, yet the majority of pathogenic micro-
organisms can be cultivated more or less readily in
artificial culture media, and are thus facultative
parasites. The saprophytic bacteria, as a rule, are
easily cultivated artificially, though some of these, as
certain organisms met with in the saliva and in water,
are very difficult or impossible to cultivate.
The essential condition for the cultivation of all
bacteria is water; salts are also indispensable, and
organic matter for the supply of carbon and nitrogen.
Most of the important bacteria and all the pathogenic
species thrive best in media containing albumin and
of a neutral or slightly alkaline reaction. The de-
mands of bacteria, however, with regard to nutrition
are various. Some water bacteria, for instance,
require so little organic food that they will grow in
water that has been twice distilled, and in which no
nutritive material can be chemically demonstrated.
But the pathogenic bacteria are seldom so easily
satisfied, though there are several species which will
develop in comparatively simple culture media and
without albumin.
Considering more in detail the source of the im-
portant chemical ingredients of bacteria, we find that
their nitrogen is most readily obtained from diffusible
albuminous material and less easily from ammonium
compounds. Their carbon they derive from carbo-
hydrates, albumin, peptone, sugars, glycerin, fats,
and other organic substances. Some bacteria grow-
best in special culture media, such as bouillon,
gelatin, agar, blood serum, potato, milk, etc. The
majority of bacteria absolutely require the presence
of free oxygen for their growth, although a consider-
able number fail to develop at all unless oxygen
is excluded. Between these two groups of aerobic
and anaerobic bacteria, we have those which grow
either with or without oxygen. Some of the strictly
anaerobic species require for their full development
the presence of fermentible substances, such as
sugars, from which they obtain their oxygen. In
so far as the amount of oxygen present acts un-
favorably upon bacteria, there will be more or less
restriction in certain of their life processes, such as
pigment and toxin production, spore formation, etc.
Some aerobic bacteria, however, can be accustomed
to grow without oxygen, while certain of the anae-
robes can be gradually made to develop in its presence.
Among other food stuffs required by bacteria are
sulphur and phosphorus; calcium or magnesium and
sodium or potassium are also usually needed. Very
few species require iron.
With regard to the more complex culture media,
whether naturally existing, such as blood serum,
ascitic fluid, etc., or artificially made, as bouillon,
glycerin, and agar, beyond the necessary amount of
soluble nutrition present, the points of greatest im-
portance are the relative proportion of each form of
food and its total concentration. Very wide differ-
ences, however, may exist in the composition of the
culture media with but slight effect upon ihe develop-
ment of bacteria, the growth usually ceasing on ac-
counl of (he accumulation of deleterious substat
in the media rather than from exhaustion ol the food
supply.
'Ihe reaction of culture media is of great importance.
Most bacteria grow besl in neutral or -lightly alkaline
media, very few requiring an acid medium, and Done
of the parasitic species. \n amount of acid <, r alkali
insufficient to prevenl the development of bacteria
may yet suffice to rob them of some of their mo I
important functions, as the production of toxins.
The influence of one species of bacteria upon the
growth of another, either w hen cultivated together or
following one another, is very noticeable. The develop-
ment of one species of bacteria in a medium causes
that substance usually to become less suitable for the
growth of other bacteria. This is due partly to the
impoverishment of the medium, but also to 'the pro-
duction of chemical substances or enzymes which are
antagonistic not only to the growth of the bacteria
producing them, but to many other species; very
rarely are the changes produced by one species of
bacteria in the media favorable to some other specie-.
A suitable temperature is also essential for the
growth of bacteria. The most favorable or optimum
temperature varies for different species, but for any
bacteria a range of about 2.5° C. above or below the
optimum covers the limits of their most vigorous
growth. Few bacteria grow well under 10° C. or over
lit C; 2° C. is about the lowest temperature at which
bacterial species has been known to grow, and
70° C. is the highest. In many cases the temperature
of the natural medium in which the bacteria have been
deposited is the controlling factor in deciding the
temperature at which they will or will not grow under
artificial conditions. Thus nearly all parasitic
bacteria require a temperature near that of the
body (36° -38° V.) for their development, while many
saprophytic bacteria can grow only at much lower
temperature. Bacteria exposed to lower temper-
ature than suffices for their growth, while having
their activity inhibited, are not otherwise injured;
but exposure to a higher temperature than that
which permits growth destroys the life of bacteria.
Vital Phenomena of Bacteria. — Motility. —
.Many bacteria when examined in the hanging drop
are seen to exhibit active movements. This motility
is produced by the fine hair-like flagella attached to
all motile species. The movements are various —
creeping, rotary, undulatory, etc., at one time being
slow and sluggish and at another so rapid that no
detailed observation is possible. The spontaneous
movements of bacteria are to be distinguished from
the so-called Browtuan or molecular movement,
which is a dancing, trembling, stationary motion
possessed by all finely divided organic particles.
Not all species of bacteria, however, which have
flagella exhibit spontaneous motility invariably;
in certain culture media and at too low or too high
temperatures, and when there is an insufficient or
excessive supply of oxygen, motility may be absent.
The property of motility, therefore, evidently depends
upon other factors than flagella. Some chemical
substances apparently exert a peculiar attraction for
bacteria, known as positive chemotaxis, while others
repel them, negative chemotaxis; not all varieties,
however, are affected alike, for the same substances
may exert on some bacteria an attraction and on
others a repulsion. Oxygen, for example, attracts
aerobic and repels anaerobic species, and for each
different species there is a definite amount of oxygen
which most strongly attracts or repels. Possibly
these chemotactic properties, which are as yet but
little understood, may, under certain conditions,
have something to do with the motility of bacteria,
831
Bacteria
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
independently of their organs of locomotion, the
flagella.
Production of Light. — Some bacteria have the prop-
erty of emitting light; these are quite widely dis-
tributed in nature, particularly in sea water, salt fish,
etc. The emission of light or phosphorescence is a
property of the living protoplasm of bacteria, and is
not usually due to the oxidation of any photogenic
substance produced by them. Anything which is
injurious to the life of the organism affects this prop-
erty, as too cold or too high a temperature, chloro-
form, etc. But while the organism is unable to emit
light except during life, it can live, as in an atmos-
phere of CO.,, without exerting this property. The
power of phosphorescence is soon lost, unless the
organism is constantly transplanted to fresh media,
the presence of oxygen, carbon, and nitrogen being
usually required to preserve the property.
Thermic Effects. — Most bacteria possess the power
of producing heat, although this does not ordinarily
attract attention because of the slight amount of
heat produced in cultures. Careful tests, however,
have shown that heat is produced. The increase of
temperature in organic substances when stored in a
moist condition, as tobacco, hay, manure, etc., is
partly, at least, due to the action of bacteria. The
high temperature thus exhibited may be caused, as
Rabinowitsch suggests, by the so-called thermo-
philic bacteria.
Chemical Effects. — The processes which substances
undergo in being decomposed depend, first, on the
chemical composition of the substances involved and
the conditions under which they exist, and, secondly,
on the action of bacteria present. Bacteria are able
to construct their body substance out of various
kinds of nutritive materials and also to produce
fermentative products and poisons, and they can do
these things either analytically or synthetically with al-
most equal facility. In the chemical building up of
their cell substance we may distinguish several groups
of phenomena: polymerization, a sort of doubling up
of a simple compound; synthesis, a union of different
kinds of simple substances into one or more complex
compounds; formation of anhydrides, by which new
substances arise from a compound through loss of
water; and reduction or loss of oxygen, which is
brought about especially by the entrance of hydrogen
into the molecule. The breaking down of organic
bodies of complicated molecular structure into sim-
pler combinations takes place, on the other hand,
through the loosening of the bands of polymerization,
by hydration or entrance of water into the molecule,
or by oxidation.
The chemical effects of bacteria are greatly in-
fluenced by the presence or absence of free oxygen.
The access of pure atmospheric oxygen makes the
life process of most bacteria more easy, but it is not
indispensable when available substances are present
which can be broken up with sufficient ease. Life
processes carried on without oxygen do not effect any
profound molecular changes in the organic material
which is decomposed; but in order that the living
organism may obtain the requisite amount of energy
from this mode of life, a proportionately large quan-
tity of material must be decomposed. Therein lies
the power of a small amount of ferment to produce
much alcohol or lactic acid, and of parasites which
have invaded the living body to generate intensely
poisonous substances out of the body proteids. In the
presence of oxygen the decomposition products
formed by the action of anaerobic bacteria are
further decomposed and oxidized by the aerobes,
being thus rendered inert, as a rule, and consequently
harmless. Some bacteria have adapted themselves
to the use of oxygen compounds, from which they
are able to obtain their oxygen; and others — the
obligatory or strict aerobes — are able to live only in
the presence of oxygen. The facts of anaerobiosis are
of great importance to technical biology and path-
ology. Under strictly anaerobic conditions, second-
ary oxidation of the products of decomposition being
impossible, the latter accumulate without the forma-
tion of by-products. Thus parasitic bacteria are
often found to produce far more poison in the ab>i
than in the presence of air.
Fermentation; the Production of Organized and
Unorganized Ferments. — The chemical effects of
bacteria are largely dependent upon the composition
of the culture media. Thus many species which in
albuminous media produce no visible changes, when
sugar is added give rise to fermentation with the
formation of gas. The term fermentation is differently
applied by different authors. Some call even kind
of decomposition due to bacteria a fermentation;
others limit the term to the process when accompanied
by the visible production of gas; while others again
take fermentation to mean only the decomposition of
carbohydrates, with or without gas production. Fer-
mentation may be properly defined as a chemical
decomposition of an organic compound, induced by
living organisms or substances contained within them
(organized ferments), or by chemical substances
thrown off from the bacteria (unorganized ferment-i.
In the first the action is due to the growth of tin:
organisms producing the ferments, as in the formation
of acetic acid from alcohol by the action of the
vinegar plant, and in the second the enzyme causes a
structural change without losing its identity, as in
digestion. These ferments or enzymes, even when
present in the most minute quantities, have the power
of splitting up or decomposing complex organic com-
pounds into simpler, more easily soluble or diffus-
ible molecules. Ferments, like albuminoids, are not
dialyzable. They withstand dry heat, but are de-
stroyed in watery solution by a temperature of over 70°
C. They are injured by acids, especially mineral acids,
but are resistant to alkalies. All fermentation has
for its object the acquisition by the organism of a
store of energy. This storing up of energy is acquired
in either of the ways above mentioned. The common-
est example of fermentation by decomposition is that
of sugar into alcohol and carbonic acid. Exactly
opposite to this, and far less common, is fermentation
by oxidation, as in the production of acetic acid from
alcohol. Proteolytic or peptonizing ferments, which
are similar to pepsin and trypsin, in that they decom-
pose insoluble albuminoids into soluble or digestible
substances, are very widely distributed. The lique-
faction of gelatin, produced by many species of bacte-
ria, is due to the presence of these peptonizing fer-
ments. Diastatic ferments, which convert starch into
sugar, like ptyalin, are also produced by bacteria.
Other bacterial ferments are the invertive ferments, or
those which convert cane sugar into grape sugar;
and the rennet ferments having the power of coagulat-
ing milk.
The process of fermentation also gives rise to prod-
ucts that are destructive to the ferments; hence
fermentation ceases when the nutriment is exhausted.
Different kinds of fermentation are called by different
names according to the products they yield. Thus,
aeetic acid fermentation, alcoholic or vinous fermenta-
tion, lactic acid fermentation, butyric acid fermenta-
tion, etc., are produced by different species of bacteria.
Putrefaction. — By putrefaction in the common
acceptation of the term is understood the decomposi-
tion of animal or vegetable matter, accompanied by
the generation of fetid odors. Scientifically con-
sidered it is a kind of fermentation or the decomposi-
tion of complex organic compounds, albuminous
substances and the like, into simpler combinations,
produced by microorganisms called putrefactive
ferments. Typical putrefaction occurs only when
oxygen is absent or scanty. As putrefactive products
we have peptone, ammonia, and the amines — leucin,
832
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Bacteria
tyrosin, and other amido-substances; oxyfatty acids,
indol, scatol, phenol; and finally sulphureted hydro
gen, mercaptan, carbon dioxide, hydrogen, and
possibly marsh gas.
,1,1 Production. — Various bacteria form
characteristic pigments as products of their growth,
S ime of these have been isolated and have been round
to possess many of the properties of the aniline dyes.
fhey have no known importance in connection with
ase, bii t are of interest and value in identifying
certain species of bacteria. The principal pigments
need by chromogenic bacteria which have been
ideally studied are: red, yellow, violet, bine, and
in pigments. All conditions which are unfavorable
he growth of the bacteria decrease their power oi
pigment production, as cultivation in unsuitable media
or too low or too high a temperature, etc.
Alkaline Products and the Decomposition of Urea. —
ibic bacteria sometimes produce alkaline products
albuminous substances in culture media free
from sugar. Most species produce acids in the pres-
ceoi sugar, neutral or slightly alkaline cultures thus
often becoming acid at first, owing to the small
quantity of sugar contained in the meat used for
making nutrient media; and later when the sugar is
( \luiusted they become alkaline again. The sub-
stances producing the alkalinity of cultures are chiefly
ammonia, the amines, and the ammonium salts.
The conversion of urea into carbonate of ammonia is
due to the action of bacteria. Several organisms also
have been isolated which separate ammonia from
Ptomaines. — Brieger has recognized a number of
complex alkaloids, closely resembling those found in
ordinary plants, which are the products of bacterial
growth; and these alkaloids he has named ptomaines
(from TTTUfia, a cadaver), because obtained from
putrefying or dead bodies. Nencke, and later
Brieger, Vaughan, and others, have succeeded in
preparing organic bases of definite chemical compo-
sition out of putrefying fluids — meat, fish, old cheese,
milk, etc., as well as from pure cultures of bacteria.
Some of these were found to exert a poisonous effect,
and for a long time were looked upon as the specific
bacterial poison, while others were harmless. The
nis are particularly interesting, as they may be
present in the putrefying cadaver, and hence must be
taken into consideration in medicolegal questions.
They may also be formed in the living body, and if
not rendered innocuous by oxidation may come
to act therein as self-poisons or leucomaines. Recent
investigations have shown that these are not the sub-
stances to which are due the specific toxic effects of
bacteria, which are designated toxins and have quite
different characteristics.
The best-known ptomaines are: CoUidine from
putrefying meat or gelatin, cadaverine from decom-
posing dead bodies, neurine, and muscarine. The first
two of these contain no oxygen, and are non-poisonous,
while the last two ptomaines contain oxygen and have
a poisonous action the opposite of atropine. Tyro-
toxicon, a ptomaine decomposing milk, and found by
Vaughan in poisonous cheese, is apparently derived
from butyric acid. Pyocyanine, which produces the
color of blue and green pus, is a ptomaine pigment.
Similar bodies may also be found in the intestinal
contents as products of bacterial decomposition.
Some of them are poisonous and can be absorbed
into the body, where they play the part of self-
poisons or leucomaines; and it has been thought that
the symptoms designated as coma and tetany may
be ascribed to the absorption of substances of this
nature. The name ptomaine was formerly, and is
still by some authors, applied to all bacterial poisons,
as in cases of so-called food poisoning due to de-
composing meat, sausage, cheese, or milk. But in-
stead of ptomaines, which are now commonly under-
stood to include only the crystalline products of
Vol. I.— 53
bacterial grow ths, these effects maj be cau ed to the
p"i onon protein or toxins, which an
formed in the beginning of putrefactive proce • .
Some of the ptomaines obtained bj cl I an not
due to put refact ive cha ngi at all, but to i he chemical
on i boas employed in separat ing them.
Toxins. — Any poisonous sub tance formed in
growth of bacteria or other microorganism ma be
called a toxin. The different bacterial toxins vary
greatly in their characteristics. As little is km
concerning their chemical nature, thej cannot be
definitely classified. But for practical porposes they
may lie divided into two group-: i. Extracellular
toxins — specific toxic producl , soluble in water,
which are excreted by \ ai iet bactei ia in ordi
nary culture media. Type diphtheria, tetanus. 2.
Intraculhdar toxins or endotoxin true toxins, which
are more or less closely bound to the living cell, and
which are only in a small degree separable in un-
changed condition outside of the body. Type —
cholera, typhoid, pneumococcus. Among the intra-
cellular toxins some which are resistant to heat are
somet imes called prott
Of the properties of the extracellular toxins the
following are the most important: They are, so far as
known, uncrystallizable, and thus differ from pto-
maine-; they are soluble in water ami they are slowly
dialyzable through thin but not through thick mem-
branes; they arc precipitated along with proteins by
concentrated alcohol, sixty-live per cent, or over, and
also by ammonium sulphate; if they are proteins they
are either albumoses or allied to the albumoses; they
are relatively unstable, Inning their toxicity dimin-
ished or destroyed by heat as well as by chemial
manipulation. Their potency is often altered in the
precipitation practised to obtain them in a pure or
concentrated condition, but among the precipitants
ammonium sulphate has but moderately harmful
effect. They are highly specific in their properties
and have the power in the infected body to excite
the production of antitoxins — which is their most
remarkable characteristic.
Regarding the properties of the intracellular toxins
much less is known, but it is probable that their
chemical nature is somewhat similar, though they
differ in their resistance to heat. For instance, some
of the toxins elaborated by tubercle bacilli withstand
boiling, while others do not. In the case of all
toxins, the fatal dose for an animal varies with the
body weight, age, and general conditions.
The most important of the extracellular toxins are
those produced by the diphtheria and tetanus bacilli.
The toxicity of the purest tetanus toxin now obtain-
able is almost incredible and is perhaps the most
powerful poison known; 0.0005 mgm. of it kills a
mouse of 15 gm. weight; hence a man of 150 pounds
weight, if he were equally susceptible, would be
killed with 0.23 mgm. In order to appreciate the
activity of this toxin, we have only to consider that it
requires a dose of from 30 to 100 mgm. of strychnine
to kill a man under ordinary circumstances.
Similar Vegetable and Animal Poisons. — Substances
similar to the bacterial endotoxins and soluble toxins
are formed by many varieties of cells other than
bacteria. The ricin and abrin poisons obtained from
the seeds of Ricinus communis and Abrus precatorius
have a number of properties similar to those of diph-
theria and tetanus. Such substances have been called
toxalbumins. Poisonous snakes also secrete a venom
having many of the characteristics of the bacterial
albumoses.
Reduction Processes. — All bacteria possess the prop-
erty of converting sulphur into H 2 S in the pres-
ence of nascent hydrogen. This is a very common
bacterial product. It may be formed: (1) From
albuminous substances; (2) from powdered sulphur;
(3) from thiosulphates and sulphites. The presence
of sugar in the culture media does not effect the
S33
Bacteria
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
production of H 2 S, but saltpetre reduces it, with the
formation of nitrites. The following reduction
processes brought about by bacteria also depend in
part upon the action of nascent hydrogen: The
reduction of blue litmus pigments, methylene blue
and indigo to colorless substances; the reduction of
nitrates to nitrites and ammonia, and even to free
nitrogen. The so-called "cholera-red reaction" de-
pends upon the reduction of nitrates to nitrites by
the cholera spirillum together with the production
of indol. When chemically pure nitric or sulphuric
acid is added to nutrient peptone cultures of the
cholera spirillum a rose-red or violet color is produced.
The mineral acid splits up the nitrites present, setting
free nitrous acid which, with the indol, gives the red
reaction. Although called " cholera red, this nitroso-
indol reaction is not confined to the cholera spiril-
lum, but may be applied to many other bacteria.
Out of sixty species examined by Lehmann, twenty-
three gave the indol reaction; but the test is of practi-
cal value in differentiating the cholera spirillum from
several other similar species for which it may be
mistaken.
Denitrification. — This process is brought about by a
number of bacteria which separate nitrogen from the
nitrates and nitrites. The practical significance of
these organisms, the denitrifying bacteria, is that
by their action large quantities of nitrates in the soil
and in manure, which are necessary for plant food,
may thus become lost through conversion into free
nitrogen.
Assimilation of Nitrogen. — Although so far as we
know none of the higher plants have the power of
assimilating nitrogen from the atmosphere, this
property is possessed by at least one species of
bacteria, the Bacillus radicicola of Beyerinck. This
organism is found in the root nodules of various
leguminous plants (peas, clover, lupine, etc.), and
can be isolated from these. Different varieties of
this bacillus exist in different kinds of legumes, each
legume apparently having a special variety adapted
to its needs. There are also certain neutral varieties,
however, existing free in the soil. By the aid of these
root bacteria, leguminous plants are enabled to
assimilate nitrogen from the atmosphere, thus en-
riching sandy soils which are naturally poor in nitro-
gen, so that- they yield good harvests.
Formation of Acids from Carbohydrates. — Many bac-
teria form free acids in culture media containing
carbohydrates (sugar). Acid formation occurs some-
times with and sometimes without the production
of gas. Excessive formation of acid may cause the
death of the bacteria from the increased acidity
of the media in which they are cultivated. All
anaerobic and facultative anaerobic species form
acids from sugar; the strictly aerobic species do not,
or they do it so slowly that the acid is hidden by
the almost simultaneous production of alkali (Theo-
bold Smith). If after the sugar is used up not enough
acid has been formed to kill the bacteria, the medium
becomes again neutralized and finally alkaline.
Among the acids produced the most important is
lactic acid, also traces of formic, acetic, propionic,
and butyric acids, and not infrequently ethyl alcohol
and aldehyde.
Gas Formation. — The only gas produced by
bacteria in visible quantity in culture media free
from sugar is nitrogen. In the presence of sugar,
so long as lactic or acetic acid is produced, there may
be no gas production; but frequently gas may be
abundantly formed, especially by anaerobic bacteria
or in the absence of air. About one-third of the
acid-producing species also develop gas, consisting
chiefly of carbon dioxide and hydrogen. Bacteria
which decompose cellulose also produce marsh gas.
Acid Production from Alcohol. — It has long been
known that the conversion of ethyl alcohol into
acetic acid is due to the action of bacteria. The
conversion of the higher alcohols — glycerin, mannit
etc. — into acids is also caused by bacterial action'
as is also the conversion of the fatty acids and their
salts into other acids, as for instance the salts of
lactic, malic, tartaric, and citric acids into butyric
propionic, valerianic, acetic acids, etc.
Effects of Outside Influences upon Bacteria.
— Very little is known about the influence of electricity
on bacteria; but the observations heretofore made on
this subject would seem to indicate that there is no
direct action of the galvanic current on microorgan-
isms, though the effect of heat and electrolysis may
produce changes in the culture which finally sterilize it
Slight agitation of cultures of bacteria seems to
act favorably on their development, but protracted
and violent shaking destroys the vitality of bacteria
by causing a molecular disintegration of their cells.
Pressure exerts comparatively little influence on
bacteria. A culture of the bacillus pyocyaneus
subjected to a pressure of fifty atmospheres unde
C0 2 still grew at the end of four hours, but the
power of pigment production was lost. After six
hours' exposure to this pressure a few colonies still
developed, but after twenty-four hours no growth
occurred.
Light. — A large number, perhaps the majority, of
bacteria are inhibited in growth by the action of
diffuse daylight, still more by that of direct sunlight.
Dieudonne found that the bacillus prodigiosus
exposed to the action of direct sunlight during the
months of March, July, and August were killed in
an hour and a half; during the month of November,
in two and a half hours. Diffuse daylight in March
and July inhibited development after three and a
half hours' exposure; in November after four and a
half hours, and vitality was completely destroyed
in from five to six hours. Exposure to the action of
the electric arc light inhibited development in five
hours and destroyed vitality in eight hours; incan-
descent light inhibited growth in from seven to eight
hours and killed in eleven hours. Similar results have
been obtained with other bacteria, as the Bacillus coli
communis, Bacillus typhosus, and Bacillus anthracis.
The tubercle bacillus was found by Koch to be killed
by the action of direct sunlight in from five minutes
to several hou*s, depending upon the thickness of the
layer exposed and the season of the year. Diffuse
daylight had the same effect in from five to seven
days. It has been shown that it is only the ultra
violet, violet, and blue rays of the solar spectrum
which possess marked bactericidal action; the green
rays very much less, and the red and yellow rays not
at all. The action of light is apparently aided in
most cases by the admission of air; but anaerobic
bacteria, like the tetanus bacillus, and facultative
anaerobic species, as the colon bacillus, are able to
withstand the action of sunlight quite as well in the
absence as in the presence of oxygen. The mechanism
of the action of light has been partially explained, at
least, by the demonstration of the formation of hydro-
gen peroxide in cultures exposed to light for a short
time.
Influence of One Species of Bacteria upon Another. —
If we examine water, milk, or the contents of the
intestinal canal of either sick or healthy persons, we
invariably find several species of bacteria occurring
together. This association may at first seem to be
purely accidental; but on further investigation it
will be found that there are among bacteria synergists
and antagonists, or at least certain species which
apparently assist or oppose one another mutually
or one-sidedly. This action is sometimes spoken of
as symbiosis and enantobiosis (Nencke). Thus it
has been found that many species of bacteria will not
834
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Bacteria
row at all or only scantily in cultures when m close
roximity to other species, the action Lent; mutual
,• one-sided. The practical application of tins tact
in making plates for the isolation of pure cultures
r for the counting of colonies, to have the plates as
liin as possible. Bacteria may also oppose one
, u ,ther antagonistically in the animal body. Km-
lerich has shown that animals infected with anthrax
,-iy often be cured by a secondary infection with the
treDtococcus. The symbiotic or cooperative action
, Bacteria is of still greater importance Some
,-u-teria thrive better in association with other
necies than alone. Certain anaerobic species for
mce as the tetanus bacillus, grow even in the
iresence of air, if associated with aerobic species.
\eain certain chemical effects of bacteria, as denitn-
icatio'n of nitrates, can be produced only when two
ics are associated. In like manner it has been
,Wrved that some soil bacteria, though non-patho-
ic in pure culture, when inoculated into animal- in
combination with other species may produce disease.
,lly, slightly pathogenic species gain in virulence
alien cultivated with common saprophytic bacteria, as
the attenuated tetanus bacillus with Proteus vulgaris.
Lack of Food and Desiccation.— Most bacteria, and
especially the pathogenic species, which require much
.rganic nutriment for their development, when
placed in distilled water soon die; and even in ster-
ilized water they live from eight to ten days only
and rarely multiply. Desiccation affects bacteria
in various ways. In dry culture media development
soon ceases, although in media dried gradually at
the same temperature bacteria may retain their
vitality often for several months even in the absence
of spores. Also under natural conditions, when
these are favorable, many non-spore-bearing bacteria
live a long time when exposed to desiccation, bpore-
bearing species, however, are much more resistant
to desiccation as also to other injurious outside
influences such as heat, light, chemicals, etc.
Behavior toward Oxygen and Other Gases.— As
already noted it is customary to divide bacteria into
three classes according to their behavior toward
oxygen: aerobic, anaerobic, and facultative aerobic
and anaerobic species.
Aerobic bacteria grow only in the presence of
oxvgen; the slightest restriction of air inhibits their
development, spore formation especially requiring
the free admission of air.
Anaerobic bacteria grow and form spores only in the
total exclusion of oxvgen. Among this class of organ-
isms are many soil bacteria, such as the bacillus of
malignant edema, the tetanus bacillus, and the bacillus
of symptomatic anthrax. Exposed to the action of
oxvgen, the vegetative forms of these bacteria are
readily destroyed; their spores, however, are very
resistant. Anaerobic bacteria being deprived of the
oxygen of the air, are dependent for their nutriment
upon decomposable substances such as glucose.
Hence for their cultivation they require, as a rule,
media containing from one to two per cent, of glucose
or some other equivalent.
Facultative Aerobic and Anaerobic Bacteria. — The
greater number of aerobic bacteria, including most of
the pathogenic species, are capable of withstanding,
without being seriously affected, a considerable
restriction of oxygen, and many grow equally well in
the partial exclusion of this gas. Life in the animal
body, for instance, necessitates an existence with a
diminished supply of oxygen. Pigment production
usually ceases with the exclusion of oxygen, but
toxins are more abundantly formed. The presence
of living or dead aerobic species may facilitate the
aerobic growth of anaerobic species. Moreover,
certain species which in their isolation at first show
more or less anaerobic development, have been
observed after a time to become aerobes, growing
only on the surface of media. The fact,
therefore, of an organism showing aerobic 01 anaerobic
growth is nol suffii ienl to make oi i) a distim I
Although all facultative as well a- obligati
anaerobes grow luxuriantly in nitrogen or hydrogen
gas, the same is not true of carbon dioxide gas. Ma
species do not grow at all but are inhibited or killed
bj rti , while others exhibit only a scanty growth,
and very few are not affected. Sulphureted hydro-
gen in large quantity is a strong bacterial poison, and
in small amount even it destroys some pi i ie -
Effect of Temperature.- Every bacterial species
makes certain demands on temperature foi it - growth.
Vegetative life is possible within the limits of 0° and
70° C; but there are some species of bacteria which
grow at the lower and others at the upper limit ol
this range. The maximum and minimum tempera-
ture- for each species lie about 30° C. apart. Bacteria
have thus been classified, according to the tempera-
ture at which they develop, into: (1) Psychrophilic
bacteria. .Minimum growth at 0° C, optimum at
15° to 20° C, maximum at about 30° C. To this
class belong the water bacteria having the power
of emitting light. (2) Mesophilic bacteria. Mini-
mum growth at 10° to 15° C, optimum at 37° C.,
maximum at about 45° C. These include all the
pathogenic species, the conditions for their growth
in the animal body requiring acclimatization to the
body temperature. (3) Thermophilic bacteria. Mini-
mum growth at 40° to 49° C, optimum at 50° to 55°
C, maximum at 60° to 70° C. This class includes
many soil bacteria and almost exclusively spore-bear-
ing species. They are found widely distributed in
feces.
By carefully elevating or reducing the temperature
it is possible to extend the limits within which different
species of bacteria will grow. Thus the anthrax
bacillus has been made gradually to accommodate
itself to a temperature of 42° C, and pigeons, which
are comparatively immune to anthrax infection, on
account of their high body temperature, wdren
inoculated with this modified organism succumb to
the disease. In the same way the anthrax bacillus
has been acclimated to a temperature of 12° C, so
that it killed frogs kept at this temperature (Dieu-
donne) A. very virulent diphtheria bacillus has
been so cultivated that it grew at 43° C. and produced
strong toxin (Park).
Bacterial growth, though retarded by temperatures
just below the minimum of the species, is not other-
wise injured. Cultures of bacteria which readily die
fas the streptococcus) are often preserved in labora-
tories by keeping them in the refrigerator at 4 to
6° C Temperatures even far below 0° C. are only
slowly injurious to bacteria, different species being
affected with varying rapidity. Ordinarily, low-
temperatures, though arresting the growth, do not
destroy the vitality of bacteria. Microorganisms
have been exposed for hours in a freezing mixture
at-lS° C and have been kept in an open tube in
liquid air at- 175° C. for two hours, and yet have been
found to grow when placed again under favorable
conditions.
Temperatures from 5° to 10° C. over the optimum,
however, affect bacteria injuriously in several ways.
The effects produced are the production of varieties
of diminished activity of growth, weakening of
virulence and decrease of the property of causing
fermentation, and finally gradual loss of power of
spore formation. One or other of these effects may
predominate under varying conditions.
If the maximum temperature is exceeded the
organism soon dies; the thermal death point for
psychrophilic species being about 37° C, for meso-
philic about 45° to 55° C, and for thermophilic about
75° C. There are no non-spore-bearing bacteria
S35
Bacteria
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
which, when moist, are able to withstand a tempera-
ture of 100° C. even for a few minutes. According
to Sternberg, ten minutes' exposure to moist heat
"will kill the cholera spirillum at -52° C, the strepto-
coccus at 54° C, the typhoid bacillus at 50° C, the
diphtheria bacillus and gonococcus at 60° C, and the
staphylococcus at 62° C., the last mentioned being
the most resistant of pathogenic organisms without
spores. When bacteria in a desiccated condition are
exposed to the action of heated air the temperature
required for their destruction is much above that
needed when they are moist or exposed to the action
of hot water or steam. A large number of bacteria
are able to resist dry heat at a temperature of over
100° C. for an hour. A temperature of 120° to 130° C.
maintained for an hour and a half is required to
destroy all bacteria, in the absence of spores, if hot
air is used.
Spores are far more resistant to all injurious in-
fluences than vegetative forms, and can withstand
also a greater degree of both moist and dry heat.
.Many spores are able to resist a temperature of 130° C.
dry heat, the spores of the anthrax and the hay
bacilli requiring, for instance, an exposure of three
hours to a temperature of 140° C. to insure their
destruction. Moist heat at a temperature of 100° C,
either boiling water or streaming steam, destroys
the spores of all known pathogenic bacteria within
ten minutes; the spores of some non-pathogenic
species resist this temperature, however, for hours.
While steam under pressure is more effective than
streaming steam in practical disinfection, it is scarcely
necessary to give it the preference, inasmuch as all
known pathogenic bacteria and their spores are
quickly destroyed by the temperature of boiling
water. "Superheated" steam has about the same
germicidal power as hot, dry air at the same tem-
perature, and is less effective, of course, than moist
steam.
Tyndalization; Fractional Sterilization. — Certain
nutrient media, such as blood serum and the transu-
dates of the body (ascitic and hydrocele fluids, etc.),
and some fluid food stuffs, require at times to be
sterilized and yet cannot be subjected to temperatures
high enough to kill spores without suffering injury.
The property of spores, when placed under suitable
conditions, to germinate into vegetative forms, is
here taken advantage of by heating the fluids to 55°
or 78° C. for one hour on six consecutive days. By
this means, upon each exposure, all the bacteria
which have grown in the interval are killed in the
vegetative form. Experience has shown that, with
few exceptions, this method of fractional sterilization
will completely sterilize all fluids thus treated.
Pasteurization. — It is often undesirable to expose
milk and other food stuffs to such a high tem-
perature, because of the deleterious effects produced,
and yet a partial sterilization is required. According
to the method of Pasteur, however, milk, etc., may be
heated for thirty minutes to 70° C, which will kill all
vegetative bacteria present, allowing only the spores
to remain alive. But even this partial sterilization
greatly retards the process of fermentation or
putrefaction.
Attenuation of Virulence. — Although pathogenic
bacteria seem to have retained, for centuries at least,
their principal characteristic in producing disease, they
have been found to suffer under certain unfavorable
outside influences a marked diminution in power, or
attenuation of virulence. This loss of power may be
effected artificially by several methods, all of which
depend upon subjecting the cultures to adverse con-
ditions of one kind or another. The first and simplest
method is by allowing the cultures to grow old. Ob-
viously a pure culture cannot last forever, and in
order to retain the virulence of species it is often
necessary to subculture upon fresh media. Another
S36
mode is to raise the pure culture to a temperature a
little below that which destroys the vitality of the
organism. A third way is to expose the culture to the
action of antiseptic agents. A fourth, but rarely
necessary method, is cultivation in the blood of au
immune animal.
Increase of Virulence. — It is much more difficult to
restore lost power or to increase the virulence of bacte-
ria than to weaken their toxicity. The method usually
employed is by the frequent replanting of cultures
or by successive inoculations into susceptible animals!
In general, pathogenic virulence is increased by succegl
sive inoculation into susceptible animals, and dimin-
ished by cultivation in artificial media under unfavor-
able conditions.
Effect of Chemical Agents. — Many chemical sub-
stances when brought in contact with bacteria unite
with their cell substance, forming new compounds and
usually destroying the life of the organisms. Bacteria
are much more easily killed by chemicals when in the
vegetative than in the spore stage, and their life
functions are inhibited by substances less injurious
than those required to destroy their vitality. But
both in the vegetative and spore forms they differ
considerably in their resistance to chemical agent -
The reason for this is but imperfectly understood, but
it probably depends upon the composition of tin h
cell substance, and is due to a true chemical combina-
tion taking place. Chemicals are more destructive to
bacteria at a high than at a low temperature, and they
act more quickly when the bacteria are suspended
loosely in fluids than when in masses. In estimating
the extent of the action of chemical agents upon
bacteria we usually distinguish the following degrees:
1. Attenuation. — The growth is not permanently
interfered with, but the pathogenic and zymogenic
functions of the organism are diminished.
2. Asepsis or Inhibition. — The organisms are not
able to multiply, but they are not destroyed.
3. Antisepsis, or Incomplete Sterilization.— The
vegetative development of the organism is destroyed,
but not the spores.
_ 4. Disinfection, or Complete Sterilization. — Vegeta-
tive forms and spores are destroyed.
Many substances which are strong disinfectants
become altered under the conditions in which they
are used, so that they lose a part, if not all, of
t heir germicidal properties. Thus quicklime and milk
of lime are disinfecting agents only so long as sufficient
calcium hydroxide is present. If this is changed by
the carbon dioxide of the air into carbonate of lime it
becomes inert. Bichloride of mercury and other
chemicals form compounds with many organic and
inorganic substances, which, though still germicidal,
are much less so than the original substances.
Disinfectants. — Among the more commonly used
disinfectants may be mentioned:
1. Mineral Disinfectants. — Bichloride of mercury.
This substance in the proportion of 1 to 1,000,000 in
nutrient gelatin or bouillon, prevents the develop-
ment of parasitic bacteria. In the proportion of 1 to
500,000 in water it will kill many species in a few min-
utes, but in bouillon twenty-four hours may be needed.
With organic substances its power is lessened, so that
1 part in 1,000 may be required. Spores are killed in
1 to 1,000 watery solution within one hour. Corrosive
sublimate is therefore less effective as a germicide in
alkaline solutions containing much albumin than in
aqueous solutions. In such fluids, besides loss in other
ways, albuminate of mercury is formed, which is at
first insoluble, so that a part of the mercuric salt is
reallj- inert. In alkaline solutions, such as blood,
blood serum, pus, tissue fluids, etc., the soluble com-
pounds of mercury are converted into oxides or hy-
droxides. The soluble compounds can therefore
remain in solution only when there are present
sufficient quantities of certain bodies (the alkaline
REFERENCE HANDBOOK OF THE MEDICAL SCIENl ES
I! I. lc I l.i
■hlorides and iodides, sodium and ammonium
■hlorides) which render solutions possible. The ad-
lition of a suitable quantity of common salt to the
'orrosive sublimate thus prevents the precipitation
if tile mercury. Compounds of mercury which, like
he cyanides, are not precipitated with alkalies, be-
ause they form double -alts, require no addition of
• nit. For ordinary use, solutions of 1 to 500 and 1 to
[000 of bichloride of mercury will suffice to kill the
etativc forms of bacteria within fifteen minut
ii much organic matt it is present the .-tronger solu-
tion should be used.
Biniodide of mercury i- very similar in its effects to
the bichloride, and is even more powerful.
• in solution has about one-fourth the
germicidal value of bichloride of mercury, but nearly
same antiseptic value.
3 Iphale of copper has about five per cent, the value
of mercuric chloride.
S Iphale of iron is a very feeble disinfectant.
istic soda in a thirty per cent, solution kills
anthrax spores in about ten minutes; in four per cent .
solution in about forty-five minutes.
rarbonale even in concentrated solution kills
spores with difficulty, but at 85° C. it kills spore- in
from eight to ten minutes; a five per cent, solution
kills the vegetative forms of bacteria in a short time,
i Irdinary soap suds have a slight bactericidal as well
aarked cleansing effect. The bicarbonate of so-
dium has almost no destructive action on bacteria.
\in m hydroxide is a powerful disinfectant; the
carbonate has little or no germicidal action. A one
per cent, solution of calcium hydroxide in water kills
bacteria in vegetative form within a few hour-: a
three per cent, solution kills typhoid bacilli in one
hour; a twenty per cent, solution added to equal parts
of feces and thoroughly mixed completely sterilizes
them in one hour.
Mineral acids, bulk for bulk, are more germicidal
than vegetable acids. But any acid which equals
40 c.c. of normal hydrochloric acid will prevent the
growth of all species of bacteria and will kill many.
Twice this amount destroys most bacteria in a short
time. A 1 to 500 solution of sulphuric acid kill<
typhoid bacilli within an hour. Hydrochloric, citric,
tartaric, malic, formic, and salicylic acids are similar
t^ acetic acid in germicidal properties. Boric acid
destroys the less resistant bacteria in two per cent,
solution and inhibits the growth of others.
II. Organic Disinfectants. — Alcohol in ten per cent,
solution inhibits the growth of bacteria; absolute al-
cohol kills bacteria in the vegetative form in from sev-
eral to twenty-four hours.
Chloroform, even when chemically pure, does not
destroy spores, but a one per cent, solution will kill
bacteria in vegetative form.
Iodoform has but little destructive action on bacte-
ria, and upon most species has no appreciable effect
at all. Winn mixed with pus from wounds, etc ,
iodoform is reduced to soluble iodine compounds,
which partly act destructively upon the bacteria and
partly unite with the poisons produced by them.
Carbolic acid in aqueous solutions 1 to 1,000 inhibits
the growth of bacteria; in the proportion of 1 to 400
it kills the less resistant organisms, and in 1 to 100
solution destroys all vegetative forms. A five per
cent, solution kills the less resistant spores in a few
hours and the more resistant in from one day to four
weeks; a slight increase of temperature aids the de-
structive action. A three per cent, solution kills strep-
tococci, staphylococci, anthrax bacilli, etc., within one
minute. Carbolic acid loses much of its value when in
solution with alcohol or ether, but the addition of 0.5
per cent, hydrochloric acid aids its activity. Carbolic
acid is so permanent and comparatively so little influ-
enced by the presence of albumin, that it is one of the
best agents for general use in practical disinfection.
Cresol is the chief ingre -called " crude car-
bolic acid." It is al si insoluble in water and has
therefore little germicidal value. Mixed with equal
parts of sulphuri render it soluble it i- a power-
ful disinfectant, but it i- then strongly corn.
Creolin i- an alkaline emulsion of tin- cresols and
other products contained in crude carbolic acid with
snap, ami is as powerfully disil pure carbolic
acid; it is used in live per cent, emulsions.
Lysul is similar to creolin and has about the same
germicidal value.
TricTi \ol i- a refined mixture of the three en
(meta-, para-, and orthocresol) ; it is soluble in water
to the extent of 2.5 per cent., and is about thi
as s( rung as carbolic acid.
The many of them, possess marked
germicidal propei ii Methyl violet ami malachite
green destroy the typhoid bacillus in bouillon cul-
tures in 1 to .'Oil solution in two hours, ami the pyo-
genic cocci in less time. Even in 1 to 100,000 solution
they are -aid In inhibit bacterial growth.
The essential oils an- also strongly disinfectant.
The oils of cinnamon, clove.-, thyme, -am la I v. I. it. .
oy most bacteria in from one to twelve hours.
Thymol and eucalyptol have about one-fourth the
strength of carbolic acid, t > i L of peppermint in 1 to
.Union inhibits bacterial growth. Oil of turpen-
tine in 1 to 200 solution does t ho same. Camphor
has very little anti.-eptic action. (See also article
on I> Is.)
III. Gaseous Disinfectants. — Formaldehyde is a
gaseous compound of strongly disinfectant properties
and posse 1 of an extremely irritating odnr. At a
temperature of 68° F. the gas is polymerized, that i- in
say, a second body is formed composed of a union of
two molecules of CH 2 0. This is known as "para-
formaldehyde," and is a white soapy substance,
soluble in boiling water and alcohol; it exists in the
solution of commerce ordinarily called "formalin,"
which is a clear watery liquid containing from 33 to
40 per cent, of the gas and 10 to 20 per cent, of methyl
alcohol, its chief impurity. When this is concen-
trated, about 40 per cent, paraformaldehyde results.
Pried over sulphuric acid a third body — "trioxy-
methylene" — is produced, consisting of three mole-
cules of CH,0, and is a white substance almost in-
soluble in water or alcohol, and giving off a strong
odor of formaldehyde. The solid polymers of form-
aldehyde when heated are again reduced to the gaseous
condition; ignited they finally take fire and burn with
a blue flame, leaving but little ash.
Formaldehyde has an active affinity for many
organic substances and forms with snme of them defi-
nite chemical combinations. It combines readily with
ammonia to produce a compound called ammoniacal
aldehyde which possesses neither odor nor the anti-
septic properties of formaldehyde. This action has
been made use of in neutralizing the odor of for-
maldehyde when it is desired to dispel it rapidly after
disinfection of habitations. Formaldehyde also forms
combinations with certain aniline colors, viz., fuchsin
and safronin, modifying their shades. The most
delicate fabrics of silk, wool, cotton, fur, leather, etc.,
however, are unaffected in texture or color by formal-
dehyde. Iron and steel are attacked after long
exposure to the gas or its solution: but copper, brass,
nickel, zinc, silver, and gold work are not at all acted
upon. Formaldehyde unites with nitrogenous prod-
ucts of decay, fermentation, and putrefaction, form-
ing true chemical compounds, which are odorless and
sterile. It is thus a complete deodorizer. Formal-
dehyde has a peculiar action upon albumin, which it
transforms into an insoluble and indecomposable
substance. It is to this property of combining chem-
ically with albuminous substances forming the proto-
pla-in of bacteria that formaldehyde owes its ger-
micidal powers. It is also an excellent preservative of
S37
Bacteria
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
organic products for the same reason; and use has
been made of it to preserve meat, milk, and other food
products. But according to Trillat and others it
renders these substances indigestible and unfit for
food. It has been successfully employed, however,
as a preservative of botanical, pathological, and
histological specimens.
The vapors of formaldehyde are extremely irritating
to the mucous membrane of the eyes, nose, and mouth,
causing profuse lacrymation, eoryza, and secretion of
saliva. Aronson has stated that rabbits and guinea-
pigs, allowed to remain for twelve to twenty-four hours
in rooms which were being disinfected with formal-
dehyde gas, were unaffected by the fumes. But
other experimenters have found that animals, such as
dogs, cats, etc., accidentally exposed for some time
to the action of the gas, suffered severely, and some
have died from its effects. It would seem, therefore,
that although formaldehyde is comparatively non-
toxic to the higher forms of animal life, nevertheless
a certain degree of caution should be observed in its
use. Roaches, flies, bedbugs, and other insects are,
as a rule, not killed by formaldehyde gas in the process
of disinfecting a room.
The results of numerous experiments in practical
disinfection with this agent have shown that two and
one-half per cent, by volume of the aqueous solution
of formaldehyde, or one per cent, by volume of the gas,
is sufficient to destroy the vegetative forms of patho-
genic bacteria in a few minutes, when they are freely
exposed to its influence and in a moist condition. The
germicidal power of the gas depends not only upon its
concentration, but also upon the temperature and
the condition of the object to be sterilized. As with
other gases, it has been found that the action is much
more rapid and complete at higher temperatures
(35° to 45° C), and when the test objects are moist
and freely exposed, than at lower temperatures and
when the objects are dry and in mass; the gas possesses
when dry little or no penetrative power. Still it has
been repeatedly demonstrated that it is possible to
disinfect the surface of rooms and articles contained
in them, under the conditions of temperature and
moisture ordinarily found, by an exposure of a few
hours to a saturated atmosphere of the gas.
Sulphur dioxide gas has been extensively used for
the disinfection of hospitals, ships, apartments, etc.
Its action depends upon the formation of sulphurous
acid in the presence of moisture. In its pure state
S0 2 does not destroy spores, and even on vegetative
forms its germicidal effect is uncertain. An exposure,
however, for eight hours to an atmosphere containing
at least four volumes per cent, of this gas in the pres-
ence of moisture will destroy most, if not all, the com-
mon non-spore-bearing pathogenic bacteria. It is
not so prompt or powerful in its action as formalde-
hyde gas, which in many respects is a preferable dis-
infectant, especially in cases where the sulphurous
acid formed from the sulphur dioxide may have an
injurious effect upon the articles to be disinfected.
Peroxide of hydrogen is an energetic disinfectant,
and in two per cent, solution (about forty per cent, of
the ordinary commercial article) will kill the spores of
anthrax in from two to three hours. A twenty per
cent, solution of good commercial peroxide of hydrogen
will quickly destroy the pyogenic cocci and other non-
spore-bearing bacteria. On account of its rapidity of
action and non-poisonous character it is a useful and
safe disinfectant, but it combines with organic matter
and becomes inert, being apt to deteriorate if not prop-
erly kept.
Chlorine is a powerful gaseous germicide, owing its
activity to its affinity for hydrogen and consequent
release of nascent oxygen, when it conies in contact
with microorganisms in a moist condition. Like
formaldehyde gas and sulphur dioxide it is much more
active in presence of moisture than in a dry condition.
Dried anthrax spores exposed for an hour in an
838
atmosphere containing 44.7 per cent, of dry chlorine
were not destroyed; whereas when the spores were
previously moistened and exposed in a moist atmos-
phere for the same time, four per cent, was effective
and when the time was extended to three hours, one
per cent, destroyed their vitality. The anthrax
bacillus, in the absence of spores, was killed by an
exposure in a moist atmosphere containing 1 part
to 2,500 for twenty-four hours. In watery solution
0.2 per cent, kills spores within five minutes, and the
vegetative forms almost immediately.
Chloride of lime owes its efficacy to the chlorine it
contains in the form of hypochlorites. A solution of
one-half to one per cent, of fresh chloride of lime in
water will kill most bacteria in from one to five
minutes; a five per cent, solution usually destroys
spores in an hour.
Bromine and iodine are of about the same germicidal
value as chlorine, in the moist condition; but, like
chlorine, they are not applicable for general use in
house disinfection on account of their poisonous and
destructive properties. They are useful for the
disinfection of sewers, and other similar places.
Trichloride of iodine in 0.5 per cent, solution destroys
the vegetative forms of bacteria in about five minutes,
(The relation of bacteria to disease — infection,
immunity, etc. — will be considered elsewhere; as
will also the subject of Bacteriological technique.)
Special Bacteria.
Under this heading will be described the chief
characteristics of the more important bacterial species
pathogenic for man and other animals. There are
many bacteria which have been found in certain
diseases, but their causal relation to the disease has
not yet been proven, and they have also been found
in other affections. These we cannot treat of here.
Nor will space allow us to consider the non-patho-
genic species, or those which do not affect man, but
are pathogenic for the lower animals only.
The Tubercle Bacillus (Koch's Bacillus tubercu-
losis). — The infectious nature of tuberculosis was
first demonstrated by Villemin in 1865, when by
inoculation with tuberculous material he communi-
cated the disease to healthy susceptible animals.
In 1882 Koch discovered the Bacillus tuberculosis,
which is now known to be the specific cause of the
disease.
Microscopical Appearances. — The tubercle bacillus
occurs in sputum and in cultures as slender rods from
1.5 to 4 [i long and about 0.3 a broad, often slightly
curved. The bacilli usually occur singly, but in
cultures sometimes form chains of four to six elements;
occasionally peculiar, club-like forms and branches
have been met with, from which they have been
supposed to be allied to the actinomyces group of
fungi or streptothrices (see Plate VIII., Fig. 1).
Motility. — Non-motile.
Spore Formation. — The clear spaces or vacuoles
which are present in stained preparations, and which
have been described by some authorities as spores, are
probably due to degenerative processes, as they do
not show the form of spores nor is anything known
as to their power of resistance or germination.
Staining Reaction. — The tubercle bacilli stain with
difficulty, but once stained they retain the dye with
great tenacity. At present the methods most com-
monly employed for staining tubercle bacilli, though
there are many modifications of these, are the Ziehl-
Neelsen with carbol fuchsin, and the Koch-Ehrlich
with aniline water and gentian violet. For special
methods of preparing and staining cover-glass speci-
mens and sections, see Bacteriological Technique.
The peculiar staining reaction found in the case of
the bacillus tuberculosis is not confined to that
organism alone, as other similar organisms, when
REFERENCE HANDBOOK OF THE MEDICAL SCI] \< I 9
Bacteria
treated in like manner, react in the same way. Thus
it has in be differentiated from the smegma bat
located in the smegma often seen beneath the prepuce
and upon the vulva, both normally and in disease;
Lustgarten's bacillus of syphilis found principally in
the primary lesions associated with that disease;
the bacillus of loprosy; ami acid-resisting or grass
bacteria found in butter. Hueppe differentiates tin-
first three organisms and the tubercle bacillus a^
follows:
1. Treat the preparation, stained with carbol
fuchsia with sulphuric acid, and Lustgarten's bacillus.
if present is at once decolorized.
2. If not immediately decolorized, treat with
alcohol and if it is the smegma bacillus it will lose
color.
:i. If it is still not decolorized, it is either the leprosy
or the tubercle bacillus. According to Baumgarten,
the leprosy bacillus is stained by an exposure of six
or seven minutes to a cold saturated watery solution
of fuchsin and retains the stain when subsequently
treated with acid alcohol (nitric acid 1 part to alcohol
10 parts). When treated for the same length of
time, the tubercle bacillus does not ordinarily become
stained.
Biological Characters. — Aerobic; does not grow in
the absence of oxygen. Growth takes place between
29° and 42° C; optimum temperature at 37° C.
Fader all circumstances the growth is slow. On the
ordinary agar and gelatin culture media development
is very scanty; for the cultivation of tubercle bacilli
practically the only media employed are coagulated
blood serum and four to six per cent, glycerin agar
and glycerin bouillon.
It is very difficult to obtain a pure culture of tubercle
bacilli, because they grow so slowly and require for
their development an incubator temperature, and
because owing to the slow growth, the other bacteria
present in tuberculous material, as sputum, grow
more rapidly and take possession of the culture
medium before the tubercle bacillus has had time to
form colonies. It is therefore best, unless human
tissues can be obtained free from other infection, first
to inoculate guinea-pigs (which are very susceptible)
both subcutaneously and intraperitoneally, with the
sputum, and then to obtain cultures from the animal
as soon as the tuberculous infection has fully devel-
oped. The animals thus inoculated usually die at
the end of three to four weeks or more. It is better,
however, to kill a guinea-pig which by its enlarged
glands shows evidence of tuberculosis, and to remove,
with the greatest antiseptic precautions, one or more
nodules from the lungs, spleen, or lymphatic glands,
and inoculate with this the solid culture medium
(blood serum) by rubbing it directly over the surface;
or a part of it may first be crushed between two
sterilized glass slides and then transferred to the
serum and gently rubbed over its surface.
Growth on Coagulated Blood Serum {Dog or Bovine
Serum) or on Egg. — On this medium, which is gen-
erally employed to obtain the first culture, the growth
becomes visible after ten to fourteen days at 37° C,
and at the end of three to four weeks a distinct,
characteristic development has occurred. Small,
grayish-white, dry, crumbly scales first appear on the
surface; then as development progresses there is
formed an irregular, membranous-looking layer. On
removing a small portion of this and placing it on a
cover glass without rubbing, then staining and examin-
ing under the microscope, the bacilli will be seen to
present a characteristic appearance and to be arranged
in parallel rows of variously curved figures.
Growth on Glycerin Agar. — Owing to the greater
facility of preparing and sterilizing glycerin agar, and
the more rapid and abundant development of the
bacilli, which have become accustomed to growth
outside the body, this medium is now usually em-
ployed in prefer to blood serum preserving
cultures. At the end of fourteen to twenty-one daya
the developmenl is more luxuriant than upon blood
-'■nun after several weeks. When numerous bacilli
ha\ e been distributed over the surface of the medium,
a rather uniform, thick, white layer, which later be-
'■ a yellowish in color, is developed; when the
bacilli are few in number, separate colonies ar«
developed with more or less irregular outlini
Growth on Glycerin Bouillon. — On bouillon con-
taining about five per cent, of glycerin the tubercle
bacillus also grows readily if a fresh thin film of grow th
from the glycerin agar is floated on the surface. '1 his
medium is used for the production of "tuberculin."
The small piece ol pellicle removed from the previous
culture continues to enlarge while it floats on the
surface of the liquid, and in the course of from three
to six weeks covers it completely as a single film,
which on agitation breaks up and settles to the
bottom of the flask, where it ceases to develop fur-
ther. The liquid remains clear, containing in solution
the products formed by the growth of the bacillus.
Vitality. — Tubercle bacilli in pure cultures are
very susceptible to the action of direct sunlight,
being destroyed in from a few minutes to some hours,
according to the thickness of the growth. Exposed
to diffuse daylight they are killed in a week. Though
they do not form spores, so far as known, the bacilli
have a somewhat greater resisting power to heat and
desiccation than many other pathogenic bacteria,
frequently retaining their virulence in a dried condi-
tion at the ordinary temperatures for months.
Portions of the lung from a tuberculous cow, dried
and pulverized, produced tuberculosis in guinea-pigs
at the end of one hundred and two days. Dried
tuberculous sputum may retain its virulence for two
or three months or more. An instance is reported
by Ducor of a healthy family having become infected
with tuberculosis from living in a room which had
been occupied by a consumptive patient two years
before, and on examining the sputum-stained wall-
paper not only were tubercle bacilli found in it, but
when guinea-pigs were inoculated with it they died of
the disease. Exposure to 100° C. dry heat does not
kill the bacilli in twelve hours; but moist heat at 60° C.
destroys them in fifteen minutes. Cold has little or no
effect upon them. The resisting power of this bacillus
against chemical disinfectants is considerable, espe-
cially in sputum, where the organisms are protected
by mucus from penetration by the germicidal agent.
They are not always destroyed by the gastric juice
in the stomach, as has been shown by successful
experiments in feeding to susceptible animals. They
are killed in sputum in about six hours by an equal
amount of a three per cent, solution of carbolic acid,
and in about one hour by a five per cent, solution.
Bichloride of mercury is unsuitable for the disinfec-
tion of sputum unless used in very strong solution
(1 to 500). Pickling and smoking are said not to
destroy the virulence of tuberculous meat.
Occurrence. — The tubercle bacillus is a strict
parasite — that is to say, it does not grow under
natural conditions outside of the bodies of man and
animals. It has frequently been found, however, in
the dust of hospitals, dwellings, railways, street cars,
etc., in places where consumptives have expectorated.
Very rarely has it been found in the air. The milk
of tuberculous cows, even when the udder is not
affected, very often contains tubercle bacilli; they are
also found in butter.
Postmortem examinations of many individuals who
have died from some other cause than tuberculosis
have revealed the presence of healed tuberculous
foci. It has been estimated that sixty-six per cent.
of all mankind have some evidence of tuberculosis,
old tuberculous lesions, of primary or secondary
origin. Tubercle bacilli are said to have been found
839
Bacteria
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
also in the secretions of the nose and throat of healthy
persons, nurses and doctors, who have been in con-
stant association with tuberculous patients.
The tubercle bacillus is the essential cause of all
forms of tuberculosis: the various affections of the
lungs and other organs, lupus, scrofula, and inflamma-
tion of the bones and joints. The following diseases
have also been traced to tuberculous infection: so-
called "inoculation lupus," tuberculosis verrucosa
cutis, and scrofuloderma; choroidal tuberculosis, idio-
pathic pleurisy, etc. Indeed, all organs and portions
of the body may become affected with this disease.
Many cases of tuberculosis are produced by the
tubercle bacillus alone, but very frequently strepto-
cocci and other pyogenic cocci play an important part
in the production of fever and the destruction of
tissue, as in phthisis, by suppurative processes.
Tuberculosis is very common among cattle, chiefly
in cows and rarely in calves. According to Klepp,
from abattoir inspections in Germany, up to thirty-
five per cent, of cattle, eighty per cent, of cows, and
three per cent, of calves, are commonly found tubercu-
lous. The disease is also quite frequent in young pigs;
less so in sheep, goats, horses, dogs, and cats. Rab-
bits and guinea-pigs are also not uncommonly
spontaneously affected with tuberculosis, when kept
in cages together with infected animals. Monkeys
in confinement almost invariably die from tubercu-
losis. Wild animals are comparatively free from
the disease; and so are birds, except canaries and
parrots.
Pathogenesis. — As seen from the above many
animals besides man are naturally susceptible to
tuberculosis. Among test animals guinea-pigs are the
most susceptible, and on this account they are com-
monly used for the detection of tubercle bacilli in
suspected material by inoculation. When inoculated
with the minutest quantity of living tubercle bacilli
they usually succumb to the disease. Infection is
most rapidly produced by intraperitoneal injection,
d ■ath following a large dose in from ten to twenty
days. On autopsy the omentum is found to be con-
stricted in sausage-like masses and converted into
hard knots containing many bacilli. There is often
no fluid in the peritoneal cavity, but generally in both
pleural sacs. The spleen is enlarged, and the various
organs contain tubercle bacilli. After smaller doses
death may be deferred from four to eight weeks,
when the peritoneum and interior organs are found to
be filled with tubercles. On subcutaneous injection
into the abdominal wall there is thickening of the
tissues about the point of inoculation, which breaking
down in a week leave a sluggish ulcer covered with
cheesy matter. The neighboring lymph glands are
swollen, and after two or three weeks they may attain
the size of hazelnuts. Soon an irregular fever is set up,
and the animal becomes emaciated, usually dying
within four to eight weeks. If the injected mate rial
contain only a few bacilli, the wound at the point of
inoculation may heal and death be postponed for a
long time. The lymphatics undergo cheesy degen-
eration, the spleen is much enlarged, and throughout
its substance, which is dark red in color, are masses of
nodules. The liver is also enormously swollen,
streaked brown and yellow, and the lungs are filled
with grayish tubercles; but the kidneys, as a rule,
contain no tubercles. Tubercle bacilli are always
found in the diseased tissues, but the more chronic the
process the fewer are the bacilli present.
Rabbits are also quite susceptible to tuberculosis by
inoculation, but much less so than guinea-pigs. In
these animals death almost always follows injection
of tuberculous material into the anterior chamber of
the eye; producing local lesions, softening of the
neighboring lymph glands, lesions of the lungs,
general miliary tuberculosis, and death in several
wi'cks or months. Subcutaneous inoculations are
very much less effective; but intravenous and intra-
peritoneal inoculations usually cause general tubercu-
losis and death in a few weeks. Field mice and cats
are also readily infected by artifical inoculation; rats,
white mice, and dogs only when very large doses are
given. Canaries and parrots are susceptible; fowls
and pigeons only slightly so; and other birds and cold-
blooded animals are apparently immune.
Besides the artificial modes of infection already
alluded to, tuberculosis may be produced in animals
susceptible to the disease by feeding them with tuber-
culous material. This has been repeatedly done with
milk, sputum, etc., containing tubercle bacilli. Here
evidence of infection is usually shown in the mesen-
teric glands before the intestinal walls are affected;
indeed, there may be no local lesions in the intestines
at all. Under such conditions, infection is probably
caused by absorption of the poisons through serous or
mucous membranes.
The experimental production of tuberculosis by
inhalation of bacilli has been demonstrated by Koch
in guinea-pigs, rabbits, mice, etc. In these cases the
bacilli were usually administered in the form of fine
spray; the inhalation of dry tuberculous dust has
seldom proved experimentally successful.
The tubercle bacillus acts upon the tissues by
means of the poisons which it produces as the result
of its growth. Soon after entrance into the tissues of
either living or dead bacilli, the cells surrounding
them begin to show signs of irritation. The connect-
ive-tissue cells become swollen and undergo mitotic
division, the resultant cells being distinguished by
their large size and pale nuclei. A small focus of
proliferated epithelioid cells is thus formed about the
bacilli, and according to the intensity of the inflamma-
tion these cells are surrounded by a larger or smaller
number of the lymphoid cells. When living bacilli
are present and multiply, the lesions progress, the
central cells degenerate and die, and a cheesy mass
results, which later may lead to the formation of
cavities. Dead bacilli, on the other hand, give off
sufficient poison to cause less marked changes only,
and never produce cavities. Of the gross pathological
lesions produced in man by the tubercle bacilli the
most characteristic are small nodules, the so-called
miliary tubercles. These when young, and before
they have undergone degeneration, are gray and
translucent in color, somewhat smaller than a millet
seed in size, and hard in consistence. But miliary
tubercles are not the sole tuberculous products. The
tubercle bacilli may cause the diffuse growth of tissue
identical in structure with that of miliary tubercles —
that is. composed of a basement substance containing
epithelioid, giant, and lymphoid cells. This diffuse
tubercle tissue also undergoes cheesy degeneration.
When caseation is rapidly spreading, as in acute
tuberculosis, the bacilli are usually abundant, being
scattered in irregular groups through the tissues.
Occasionally they are found in the leucocytes, and in
the giant and epithelioid cells. The more chronic the
lesions the fewer they are in number.
Modes of Infection. — The chief modes of infection by
the tubercle bacillus are through the respiratory tract
or the intestines, more rarely through wounds of the
skin, and still more rarely through the sexual organs.
Pulmonary tuberculosis, as a primary infection, and
not occurring in young children, may be considered to
be caused chiefly by the direct transmission of tubercle
bacilli through kissing, soiled hands, handkerchiefs,
etc., or by the inhalation of tuberculous dust. Intes-
tinal and mesenteric tuberculosis, which is rare among
adults and common with children, is probably due
not only to swallowing the bacilli received in the
above-mentioned ways, but also to the ingestion of
tuberculous milk. Lupus is probably always pro-
duced by the inoculation of tubercle bacilli on the skin
or mucous membranes, the original seat of the disease
being often on a wounded surface. Localized skin
tuberculosis is sometimes produced by accidental
Sill
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Bacteria
aoculation at autopsies. The transmission of in-
ection through the sexual organs of the mule or
emale, though possible, is extremely rare. There
,.. to b<- some evidence of the communication of
uberculous infection from the mother to the fetus in
mimals; and two rases are recorded of probable
ilacental tuberculosis in the human fetus. But we
ao reason to suppose that infection of the
ivum of healthy mothers from the paternal side ever
occur, even when the father has tuberculosis of
be scrotum or seminal vesicles. The mere fact that
statistics show a greater frequency of tuberculous
[iseases in children during the first than in the follow-
ears of life does not strengthen the hypot hesis of
tion in ulero; for nursing babies would naturally
... i posed to infection through the moth
milk and through personal contact than others; and,
besides, the more tender the life of the infant the more
eptible it would be ordinarily to indirect infection
a t uberculous mother.
By far the commonest mode of infection, therefore,
is undoubtedly by means of tuberculous sputum,
which, being coughed up by consumptives and care-
. expectorated, dries and distributes numerous
virulent bacilli in the dust. As long as the sputum
remains moist there is no danger of dust infection, but
only of direct contact. A great number of the ex-
pectorated and dried bacilli very probably die, espe-
cially when exposed to the action of direct sunlight ;
but when we consider the enormous masses which are
expectorated,* it is evident that a sufficient quantity
remains alive to produce infection in the immediate
vicinity of consumptives unless precautions are
n to prevent it. There is comparatively little
danger of infection in the streets or at a distance from
consumptive patients, because even if present in the
. the tubercle bacilli have become so diluted that
they are not much to be feared. It may, therefore,
be said that the probability of infection from tubercu-
losis in general is not so great after all, but at the
same time it is all the more to be dreaded and guarded
against in the immediate neighborhood of consump-
tives. Those who are most liable to infection from
this source are the families, nurses, fellow-workmen,
fellow-prisoners, etc., of persons suffering from the
disease. In this connection, also, attention may be
drawn to the fact that rooms which have been re-
cently occupied by consumptives are not infrequently
the means of producing infection (as has been clinic-
ally and experimentally proved) from the deposition
of tuberculous dust on furniture, walls, floors, etc.
Fliigge has lately pointed out that in coughing, sneez-
and even in speaking, very fine particles of
secretion, containing tubercle bacilli, may be thrown
out and carried by air currents many feet from the
patient and remain suspended in the air for a con-
siderable time. For this reason consumptives should
be careful to hold their hands or a handkerchief
before their mouths, or at least avoid as much as
possible contaminating other persons with whom
they come in contact.
Phthisical sputum, however, cannot be held re-
sponsible for the occurrence of all human tubercu-
losis. .Milk also serves as a frequent conveyer of
infection, whether it be the milk of nursing mothers
suffering from consumption or the milk of tuberculous
cows. The transmission of tubercle bacilli in the
milk of tuberculous cows has been abundantly
proved by feeding and inoculation experiments on
animals. Formerly it was thought that in order to
produce infection by milk there must be local tubercu-
lous infection of the udder; but it is now known that
tubercle bacilli may be found in milk when an
internal organ is infected, and when no disease of the
* Xuttall has estimated that from one and one-half to three
billion virulent tubercle bacilli may be expectorated by a single
tuberculous individual in twenty-four hours.
udder, so far a j careful is
The milk of all cows, then fore, which have any tuber-
culous infection whatever, m considered as
ibly containing tubercle bacilli. 'With regard to
the flesh of tuberculous cattle, ti conditions
hold g 1 as in the infection by milk, only the danger
iderably less from the fact thai meat I
cooked, and also because the muscular ti
seldom attacked. In view of the great rtality
from tuberculous diseases among mankind,
legi lative control and inspection of cattle and milk
would seem to be an absolute necessity. A- a practi-
cal and simple method of preventing it
e pecially among children, the sterilization (by hi
of the milk used as food must commend itself to all.
With regard to bovine infection in man numerous
investigations have been made. To Ravenel properly
belongs the credit, of isolating the firsl bovine bacillus
from a child. It has been shown that children are
especially the ones infected, and usually the point of
entry is clearly alimentary. Cervical adenitis and
abdominal tuberculosis are the most frequent types
of infection. Generalized tuberculosis due to bovine
infection is less frequent and bone and joint, tubercu-
losis is almost exclusively of the human type, infec-
tion of adults is very uncommon. According to
I'arth, a careful study of all the factors leads to the
belief that about ten per cent, of all tuberculosis in
children under five is due to bovine infection.
Individual Susceptibility. — Another most important
factor in the producion of tuberculosis, as of all infec-
tious diseases, is individual susceptibility. That this
susceptibility or "predisposition," improperly so
called, may be either inherited or acquired is now an
accepted fact in medicine. There is no doubt that
great differences exist in different persons in their
susceptibility to tuberculosis, as there are also
differences in the intensity of the tuberculous process
in the lung. The fact that individuals contracting
tuberculosis from the same source are attacked with
different severity, and that there is, as a rule, no great
variation in degrees of virulence in the tubercle
bacilli of different origin, shows that this depends
upon something else than a variation in virulence of
the infection. The results of postmortem examina-
tions also demonstrate that many cases of pulmonary
tuberculosis evidently occur without showing any
visible signs of disease, and heal spontaneou-ly.
The possibility of favorably influencing, in an existing
tuberculosis, "the course of the disease by treatment
proves, too, that under natural conditions there is a
varying susceptibility. Clinical experience teaches
likewise, that the children born of tuberculous
parents, and persons living in poor hygienic conditions
and depressing surroundings, as in prisons, asylums,
and convents, and those suffering from exhausting
diseases, more especially bronchial affections, diabe-
tes, typhoid fever, etc., are more susceptible to
tuberculosis than others not so situated or affected.
Animal experiments, moreover, have shown that not
only are there differences of susceptibility in various
species, but also an individual susceptibility in the
same species. The doctrine of individual suscepti-
bility, therefore, is apparently founded on fact,
although the reasons for it are only partially
understood.
Immunization: Koch's Tuberculin. — As in other
infectious diseases, many attempts have been made
to produce an artificial immunity against tubercu-
losis, but so far the results have been unsatisfactory.
Among the numerous agents that have been tried to
protect animals against the action of the tubercle
bacillus, the most important is Koch's tuberculin.
Tuberculin contains all the products of the growth of
the tubercle bacillus in nutrient bouillon and certain
substances extracted from the bodies of the bacilli
themselves; also the albuminoid and other materials
841
Bacteria
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
originally contained in the bouillon which are unaf-
fected by the growth of the bacilli. There are two
preparations known respectively as the "old" or
original ("T. O.") and the "new" tuberculin or
"tuberculin T. R.," or Bacillus Emulsion (" B. E.").
Old tuberculin is prepared as follows: The tubercle
bacillus is cultivated in peptone-glycerin-bouillon.
At the end of from three to six weeks, according to
the rapidity with which the culture grows, an abund-
ant development takes place with the formation of a
thick, dry, white crumpled layer, which finally covers
the entire surface of the bouillon. (It was originally
inoculated on the surface.) After development
ceases, this layer breaks up and sinks to the bottom
of the flask. Fully developed cultures, having been
tested for purity by microscopical examination, are
evaporated by boiling to one-tenth of their original
bulk. The liquid is then filtered, and the crude
tuberculin thus obtained contains forty to fifty per
cent, of glycerin (the broth medium contained four to
five per cent.), and keeps well, retaining its activity
indefinitely. This substance when injected into
tuberculous individuals affects the tuberculous
process in a peculiar way. Very small doses produce
a moderate increase of inflammation with slight
elevation of temperature in tuberculous persons,
while healthy individuals have neither fever nor
marked local symptoms. The following is the
method of treatment employed. After each injec-
tion, which should be large enough to cause a slight
but not a great rise of temperature, a noticeable
change in the tuberculous process results. The
amount of tuberculin injection is constantly increased,
so as to continue the moderate reactions. After
several months all reactions cease, the patients
having become temporarily immune to the toxin, but
not to the growth of the bacillus. Further injections
are now useless, until this immunity has passed.
Inasmuch as the bacilli themselves have not been
directly affected by the treatment, when this is inter-
rupted the tuberculous process is apt to progress
(Koch).
Although Koch and some of his followers appar-
ently, from their reports, obtained satisfactory results
in the treatment and immunization of man and
animals with old tuberculin, the majority of invest i-
gators, after a short period of enthusiasm, abandoned
its use as very rarely beneficial, if not often injurious.
Koch therefore attempted to improve his method and
recommended a new preparation under the name of
"Tuberculin T. R.," or new tuberculin or Bacillus
Emulsion (" B. E "). The substances produced in
the body by the old tuberculin neutralized the tuber-
culous toxins, according to Koch, but were not bac-
tericidal. This he considered due to the nature of the
envelope of the tubercle bacillus, which rendered it
difficult to obtain the substance of the bacilli in soluble
form without so altering it by heat or chemicals that
it was useless for immunizing purposes. Immunity,
he thought, was not produced in man for similar rea-
sons, the bacilli never giving out sufficient toxin, per-
haps, to bring about the production of curative sub-
stances. He therefore decided to grind up the dried
bacilli and soak them in water, and thus obtain, if
if possible, without the aid of heat, a soluble extract of
the cell substance of the bacilli, which he hoped would
1«- immunizing. Buchner, by crushing under a great
pressure tubercle bacilli mixed with sand and thus
squeezing out their protoplasm, obtained a simi-
lar substance, which he called "tuberculoplasmin."
The new tuberculin is thus a watery extract of the
soluble portions of the unaltered tubercle bacilli.
Owing to the method of preparation, it is evident
that contamination is difficult to avoid, freedom
from intact bacilli is uncertain, and the strength of
the solution is variable. Twentv per cent, of glycerin
is added to preserve the preparation. Dilutions are
842
made in 0.5 per cent, carbolic acid in O.S salt solution
Before marketing the preparation is usually subieetpri
to heating at (30° C. ""jeciea
Bouillon Filtrate Tuberculin ("B. F."). This i s
the unheated filtrate from bouillon cultures of human
tubercle bacilli, suggested by Denys. Many other
tuberculins have been proposed during the last
twenty years, all of which are vaccines made from
either the body substance of the germ or the liquid
medium in which it has grown, or both, and their aim
is to stimulate the defensive resources of the system
or to induce antitoxic and antibacterial immunity
They all produce, when given in sufficient doses
local reactions in tuberculous foci, and the well-known
but little understood phenomena of general tuberculin
reaction. These new tuberculin preparations are
now considered superior to those obtained from the
older product of Koch in the treatment of human
tuberculosis.
Regarding the results from tuberculin treatment
it has been demonstrated by bitter experience that
tuberculin is not the vaunted and long-looked-for
specific it was at first thought to be. Trudeau, and
other reliable investigators, however, have formed
favorable impressions of its influence by noticing
that the disease seemed to progress more rarely with
the usual exacerbations and relapses in patients
who were tolerating the tuberculin treatment than
in those who had the climatic and open-air treatment
only.
The chief use to which the old or original tuberculin
has been put is as an aid to the diagnosis of obscure
cases of tuberculosis in cattle and man, and for this
purpose it has proved to be of inestimable value.
Cows are generally injected subcutaneously with 0.3
to 0.5 c.c. (diluted with water to 30 or 50 c.c.) of
tuberculin and watched to see whether there is a rise
of temperature of 1.5° to 3° C. in twelve to fifteen
hours. Occasionally the reaction does not occur
when the animals are in an advanced stage of the
disease, but in such cases the test is not needed. The
reaction never takes place, or one very much less
marked occurs, in healthy animals, though small
centers of infection are often difficult to locate later
on autopsy. Latent tuberculosis is rarely if ever
stimulated to renewed activity. It is important
to note that an animal frequently requires an interval
of a month to give a second positive reaction, if it
has reacted typically on the first trial. In man it is,
of course, much more difficult to form any opinion as
to the reliability of the tuberculin test, from the fact
that it cannot be controlled by postmortem examina-
tions. It, is, however, of great value in selected cases,
both surgical and medical, where slight tuberculosis
is suspected, and yet no decision can be reached.
In the first small dose advised (0.5 mgm. in adults
and 0.3 in children) an absolutely latent infection
should usually give no rise of temperature.
Von Pirquet's cutaneous tuberculin test has for
many purposes supplanted the subcutaneous injec-
tions, as it is perfectly harmless. This is carried out
by placing a drop of a 25 or 50 or 100 per cent, solution
of tuberculin upon the skin of the forearm and then
with a needle or instrument making through it a
slight abrasion without drawing blood. A central
abrasion without tuberculin is made at another point.
Within twelve to twenty-four hours a papule with a
surrounding congested area forms about the inocu-
lated point. In Moro's test equal parts of tuberculin
and lanolin are mixed together to make an ointment,
which is rubbed upon the skin. A crop of papules
develops in twelve to twenty-four hours in cases in
which the test proves effective. In the ophthalmo-
tuberculin test, two solutions of different strengths
are employed, one of the alcohol precipitate of tuber-
culin in 0.5 per cent, and 1 per cent., and the other
of 1 and 2 per cent, tuberculin ("T. O."). The
REFERENCE HANDBOOK OF THE MEDICAL S< [EN( ES
Bacteria
weaker and stronger are used successively ineacheye.
In from three to twelve hours, or longer, reaction
occurs, unci occasionally conjunctivitis, keratitis, or
iritis results. Preference is therefore given to the
cutaneous tes( .
Haragliano and others claim to have obtained with
an antituberculous scrum, prepared chiefly from
horses, encouraging results; and Behring hopes to
be able to make an antitoxic serum which will be
curative and protective. Rut whether serum therapy
is destined to solve the problem of the treatment ol
tuberculosis remains for the future to decide. Judg-
ing, however, from the progressive nature of the
disease, there is not much ground to hope for the
abundant development of curative substances in the
blood of animals.
Meanwhile all energies should be directed to the
prevention of tuberculosis, nol only by the enforce-
ment of proper sanitary regulations as regards the
care of sputum, milk, meat, disinfection, etc., but
also by continued experimental work and by the
establishment of consumptive hospitals; and by efforts
to improve the character of the food, dwellings, and
condition of the people in general we should endeavor
to build up the individual resistance to the disease.
It may be years yet before the public are sufficiently
educated to cooperate in adopting the necessary
hygienic measures to stamp out tuberculosis entirely;
but from the results which have already been obtained
in reducing the mortality from this greatest scourge
of the human race, we have reason to hope that in
time it may be completely eradicated.
The Leprosy Bacillus (Bacillus lepra:). — This
organism, discovered by Hansen in 1879, is found
chiefly in the interior of the peculiar round and oval
cells met with in leprous tubercles. The bacilli have
also been observed in the lymphatic glands, liver,
spleen, and testicles, and in the thickened portions of
nerves involved in the anesthetic forms of the disease.
According to some authorities they occur likewise in
the blood. The bacilli lie in the leprous cells in great
numbers, and also in the lymph spaces outside of these
cells. They are not found in the epidermal layers
of the skin, but, according to Babes, they may
penetrate the hair follicles.
Microscopical Appearances. — The bacillus lepra?
resembles the tubercle bacillus in form, but is some-
what shorter and not so frequently curved. The
rods have pointed ends; and in stained preparations,
unstained spaces, similar to those observed in the
tubercle bacillus, are seen. (See Plate VIII., Fig. 2.)
Motility. — Non-motile.
Staini?tg Reactions. — The leprosy bacillus cannot
be positively differentiated from the tubercle bacillus
by staining reactions. It stains readily with the
a liline colors and also by Gram's method. Although
di.Tering from the tubercle bacillus in the ease with
which it takes up the ordinary aniline dyes, it behaves
like the former in the manner in which it retains its
color when subsequently treated with strong solutions
of the mineral acids and alcohol. Inasmuch as
leprosy and tuberculosis not infrequently occur
together in the same person (according to Hansen and
Looft tuberculosis being the cause of death in forty
per cent, of the cases of leprosy), in making a differen-
tial diagnosis, all the various points, histological
and pathological, must be considered and animal
inoculations made, in addition to microscopical
examination.
Biological Characters. — Attempts to cultivate the
bacillus lepne have frequently been made, but so far
with only questionable results, as none of the cultures
obtained has produced a similar disease when inocu-
lated into animals. The etiological relation of this
bacillus to leprosy is based, therefore, chiefly upon its
constant presence in the leprous tissues. It has been
shown by Spronk, however, thai the blood serum of
many lepers even in weak dilution give-, the agglu-
tinating reaction with cultures "I" the bacillus lepi
a fact which goes to prove thai the organism culti-
vated is the true cause of the disease with which it
is associated.
Pathogenesis. — Some investigators claim to ha
had positive results in Inoculation experiments on
animals with portions of leprous tubercles, excised for
the purpose; Dul none has succeeded in producing the
typical lesions of the disease a- tmi in man. Arning
inoculated a condemned criminal in the Sandwich
Islands with fresh leprous tubercles, bis death occur-
ring from leprosy five year-, later; bul there i- no con-
clusive evidence of the transmissibility of the di
in this way, as tin- man, according to .Swift, had oilier
opportunities for becoming infected.
It is generally assumed that infection takes place
through the mucous membranes ami through slight
skin wounds. There is said to be no infect ion by way
of the digestive tract. With regard to the question
of direct inheritance from the mother to the unborn
babe, there is considerable difference of opinion.
Some cases of intrauterine infection have been repor led
but they are at least very rare. Leprosy bacilli are
frequently present in the spermatic fluid and in the
milk, but they have never been found in the ovaries.
Most commonly they are met with in purulent nasal
secretions (one hundred and twenty-eight out of one
hundred and fifty-three cases examined by Sticker),
and in the mucous membranes of the mouth, throat,
etc.; but they have also been found in various other
organs of the body, in the nerves, and in the blood.
The widespread opinion, which was held before the dis-
covery of the leprosy bacillus, that the disease was
associated in some way with the eating of certain
kinds of food, as salt fish, has now been generally
abandoned. The negative results obtained from
inoculation experiments, together with the fact that
infection is not readily transmitted to persons exposed
to the disease, have been explained by the assumption
that the bacilli contained in the leprous tissue are
mostly dead and non-virulent; but it is much more
probable that a special susceptibility to the disease,
inherited or acquired, is requisite for its production.
The great similarity in many respects of leprosy to
tuberculosis has recently been still more emphasized
by the observations of Babes and Kalindero, who
state that leprosy reacts, both locally and generally,
to an injection of tuberculin in the same manner as
tuberculosis.
The Smegma Bacillus (Bacillus srnegmatis). —
Found by Tavel and Matterstock in the smegma
pra?putii, between the scrotum and thigh, and between
the labia; also in the cerumen and occasionally on the
skin. The bacilli lie in clusters either in or between
the epithelial cells, the rods being very similar, in size
and form, to those of the tubercle bacilli. They stain
with difficulty, and resist decolorization with acid
when stained by the methods for staining the tubercle
bacillus, but are decolorized when treated for one
minute with absolute alcohol. This bacillus is most
likely to be mistaken for the tubercle bacillus in the
examination of urine.
Lustgartex's Bacillus. — This organism, which
very closely resembles the tubercle bacillus, was found
by Lustgarten (1SS4) in the secretions of syphilitic
ulcers and believed by him to be the specific cause of
syphilis. Doutrelepont about the same time also
observed a similar organism and came to a like
conclusion. It has since been shown that in nor-
mal smegma, bacilli are found in great abundance
similar in their morphology to the bacillus of Lustgar-
ten, but differing, as a rule, in certain staining
peculiarities.
Lustgarten's bacillus stains with equal difficulty as
S43
Bacteria
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
the tubercle bacillus, but is much less resistant to the
action of acids; it is also more resistant, as a rule,
to the decolorizing action of alcohol than is the
smegma bacillus.
Numerous attempts have been made to cultivate
this bacillus artificially but without success. The
inoculation of animals with syphilitic tissues and secre-
tions has also given only negative results, though in
man, as is well known, infection by inoculation fre-
quently takes place, the tertiary lesions only being
non-infectious.
Lustgarten's bacillus has been found in various
syphilitic tissues, in beginning sclerosis, in the papules,
in condylomata and gummata, and not only in the
vicinity of the genitals, but also in the mouth, throat,
heart, and brain. No satisfactory experimental evi-
dence has been given, however, of its causative rela-
tion to syphilis. It is now recognized that Trep-
onema pallidum (spirochata pallida), discovered by
Sehaudinn and Hoffman, in 1905, is the specific
cause of syphilis.
The Influenza Bacillus (Bacillus influenza'). —
Discovered by Pfeiffer and isolated in pure cultures
(1S91-92) from the purulent bronchial secretion^ of
patients suffering from epidemic influenza. Pfeiffer's
discovery has been fully confirmed by others, the
results of whose researches give us reason to believe
that this bacillus is the chief etiological factor in the
production of influenza or "la grippe."
Microscopical Appearances. — Extremely small, mod-
erately thick bacilli, about two or three times as long
as broad, with rounded ends, occurring singly or in
pairs, but threads or chains of three or four elements
are occasionally met with in cultures; often found in
the interior of cells. (See Plate VIII., Fig. 3.)
Motility. — Non-motile.
Spore Formation. — Does not form spores.
Staining Reactions. — The influenza bacillus stains
with difficulty with the ordinary aniline colors; best
with dilute ZiehFs solution of carbol fuchsin or
Loeffler's methylene blue solution, with heat. When
faintly stained the two ends of the bacilli are somewhat
more deeply stained than the middle portion. It
does not usually stain with Gram's solution, though
some investigators report such staining reaction.
Biological Characters. — Strictly aerobic; no growth
occurs below 26° C, or above 43° C, or in the entire
absence of oxygen; optimum temperature, 37° C.
Grows on the surface of solid nutrient media contain-
ing hemoglobin or pus cells, as blood agar or blood se-
rum. At the end of eighteen to twenty-four hours on
such culture media in the incubator very small, drop-
like colonies are developed, which under a low mag-
nification appear as shining, transparent, homogene-
ous masses; older cultures are sometimes colored
yellowish brown in the center. A characteristic
feature of the growth of the influenza bacillus is that
the colonies tend to remain separate, although when
thickly sown in a film of moist blood upon nutri-
ent agar they may occasionally become confluent.
Spread out in a thin layer upon the surface of blood
bouillon the growth develops as delicate white flakes.
According to Grassberger a mixture of nutrient agar
and defibrinated blood, which has been kept for one
hour at 50° to 60° C, makes an especially good soil
for their growth.
Vitality. — The influenza bacillus is very sensitive to
desiccation; a pure culture diluted with water ami
dried is destroyed with certainty within twenty-four
hours. In dried sputum vitality is retained for from
twelve to twenty-four hours, according to the degree
of drying. It does not grow, but soon dies in water.
The thermal death point is 60° C. with five minutes'
exposure. In bouillon cultures at 20° C. the bacilli
remain alive for from a few days to two or three weeks.
Pathogenesis. — The bacillus of influenza, so far a-; is
known, produces the disease by artificial infection only
844
in monkeys and rabbits. From numerous experi-
ments made in guinea-pigs, rats, mice, and pigeons
these animals seem to be immune to influenza. When
a small quantity of a twenty-four-hour-old culture on
blood agar is injected intravenously into rabbits
Pfeiffer found that a characteristic pathogenic effect
was produced. Within one and one-half to two hours
after the infection, the animals became very feeble
and suffered from dyspnea, the temperature rising to
41° C. or more. At the end of five or six days they
were able to sit up and move about again, and later
they recovered. Larger doses caused death. When
cultures were rubbed into the nasal mucous mem-
branes of monkeys, these animals showed a febrile
condition, lasting for a few days, but in no instance
has Pfeiffer observed a multiplication of the bacilli
introduced, the results being due to toxic products.
Cantani has shown that it is possible to produce
an infection of influenza in rabbits when inoculated
with small doses (0.25 to 0.5 c.c.) of living bacilli,
provided the point of least resistance is chosen, viz.,
the brain, the toxic products of the influenza bacillus
acting most powerfully upon the central nervous
system. The cell bodies of the bacilli seem to posse-
considerable pyogenic action.
It is possible that an immunity against the influenza
poison lasting for a short period may be established
after an attack. At least in three experiments made
by Pfeiffer on monkeys, these animals, after recover-
ing from an inoculation, seemed to be less susceptible
to a second injection.
The influenza bacillus has not been found outside of
the body. In patients suffering from influenza the
bacilli are chiefly met with in the nasal and bronchial
secretions more especially in the characteristic light
yellowish to green purulent sputum. The older the
process the fewer bacilli will be found, and the more
frequently will they be seen lying within the pus cell?.
At this time they stain less readily and present more
irregular and swollen forms. Very often, perhaps
almost invariably, the process invades portions of the
lung tissue. In severe cases a kind of lobular pneu-
monia results, and is accompanied by symptoms
almost identical with bronchopneumonia. In fatal
cases the bacilli have been found to have penetrated
not only into the peribronchial tissue, but even to the
surface of the pleura. The pleurisy which follows in-
fluenza, however, is usually a secondary infection, due
to the streptococcus or pneumococcus. Ordinarily
the disease runs an acute or subacute course, and not
infrequently it is associated with a mixed infection of
the pneumococcus or streptococcus. But sometimes
a chronic condition may be produced depending upon
the influenza bacillus; the bacilli remaining latent for a
while and then becoming active again, with a resulting
exacerbation of the disease. Phthisical patients are
particularly susceptible to attacks of influenza. It
would appear, therefore, that given proper climatic
conditions, we have at all times the seeds of influenza
present in sufficient numbers to start an epidemic.
The discovery of this bacillus enables us to explain
many things previously unaccountable in the cause of
epidemic influenza. We now know from the fact that
the bacillus cannot exist for any considerable length of
time in water or in dust, that the disease is not trans-
missible to great distances through these means. We
also know that the infective material is contained
chiefly in the catarrhal secretions. The occurrence of
sporadic cases, or the sudden eruption of an epidemic
in a locality from which the disease has been long ab-
sent, and where there has been no new importation of
infection, may possibly be explained by the supposi-
tion, as already noted, that the influenza bacilli re-
main latent in the air passages of certain individuals
for months at a time, and then become active under
conditions favorable for their growth, when the in-
fection mav be communicated to others in close con-
REFERENCE IIAXDHooK OF THE MEDICAL SCIENCES
i: i. i. 1 1. 1
tart with them. The bacteriological diagnosis of in-
fluenza is of considerable importance for the identifi-
i, of clinically doubtful cases, which from the
symptoms may be mistaken for other diseases, such, as
bronchitis, pneumonia, or tuberculosis.
In acute uncomplicated cases the probable diag-
nosis can be frequently made by microscopical
nination of stained preparations of the sputum,
there being present enormous numbers of the small
bacilli. In chronic cases or those of mixed infection
the culture method must usually be employed if we
wish to arrive at positive results. The bacillus of
influenza is so well characterized by its morphological,
staining, and cultural peculiarities that it may be
distinguished from all other bacteria by an expert
bacteriologist with sufficient certainty for diagnostic
purposes. The only bacillus which at all closely
resembles it is the pseudo-influenza bacillus found by
Pfeiffer in three cases of bronchopneumonia; and
this is distinguished from the genuine influenza
lus by its larger size and tendency to grow out,
iu cultures on blood agar, into long threads.
The Koch-Weeks Bacillus op Conjunctivitis. —
This bacillus was first observed by Koch in 1883,
later, in 1887, it was specifically described by Weeks,
who obtained it in pure cultures. The infective
disease, of which it is the cause, seems to be widely
distributed, no land or clime being exempt from it.
In this country it occurs epidemically during the
spring and fall months. It is known commonly as
"pink eye."
Motility. — Non-motile.
Spore-Formation. — Absent; in culture media the
bacilli die rapidly, seldom living more than five days.
They resist a temperature of 50° for ten minutes.
They cannot resist drying for any length of time.
Morphology. — The "bacilli from the purulent secre-
tion are small and slender, being not unlike the
influenza bacilli but somewhat longer. The shorter
bacilli not infrequently have the appearance of
diplococci and sometimes they exhibit polar staining.
Their width is constant. The ends are rounded.
They are rapidly decolorized by Gram.
Staining. — They are best stained by dilute solutions
of carbol fuchsin or Loeffler's methylene blue, but do
not stain readily. In smear preparations the Koch-
Weeks bacilli are, as a rule, seen alone or associated
with isolated cocci and bacilli within the cells, and
are very rarely associated with gonococci and pneu-
mococci, such mixed infections being very uncommon.
Biological Characters. — The Koch-Weeks bacillus
grows only at temperatures near to 37° C. of the
ordinary culture media. None but moist and slightly
alkaline peptone agar can be employed. The best
results have been obtained with serum agar or a mix-
ture of glycerin agar and ascitic fluid, 2 to 1. Pure
cultures are rarely obtained at first, being usually
associated with colonies of xerosis bacilli or staphylo-
cocci. After twenty-four to forty-eight hours the colo-
nies are noticeable as moist, transparent, shining drops.
Microscopically examined under low power they ap-
pear like small gas bubbles; on closer examination they
are seen to be round, lying loosely on the surface, and
are readily removed. Under higher power a number
of fine points are observable. The colonies resemble
t hese of influenza, have a tendency to confluesce, but are
not so sharply defined as the latter and become more
quickly indistinguishable. In serum or blood bouillon
a slight cloudiness is produced which finally settles
down.
Pathogenesis. — The Koch-Weeks bacillus is not
pathogenic for animals. Man, on the contrary, is
extremely susceptible to infection. Transmission
of the disease occurs only by contact either by direct
or indirect conveyance of the moist infective material.
Infection is not communicated through the air by
ans of dust, as the bacilli soon die when dried.
it may, however, be conveyed by flies, etc. Im-
munity is not produce, 1 to any extent by i
attack, but there doe i seem to bi i dual
susceptibility.
The only mic-roc, i from which the Koch-
Weeks bacillus would seem to require differentiation
are those of the influenza group. These latter
bacilli, however, grow well only on hemoglobin media,
which the Koch-Wi I iculus does not require.
The colonies on ,-ei uin agar are also .-mailer than
those of the influenza bacilli and thi more
granular.
The Diphtheria Bacilli dipht)
Klebs-Loeffler b -This bacillus was first
ol erved by Klebs (1883) in diphtheritic false
membrane. Ii ated in pure cultures and its
pathogenic properties demonstrated by Loeffler in
L884. In lss7 ss further studies by Loeffler, Roux,
an,l Yer-in added to the proof of the dependence of
diphtheria upon this bacillus. The results of thi
investigations have since been confirmed by a gri
number of combined clinical and bacteriological
observations both in animals and man. All the
conditions have been fulfilled for diphtheria which are
necessary to the most vigorous proof of the causative
relation of a given microorganism to an infectious
disease, viz., the constant presence of the organism
in the lesions of the disease, the isolation of it in pure
culture, the failure to produce the disease by any
other bacteria, and the additional demonstration (if
the immunizing value of the specific antitoxic sub-
stances developed in animals subjected to injections
of diphtheria toxin. In view of these facts we are
justified in concluding that all cases of U-iir or primary
diphtheria are due to the Klebs-Loeffler bacillus.
Microscopical .1 /ipcaranccs. — .Somewhat slender
rods of variable size, 1 to 6 /i long and 0.3 to 0.8 ».
broad, either straight or slightly curved, with rounded
ends, occurring singly or in pairs. Irregular forms
are very common, and indeed are characteristic of
this bacillus. In the same culture and in unfavorable
media great differences in form and dimensions occur;
one or both ends may appear swollen, or the central
portion may be thicker than the extremities, or the
rod may consist of irregular spherical or ovoid seg-
ments. The rods sometimes lie in clusters alongside
of one another in a characteristic manner, like a
bundle of fagots. Threads with swollen ends and
branching forms sometimes occur, but these are com-
paratively rare. (See Plate VIII., Fig. 4.)
Motility. — Non-motile.
Spore Formation. — Absent, but cultures retain their
vitality for months.
Staining Reactions. — Stain readily with the ordinary
aniline dyes and retain fairly well their color after
staining by Gram's method. When Loeffler's alkaline
solution of methylene blue is applied cold for five
minutes or warm for one minute, the bacilli, from
blood-serum cultures especially and from other media
less constantly, stain in an irregular and extremely
characteristic way. Carbol fuchsin and gentian violet
stain the bacilli too intensely, obscuring the struc-
ture of the organisms.
Neisser has recently described a double stain which
brings out the metachromatic bodies of the diphtheria
bacillus, and which he claims may be used as a method
of differential diagnosis between the virulent and non-
virulent diphtheria bacilli without the delay of in-
oculating animals. The cover-slip smear of diphtheria
bacilli is placed for two or three seconds in a solution
composed of alcohol (96 per cent.) 20 parts, methylene
blue 1 part, acetic acid (glacial) 50 parts, and distilled
water 950 parts, and then, after washing, in a second
solution (for from three to five seconds) composed of
Bismarck brown 1 part, and boiling distilled water
845
Bacteria
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
500 parts. By this method the bacilli are usually
stained brown and at one or both ends a blue granule
is seen; while the non- virulent bacilli ordinarily are
not so stained. But sometimes the pseudodiphtheria
bacilli show the same dark bodies, and occasionally
the virulent bacilli fail to take the Neisser stain.
Neither this nor any other stain, therefore, can be
depended upon to give positive information as to the
virulence of the bacilli, the only certain way of
obtaining a differential diagnosis between the pseudo-
and true diphtheria bacilli being by animal inocula-
tions with control injections of antitoxin. (See Plate
VIII, Fig. 5.)
Biological Characters. — Aerobic and facultative
anaerobic; grows best in the presence of oxygen, but
also less readily without it. Development is good and
abundant only at 37° C, the extremes being 20°
and 41° C. It grows on all the ordinary culture
media, glycerin agar being a favorable medium,
though blood serum and ascitic fluid are still better.
Loeiller's blood-serum mixture (see Bacteriological
Technique) is much used and is the best culture
medium for diagnostic purposes in examining cul-
tures from the throats of persons suspected of having
diphtheria. The growth in gelatin at 22° to 24° C.
is not characteristic, and is so scanty that it is seldom
employed for the cultivation of the diphtheria ba-
cillus. The gelatin is not liquefied.
Growth on Blood Serum. — On Loeffler's blood-
serum mixture at the end of eight to twelve hours
small colonies develop which appear as pearl gray,
or more rarely yellowish gray, slightly elevated points.
The borders are usually uneven. After forty-eight
hours the colonies when separated may so increase in
size that they are one-eighth of an inch in diameter;
these lying close together become confluent and fuse
into one mass, if the serum be moist. During the
first twelve hours the colonies of the diphtheria
bacilli are about equal in size to those of other
pathogenic bacteria which are often present in the
throat; but after this time the diphtheria colonies
become larger than those of the streptococci and
smaller than those of the staphylococci. The blood
serum is not liquefied.
Growth on Agar. — On one per cent, slightly alkaline,
nutrient or glycerin agar the growth of the diphtheria
bacillus is less certain and luxuriant than upon blood
serum, but the appearance of the colonies when ex-
amined under a low-power lens is often more charac-
teristic; the growth, however, is variable, and when
obtained fresh from pseudo-membranes the colonies
develop slowly or fail to develop at all. On agar
plates the deep colonies are usually round or oval and
as a rule present no extensions, but the surface colonies
commonly from one and sometimes from both sides
spread out an apron-like extension which exceeds in
area the rest of the colony. These surface colonies
are more or less coarsely granular in structure and
usually have a dark center. Some are almost trans-
lucent, others are thick and luxuriant with irregular
borders shading off into a delicate lace-like fringe,
though sometimes the margins are more even and the
colonies are nearly circular. With a high-power lens
the edges show sprouting bacilli, the colonies being
gray or grayish white by reflected light and pure gray
with olive tint by transmitted light. A mixture com-
posed of two parts of a one and one-half per cent,
nutrient agar and one part of sterile ascitic fluid
makes a medium upon which the bacillus grows much
more luxuriantly but not so characteristically. Nut-
rient plain or glycerin agar, with or without the addi-
tion of ascitic fluid, is the medium employed for the
isolation of the diptheria bacillus by plate methods from
the original serum tube. The agar should be freshly
melted and poured into the Petri dish for this purpose,
and after it has hardened streak cultures from the colo-
nies on blood serum are made upon this, the plates
846
being left in the incubator at 37° C. for twelve
hours.
Growth on Gelatin. — The growth on gelatin is much
slower and more scanty than that on blood serum or
agar, on account of the lower temperature at which it
is used. Gelatin is not liquefied.
Growth in Bouillon. — In slightly alkaline or neutral
bouillon the diphtheria bacillus grows in fine grains
which are deposited along the sides and on the bottom
of the tube, leaving the broth nearly clear. Some-
times the bouillon may appear diffusely clouded to
the naked eye, but when examined microscopically
in the hanging drop the clumpy arrangement is
readily observed. Frequently a whitish film forms
over part of the surface, but in shaking this breaks up
and slowly sinks to the bottom. This film is more
apt to develop in cultures which have been long
cultivated in bouillon. The reaction of the bouillon
is subject to changes — the diphtheria bacillus in
its growth causes a fermentation of the meat sugars
with the production of acid; hence the bouillon
becomes at first acid and subsequently alkaline,
when the fermentable sugars have been decomposed
this latter change being favored by the admission of
air.
Growth in Milk. — The diphtheria bacillus grows
readily in milk, beginning to develop at a compara-
tively low temperature (20° C). Thus milk having
become inoculated with the bacillus from a case of
diphtheria may under certain circumstances be the
means of conveying infection to previously healthy
persons. The growth takes place better in raw than
in boiled milk. The milk is not coagulated, remaining
unchanged in appearance, but the cultures may
retain their vitality for a long time.
On potato which is rendered alkaline a delicate
coating develops.
Vitality. — Virulent diphtheria bacilli may persist in
the throats of convalescents from diphtheria, after the
disappearance of the false membrane, for weeks and
months even. In 304 of 005 consecutive cases of
diphtheria examined by Park and Beebe the bacilli
were found to be no longer present within three days
after the disappearance of the false membrane; in
176 cases they persisted for seven days, in 64 cases for
twelve days, in 36 cases for fifteen days, in 12 cases
for three weeks, in 4 cases for four weeks, in 2 cases
for nine weeks, and recently a case has been noted
in which the virulent bacilli were present for eight
months. The practical importance of this fact is the
evident necessity for the isolation of convalescents
from diphtheria, whether showing clinical symptoms or
not, until all the Klebs-Loeffler bacilli have dis-
appeared from the throat.
In cultures kept in a cool, dark place, the bacilli
retain their vitality for from six months to a year or
more. In the incubator they are generally killed by
desiccation in from one to three months; but even
here, when the air is excluded, they remain alive in
bouillon for a long time. They also retain their
vitality for a considerable time in water and articles
of food, etc.
The diphtheria bacillus possesses a considerable re-
sistance to desiccation. Pure cultures in saturated
silk threads at room temperature remain alive under
favorable conditions for months. In dried diphther-
itic exudate, even when pulverized, they retain their
virulence for a long time. They are soon killed by
moist heat at 60° C. Cold has comparatively little
influence upon them, and even when dried they retain
their virulence in winter for several months. Sus-
pended in water and exposed to the action of direct
sunlight the bacilli die in a few hours, but in agar and
bouillon cultures they remain alive for six hours.
Chemical Effects. — The diphtheria bacilli produce
gas and acids from carbohydrates, as from glucose
present in ordinary nutrient bouillon. They also
REFERENCE HANDBOOK OF THE MEDICAL SCIENt ES
Bacteria
oduce sulphurated hydrogen ami indol. In old
Itures some nitrites are present, which with the
dol give the nitroso-indol reaction on the addition
pure sulphuric acid. Pigment production is rare,
ough occasionally yellow to reddish species have
in met with. Old bouillon cultures of the diph-
eria bacillus filtered through porcelain produce the
me symptoms as inoculations with t he bacilli t hem-
Ivcs. Particularly active toxins are obtained,
cording to von Dungern, by the addition of ascitic
lid to the bouillon. Sugar is to be avoided. Bouil-
n cultures as long as they are acid contain no toxins.
two per cent, peptone nutrient bouillon, having an
kalinity equal to about 8 c.c. of normal soda solu-
.iii per liter above the neutral point to litmus, is a
litable medium for the development, of toxin. Free
cess of air favors its production. The greatest
umulation of toxin in bouillon is after a growth of
urn five to ten days in the incubator at 35° to 37° C.
These poisons of diphtheria have been partially
olatcd. They are precipitated in part by alcohol,
ilcium phosphate, calcium chloride, and magnesium
ilphate. The toxin has not yet been successfully
tialyzed, so that its chemical nature is unknown. It
as many of the properties of protein substances, but
is formed not only in albuminous culture media
ut also in those free from albumin. It is not a
table body, being totally destroyed by boiling for
ve minutes, and losing ninety-five per cent, of its
i rength when exposed to a temperature of 75° C. for
oine time. Temperatures under 60° C. alter it only
ery gradually. It is slowly decomposed when ex-
losed to light and air, but kept in a cold, dark place it
nay be preserved almost indefinitely. According
o Kossel diphtheria toxin is formed in the cell bodies
if the bacilli and thence secreted. Ehrlich, sub-
livides toxins, according to their degrees of toxicity,
nto protoxoids, syntoxoids, and epitoxoids.
Pathogenesis. — The diphtheria bacillus is patho-
;enic for guinea-pigs, rabbits, chickens, pigeons, small
jirds, and cats; also in a lesser degree for dogs, goats,
•attle, and horses, but scarcely at all for rats and mice.
True diphtheria, however, as observed in man, is
■xtremely rare among these animals, the so-called
iiphtheritic inflammations in them being due, as a
rule, to other bacteria than the Klebs-Loeffler bacillus.
The virulence of pure cultures of the diphtheria
bacillus from different sources, as measured by their
toxin production, varies enormously. In general,
severe cases of diphtheria yield strongly virulent
cultures, and mild cases slightly virulent ones; but
there are exceptions to this rule. One of the most,
virulent cultures so far known — culture No. 8, which
is used not only by the New York Health Department
Laboratory, but by many other laboratories in the
United States and Europe, for the production of toxin
— was obtained from an extremely mild case of diph-
theria. Experimental and accidental attenuation of
the diphtheria bacilli has often been observed. Roux
and Yersin maintain that there is a uniform and
gradual decrease in virulence of the bacilli found in
the throats of convalescents from diphtheria, but this
has not been confirmed by others, highly virulent
bacilli having been repeatedly found in the throats of
those recovering from the disease long after the disap-
pearance of all clinical symptoms. The same marked
variation occurs in the amount of toxin produced by
different bacilli in their growth in media outside of the
body. There are also bacilli which produce no specific
toxin whatever and yet appear to have all the other
characteristics of virulent bacilli. Moreover, some
diphtheria bacilli retain their virulence, when grown
in artificial media, much longer than others. The
passage of the bacilli through the bodies of suscep-
tible animals does not increase their virulence to
any appreciable extent, this being probably due to
the fact that they multiply but little in thi !'
The best guide for the virulence of a diphtheria
bacillus is the toxicity of the lilt rate of a culture of defi-
nite age, as shown by inoculation Into guinea-pig
for tin purpo e an alkaline broth culture of forty-eight
hours' growth is used. The amount injected should
not be more than one-fifth per cent, of the body
weight of the animal inoculated, unless controls with
antitoxin are made. In the large majority oi ca i ,
when the bacilli are virulent, thi a urn causes death
within seventy-two hours. For an absolute test of
specific virulence antitoxin must be used. A guinea-
pig is injected subcutaneously with antitoxin, and
then this and a control animal are injected with
double the fatal dose of a broth culture of the bacilli
to be tested. If the animal which received the anti-
toxin lives, while the control animal dies, it was surely
a virulent diphtheria bacillus which killed by means
of the toxin produced.
About twenty-four hours after the subcutaneous
inoculation of a virulent culture of the diphtheria
bacillus the animal becomes languid, has no appetite,
its hair is rumpled, its nose cold and blue, and its
respiration rough; the point of injection is infiltrated,
sometimes also the surrounding tissues. Certain
symptoms, however, exclusive of Toss of weight, may
be wanting. On autopsy there will be found at the
seat of inoculation a grayish deposit surrounded by
an area of congestion; the subcutaneous tissues for
some distance around are edematous; the adjacent
lymphatics are swollen, and the serous cavities,
especially the pleural and the pericardial, frequently
contain an excess of fluid, usually clear, but at times
turbid; the lungs are generally congested. In the
organs are found numerous smaller or larger masses
of necrotic cells, which are permeated with leucocytes.
The heart and voluntary muscular fibers usually show
degenerative changes. Occasionally there is fatty
degeneration of the liver and kidneys. From the area
surrounding the point of inoculation virulent bacilli
may be obtained, but in the organs they are only
occasionally found, unless an enormous number of
bacilli have been injected. Paralyses, commencing
generally in the posterior extremities and gradually
extending to other portions of the body and causing
death by cardiac paralysis or paralysis of the respira-
tory organs, are also produced in many cases in which
the inoculated animals do not succumb to a too rapid
intoxication. In rare instances the muscles of the
neck or of the larynx are first paralyzed and thus
characteristic symptoms are produced.
Rabbits are much less susceptible to subcutaneous
inoculation than guinea-pigs; white mice and rats are
almost immune. On the other hand, cats, dogs, cows,
and horses are susceptible, as are also young pigeons
and chickens, and small birds.
Diphtheritic false membrane, analogous to human
diphtheria, may be produced in animals by rubbing
diphtheria bacilli on the slightly abraded surface of
mucous membranes of the trachea and conjunctiva
of rabbits, of the throats of monkeys, and of the
pharynx and larynx of pigeons and chickens. The
process remains local. According to Loeffler, the
best results are obtained by inoculation of the vagi-
nal mucous membranes of guinea-pigs.
In man no experimental inoculations have been
made but in two involuntary laboratory experiments
made in the New York City Health Department severe
diphtheria was contracted by inadvertently sucking
up virulent bouillon cultures of the diphtheria bac-
illus into the mouth.
Outside of the body diphtheria bacilli have been
found upon articles used by diphtheria patients, as
upon linen, brushes, toys, walls and floors of rooms,
etc., and in the hair of nurses. The air (exclusive of
momentary contamination through the coughing of
847
Bacteria
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
patients) never contains the bacilli. They have also
been found at times in the throat and nasal cavities as
well as in the conjunctiva of healthy individuals,
especially of those coming in contact with diphtheria
patients. Out of three hundred and thirty healthy
persons who had not been in contact, so far as known,
with cases of diphtheria, Park and Beebe found viru-
lent bacilli in eight only, two of whom later developed
the disease. It is evident, therefore, that infection
from diphtheria, as in other infectious diseases re-
quires not only the presence of virulent bacilli in the
throat, but also an individual susceptibility at the time
to the disease. Among the predisposihg factors which
may contribute to the production of diphtheria are
the breathing of foul air and living in overcrowded
and ill-ventilated rooms, poor food, and certain other
affections more especially catarrhal inflammations of
the mucous membranes, but all depressing conditions
in general favor the development of the disease.
The chief locations of the bacilli in diphtheria are on
the surface of the pseudomembranous inflammations
of the fauces, larynx, and nasal cavities, but also occa-
sionally in membranous affections of the skin, vagina,
rectum, conjunctiva, nose, and ear (membranous
rhinitis and otitis media). Occasionally they have
been found in the blood and interior organs (spleen
and kidneys).
Almost always the streptococcus pyogenes is asso-
ciated with the diphtheria bacillus, with which it acts
pathologically as a synergist. Regarding the im-
portance of mixed infection in diphtheria, Bernheim
has stated that the streptococcus products of decom-
position favor the growth of the diphtheria bacilli and
increase their virulence for production of toxin.
Nevertheless, the diphtheria bacillus alone undoubt-
edly may produce all the clinical symptoms of sepsis.
Xiin-rirulent Diphtheria Bacilli. — There are some-
times found in inflamed throats as well as in healthy
throats, either alone or associated with virulent
diphtheria bacilli, microorganisms which though
morphologically and biologically identical with the
Klebs-Loelller bacillus appear to be non-virulent —
that is, in artificial culture media and with the usual
animal tests they produce no appreciable diphtheria
toxin. Between the bacilli which produce a great
deal of toxin and those which seem to produce none at
all we find all grades of virulence. These are prob-
ably attenuated varieties of the diphtheria bacillus
which have lost their power of producing toxin
(Roux and Yersin). Bacilli are also found which
resemble the Klebs-Loeffler bacilli very closely except
in toxin production, but differ also in some other
respects. From varieties of this kind having been
found in a number of cases of so-called xerosis con-
junctives these bacilli are often designated as xerosis
bacilli. They are usually much larger than diphtheria
bacilli and have club-like extremities. They may be
almost non-pathogenic for guinea-pigs, or they may
kill. Animals are not protected by diphtheria anti-
toxin from the action of these bacilli. Whether they
are derived from the original diphtheria stock is
not known.
Pseudodiphtheria Bacilli. — Besides the typical
bacilli which produce diphtheria toxin and those
which do not, but which, so far as we can determine,
are otherwise identical with the Loeffler bacillus, there
are other bacilli found in positions similar to those in
which diphtheria bacilli occur, and yet, though re-
sembling these organisms in many particulars, differ
from them in certain important characteristics.
.The variety most prevalent is rather short, plump, and
more uniform in size and shape than the true Loeffler
bacillus, and the great majority of them in culture
show no polar granules when stained by the Neisser
method, staining evenly throughout with Loeffler's
alkaline methylene blue solution. Their . colony
growth on blood serum is very similar to that of the
SIS
diphtheria bacilli, but they do not produce acid by the
fermentation of glucose, and they never produce
diphtheria toxin. These are called pseudodiphtheria
bacilli, or more properly, B. hofmani. When found in
cultures from cases of suspected diphtheria they may
lead to an incorrect diagnosis; and here the Neisser
method of staining is of value, though the only
absolute test of virulence is by inoculation or sus-
ceptible animals. (See Plate VIII., Fig. 6.)
Pseudomembranous Inflammations due to Bacti ri,i
other than the Diphtheria Bacilli. — The diphtheria
bacillus, though the most usual, is not the only micro-
organism that is capable of producing pseudomem-
branous inflammations. The streptococcus, staphylo-
coccus, and pneumococcus are the forms most often
found in angina simulating diphtheria, but there are
also others which, under suitable conditions, take an
active part in producing this kind of inflammation.
But the bacteria which occur in this so-called false
diphtheria are all morphologically and culturally
distinct from the Loeffler bacilli.
Susceptibility and Immunity. — It is now commonly
recognized that an individual susceptibility, both
general and local, to diphtheria is necessary to con-
tract the disease. Age has long been known to be an
important factor in the production of diphtheria,
children within the first six months of life being but
little susceptible, most so between the third and tenth
years, while adults are comparatively immune. An
apparent inherited susceptibility to the disease has
also been observed. Two attacks of diphtheria have
rarely been known to occur in the same individual
within a short time. But to what this natural sus-
susceptibility or immunity is due is as yet only par-
t ially understood. As the result of animal experiment b,
however, it has recently been shown that an artificial
immunity against diphtheria can be produced, at
least for a considerable period, by the development,
in the body, of substances antidotal to the diphtheria
toxin.
Animals may be immunized against the diphtheria
bacillus in various ways: By treatment first with
slightly virulent and then with highly virulent cultures
of the bacillus; by injection of small quantities of
attenuated cultures or of toxin, and then with gradu-
ally increasing doses; by injection of the blood serum
of animals immunized in one of the above ways
against diphtheria. In the earlier experiments on
immunization against diphtheria the names of
Fraenkel, Wernicke, Aronson, Roux, and others are
conspicuous; but to Behring and Kitasato belongs
the credit of the fundamental discovery that the
blood serum of an animal immunized for certain infec-
tious diseases may be employed for protective inocu-
lations, and that in larger quantity it may even exer-
cise a curative influence after infection has occurred.
This is one of the greatest discoveries in scientific
medicine of recent years, and the practical results
obtained in the treatment of diphtheria, at least,
have justified all the expectations that were enter-
tained regarding it. The mortality of this fatal
malady among children has been reduced fifty per
cent, or more in places where diphtheria was prevalent
and where the treatment was continuously and uni-
formly employed. As to immunity, it stands to reason
that a disease which can attack the same person more
than once within a comparatively short time does not
belong to the class of affections producing a permanent
immunity after recovery. It is, however, well known
that a certain temporary immunity is thus conferred,
and the blood serum of persons during convalescence
from diphtheria has been found to possess immunizing
properties. The protection afforded by artificial
immunization, therefore, does not last usually more
than three or four weeks, but this is usually sufficient
to tide over the period of exposure to infection, and
if necessary repeated immunizing injections of the
EXPLANATION OF
PLATE VIII.
EXPLANATION OF PLATE VIII.
Fig. 1. — Bacillus Tuberculosis in Sputum. X 1,000. Photomicrograph from Sternberg's
" Bacteriology" by permission.
Piq, 2. — Bacillus of Leprosy, Section of Skin Nodule. X 1,000. Photomicrograph from
Bowhill's "Bacteriology" by permission.
Fig. 3. — Bacillus of Influenza in Bronchial Mucus. X 1,000. Photomicrograph from
Sternberg's " Bacteriology" by permission.
Fig. 4. — Bacillus of Diphtheria (Klebs-Loeffler). Blood-serm culture stained with Loeffler's
solution of methylene blue. X 1,000. Photomicrograph from Sternberg's "Bacteri-
ology" by permission.
Fig. 5. — Bacillus of Diphtheria. Stained with Neisser's solution, showing bodies of bacilli
in smear faint brown; points, dark blue. X 1,000. Photomicrograph from Park's
"Bacteriology" by permission.
Fig. 6. — Pseudo-Diphtheria Bacillus, Small Type. X 1,000. Photomicrograph from Park's
" Bacteriology" by permission.
Fig. 7. — Bacillus of Typhoid Fever, from Agar Culture. X 1,000. Photomicrograph from
Sternberg's "Bacteriology" by permission.
Fig. S. — Bacillus of Typhoid Fever with Flagella. Agar culture. X 1,000. Photomicro-
graph from BowhUl's "Bacteriology" by permission.
Reference Handbook
of THE
Medical Sciences
Plate VIII
**
I.
Tubercle Bacilli in Sputum.
Vv
V
VI
4 "-,vj'-.V
'!• t- >
Pseudo-diphtheria Bacillus,
i Small Type).
'<:
f
»
» A"' V
, > - / ' » fl .V//7
Diphtheria Bacillus. V?* , »»* *' *|
' I Blood-serum Loefllers Meth- " • »V > **' , -f , * ^ ,/«J
VN ylene-blue stain). / y t • - « Nl>f &"' *'•.
e ■
.,?■■ •• >-
•r- ••
a.
Leprosy Bacillus.
• ' • -.- - • ••■• '
- . -.• • • v.f
1 ^ v.*
VII.
-.-*■? ■-.' .. .;»»- Bacillus of Typhoid Fever.
Diphtheria Bacillus.
(Ncisscr Stain).
III.
Influenza Bacillus.
Pathogenic Bacteria.
VIII.
Bacillus of Typhoid Fever
with Flagella.
REFERENCE HAN'DRooK OK THE MEDICAL SCIENCES
Bacteria
ntitoxic serum may bo given. Regarding the cura-
ivc injections, the earlier the remedy is administered
!»■ more certain and rapid is the effect produced
his effect being, indeed, one of immunity or protection
gainst further infection or absorption by the system
if the diphtheria toxin, rather than of neutralization
,f the poisons already absorbed.
Preparation of Diphtheria Antitoxin. — The principal
teps in the preparation of diphtheria antitoxic serum
the production of toxin, the immunization of the
lorses, and the testing of the antitoxin obtained from
ii. The following is the met hud in brief now
mployed in the laboratories of the Health Depart-
ment of New York City: The strongest diphtheria
oxin possible is obtained by taking a very virulent
laciilus and growing it under the conditions already
ribed. The culture, after a week's growth, is
emoved, and having been tested for purity is rendered
terile by the addition of ten per cent, of a five per
ent. solution of carbolic acid. This sterile culture is
hen tillered through ordinary sterile filter paper and
lured in full bottles in a cold place until needed,
ts strength is tested by giving a series of guinea-pigs
fully measured amounts injected subcutaneously.
.ess than 0.01 c.c., administered hypodermatically,
hould kill a 250 gm. guinea-pig. The horses used
or immunization should be young and absolutely
lealthy. A number of such animals are severally
ejected with an amount of toxin sufficient to kill
i,000 guinea-pigs of 250 gm. weight (about 20 c.c. of
trong toxin), the point of injection being usually
inder the skin of the neck or behind the shoulder.
\ftcr an interval of from three to five days, so soon
is the febrile reaction has subsided, a second sub-
cutaneous injection of a slightly larger dose is given.
With the first three injections of toxin 10,000 units of
mtitoxin are administered. If antitoxin is not
nixed with the toxin only one-tenth of the doses
ibove mentioned is to be given. At the end of about
wo months, increasing doses of pure toxin having
jeen injected every five to eight days, from ten to
wenty times the original amount is administered.
ii about three months the antitoxic serum drawn
rom the horses should contain at least 300 antitoxin
tnits, when tested, and the best of them from 800 to
1,000 units, in each cubic centimeter. Very few
lorses ever yield over 1,000 units, and none so far has
;iven as much as 2,000 units per cubic centimeter.
(f every nine months an interval of three months'
reedom from inoculations is given, the best horses
■ontinue to furnish high-grade serum during their
leriods of treatment from two to four years.
In order to obtain the serum the blood is withdrawn
'rom, the jugular vein by means of a sharp-pointed
"annula, which is plunged through the vein wall, a slit
laving been made in the skin. It is run into large flasks
through a sterile rubber tube, and then allowed to clot,
the flasks having been previously placed in a slanting
position. From these the serum is drawn off after
four days by means of sterile glass and rubber tubing,
ind is stored in large bottles, small vials being filled
is needed for use. Every possible precaution should,
of course, be taken in the preparation of the serum to
avoid contamination. An antiseptic may be added
to the serum as a preservative, but it is not ordinarily
necessary. Kept from access of air and light and in a
cold place, it is fairly stable, deteriorating not more
than thirty per cent., and often much less, within a
year. When stored in vials and kept as above, diph-
theria antitoxin continues within ten per cent, of
its original strength for at least two months; after
that it can be used by allowing for a maximum de-
terioration of two per cent, for each month.
Diphtheria antitoxin has the power of neutralizing
diphtheria toxin, so that when a certain amount is in-
jected into an animal before or together with the
toxin it overcomes its poisonous action. This power
Vol. I.— 54
is utilized in testing antitoxin. Guinea-pigs of about
250 gm. weight are subcutaneously injected with one
hundred or with ten fatal dose "i toxin which have
been previously mixed with an amount of antito in
believed to be sufficient to protect from the to a.
If the guinea-pig lives lour day.-, but di n after,
the amount of antitoxin added to the toxin was just
1 or 0.1 unit, according as one hundred or ten fatal
doses were employed. If the animal dies cm her, I. ,
than I unit was added. An antitoxin unit has thus
been defined as "ten times the amount of antitoxic
serum required to protect a guinea-pig weighing 250
gm. from death, when ten times tne fatal dose of
toxin is mixed with the serum and the mixture in-
jected subcutaneously into tile animal."
The Uxe of Diphtheria Antitoxin in Treatment and
Immunization. — tor the injection a hypodermic
syringe is employed, holding 10 to 12 c.v., which
mu i be previously thoroughly sterilized with alcohol
and a livc-per-eent. solution of carbolic acid. The
injection is made at some point on the anterior sur-
face of the body, as the abdomen or thorax or outer
surface of the thigh, where there is an abundance
of subcutaneous cellular tissue. II. -lore injection
the skin should be carefully washed with alcohol or
some disinfecting solution. The serum is rapidly
absorbed, and it is belter not to employ massage over
the point of injection. For treatment of mild ca
of diphtheria the dose is 1,500 antitoxin units, for
moderate cases 2,000 to 4,000 units, and for severe
eases 10,000 to 20,000 units. When no improve-
ment follows in twelve hours the dose should be
repeated. For immunization of children or adults
who have been exposed to diphtheria the dose is
from 300 to 500 units for an infant, 500 to 1,000 for an
adult, and proportionally according to age, to be re-
pealed if necessary at the end of two or three weeks.
In all cases it is better to use a small quantity of a
high-grade serum than a large quantity of a low-grade
preparation, as there is in the former instance less
danger of rashes and other deleterious effects. The
only untoward results to be feared in any case in
which proper aseptic precautions are taken in the in-
jection, are occasional rashes with perhaps some
slight rise of temperature, known as serum sickness.
About 1 in 10,000 persons, within a few minutes after
an injection of serum, develops alarming symptoms.
About twenty deaths in all have been reported. Those
suffering severe symptoms have usually been subject
to asthma, while the fatal cases have the pathological
changes known as status lymphaticus. In sus-
picious cases of any severity, particularly in croup, it
is better to administer the remedy at once, making
a culture at the same time for bacteriological diagnosis,
than to delay treatment until a positive diagnosis has
been made by bacteriological examination.
Concentrated Antitoxin. — Many attemps have been
made to seperate the antitoxin from the serum, with
a view to concentrate the dose and at the same time
reduce the possible ill effects of the serum. A con-
centrated antitoxic globulin solution is now made in
the laboratoies of the Health Department of new
York City, and by other manufacturers, which is
being used in preference to the antitoxic serum and
apparently with good results. The curative effects
have proved to be identical with that of the whole
serum and decidedly less severe rashes, etc., than
formerly have been noted.
The material used in the Health Department is
blood plasma instead of blood serum. The globulins
of the plasma are removed from the other non-anti-
toxic or toxic constituents of albumin, cholesterin,
lecithin, bile salts and acids, etc., by precipitation with
ammonium sulphate. This precipitate contains the
globulins of the blood which are antitoxic, those which
are non-antitoxic, and nucleoproteins. The antitoxic
globulins are extracted by treating with saturated
849
Bacteria
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
solution of sodium chloride, in which this compound
is soluble. The antitoxic globulins are then isolated
from the solution by precipitation with dilute acetic
acid. The ammonium salts are washed out by repeated
treatment with sodium chloride solution and filtered.
Finally, the sodium chloride is removed by dialysis.
After dialysis, the antitoxic globulins are dissolved in
dilute saline solution, filtered to remove the traces of
undissolved matter, passed through a Berkefeld clay
filter to remove bacteria, and then put in sterile
syringes.
The concentration of antitoxin made possible by
the elimination of the non-antitoxic substances is not
only a convenience but is of distinct importance,
a- it tends to encourage large doses as well as to re-
duce to a minimum the serum or anaphylactic effects.
The Bacillus op Tetanus (Bacillus tetani). —
Nicolaier in 1884 produced tetanus in mice and rab-
bits by subcutaneous inoculation of particles of gar-
den earth, and showed that the disease was trans-
missible by inoculation from these animals to others.
Carl and Rattone soon after this demonstrated the
infectious nature of tetanus as it occurs in man.
Finally, in 1889, Kitasato obtained the bacillus of
tetanus in pure culture and described its biological
characters.
Microscopical Appearances. — Slender rods with
rounded ends, 0.3 to 0.8 ji in diameter by 2 to 4 p. in
length, usually occurring singly, but often growing
into long threads, especially in old cultures.
Spore Formation. — Forms rounded spores thicker
than the cells, occupying one extremity of the rods
and giving them the appearance of minute drumsticks.
(See Plate X., Fig. 3.)
Motility. — Motile, although not actively so in hang-
ing drop cultures with exclusion of air; numerous
flagella are attached to the bodies of the bacilli. In
the spore stage they are non-motile.
Staining Reactions. — Stains with the ordinary
aniline dyes, and is not decolorized by Gram's solution.
The spores may be demonstrated by double staining
with Ziehl's method.
Biological Characters. — When freshly isolated from
the animal body, this organism is strictly anaerobic;
but by long cultivation at high temperatures it often
becomes less sensitive to the presence of oxygen, this
cultivation being facilitated by association with
certain saprophytic bacteria. Carbone and Pessero
have obtained from a case of rheumatic tetanus in
which there was no sign of injury in the bronch al
mucous membranes virulent tetanus bacilli, which
grew more luxuriantly under aerobic than anaerobic
conditions; in pure cultures, however, they proved
to be non-virulent. The Bacillus tetani does not
grow at temperatures below 14° C, though slowly
from 20° to 24° C; best at 37° C, when it rapidly
forms spores. It develops in the ordinary nutrient
gelatin and agar media of a slightly alkaline reaction.
The addition of 1.5 per cent, glucose to the media
causes the development to be more rapid and abun-
dant. According to von Hibler, the less pathogenic
the organism the more luxuriantly it grows on arti-
ficial culture media, and the more energetically it
liquefies gelatin. In the animal body its growtli is
comparatively scanty, and it is usually associated
with other bacteria, pure cultures being difficult to
obtain. Kitasato's method, which is not always
successful, however, consists in inoculating an agar
tube with the tetanus material (pus from wounds),
keeping this for twenty-four hours or more in the
incubator at 37° C, and, after the spores have formed,
heating it for about an hour at S0° C. to destroy the
associated bacteria. The spores of Bacillus tetani are
able to survive this exposure, and anaerobic cultures
are then made in the usual way, and the tetanus
colonies isolated.
850
Growth on Gelatin. — On gelatin plates the colonies
develop slowly, the middle portion being generally
of a yellowish-brown color, with numerous threads
radiating from the center; the gelatin is liquefied.
In old cultures the entire mass is made up of fine
threads, the colonies presenting an appearance not
unlike that of the common mould. In gelatin stab
cultures the growth exhibits the appearance of a
cloudy, linear mass with outgrowths radiating into
the medium from all sides. Liquefaction take<
place slowly, generally with the production of gas
having an unpleasant empyreumatic odor.
Growth on Agar. — The colonies on agar are quite
characteristic. To the naked eye they present the
appearance of light, fleecy clouds; under a low-power
microscope they resemble a tangled mass of threads.
The extreme fineness of these threads enables the
colonies of the tetanus bacillus to be distinguished
from those of other anaerobic bacteria. In stab
cultures on agar the growth resembles that of a
miniat ure fir-tree.
Alkaline bouillon is moderately clouded by the
growth of the tetanus bacillus. It grows also in
culture media, but itself produces no acid. Milk is
not coagulated.
Vitality. — The spores of tetanus are very resistant
to outside influences, retaining their vitality for
months or years in a desiccated condition and not
being destroyed in two and a half months when
present in putrefying material. They withstand
exposure to 80° C, for an hour, but are killed by a
temperature of 100° C. in five minutes. They resist
the action of five per cent, carbolic-acid solution for
ten hours, but succumb when acted upon for fifteen
hours. The addition of 0.5 per cent, hydrochloric
acid to the carbolic solution enables it to kill the
spores in two hours. In a solution containing 1 to
1,000 bichloride of mercury, five per cent, carbolic acid
and 0.5 per cent, hydrochloric acid, the spores are
destroyed in ten minutes.
Chemical Effects. — The tetanus bacillus produces
gas in media containing sugar, but no acid. It forms
sulphureted hydrogen abundantly and a little indol.
It produces powerful toxins, which can be separated
from the cultures by filtration. One one-hundredth
of a milligram of an eight-day filtered bouillon culture
is sufficient, as a rule, to kill a mouse. From this
filtrate, however, the active toxin has been obtained
in a much more concentrated form. The purified and
dried tetanus toxin prepared by Brieger and Cohn was
surely fatal to a 15-gm. mouse in a dose of 0.000005
gin. Reckoning according to the body weight of
75 kgm. or 150 pounds, it would require but 0.00023
gm., or 0.23 mgm., of this toxin to kill a man. Com-
paring this with other known poisons, the appalling
strength of the tetanus toxin can be readily appreci-
ated. For instance, Calmette has found that dried
cobra venom requires 0.25 mgm. to kill a rabbit of 4
kgm. weight, and it would thus require, at the same
rate, 4.375 mgm. to kill a man of 150 pounds; the fatal
dose of atropine for an adult is 130 mgm., of strych-
nine from 30 to 100 mgm., and of anhydrous prussic
acid 54 mgm. The true composition of the tetanus
toxin is unknown; it has been shown, however, that
it is neither an alkaloid nor an albuminous body. The
quantity of toxin produced varies, even when derived
from one and the same culture, according to its age,
composition, reaction, etc. It is extremely sensitive
to the action of light, most chemical agents, and heat.
It retains its strength best in the dry state.
Pathogenesis. — Man and almost all domestic animals
are subject to tetanus. Among animals those most
susceptible are horses, goats, guinea-pigs, and mice,
less so rabbits and sheep; dogs, rats, pigeons and
chickens are almost immune. It is worthy of note
that an amount of tetanus toxin sufficient to kill a hen
would suffice to kill 500 horses. A mere trace — only
REFERENCE HANDBOOK ( >F THE MEDICAL SCIENCES
Bacteria
,- much as remains clinging to a straight platinum
die -of an old culture is often enough to cause I h
leath of mice and guinea-pigs.
ibcutaneous inoculation of virulent b
Material mice and other susceptible animals .-how
■ymptom- of t\ pical tetanus in from one to three days.
parts tirst to bo affected are, in about one- third nf
he case- in man. and usually in animals, the muscles
ying in the vicinity of the inoculation — for instance,
hind foot of a mouse inoculated on that leg, then
the tail, the other foot, the back and chest muscles
an both sides, the fore leas, until finally there is a
general tetanus of the entire body. In mild cases of
infection, or when a dose too -mall to be fatal has
been received, the tetanic spasm may be one-sided or
remain confined to the muscles adjacent to the point
of inoculation, and result in recovery. There may be
no general increase of reflex excitability. In mat
horses the local symptoms may be absent, but in-
id tonic spa-in- of special muscles: in man, of the
muscles of the jaw, and in horses of the muscli
the jaw, neck, and tail. At the point of inoculation
in test animals there may be on autopsy a hemor-
rhagic -pot, but no chances here or in the interior
lis other than this. A few bacilli may be detected
lly with great difficulty, often none at all; appar-
ently show ins; that the lesions produced are due. not to
the multiplication of the bacilli in the living body, but
to the absorption of the poison formed by them at the
point of inoculation. It has been found that cultures
freed from spores, and such as have been subjected to
heat at 80° C, after sporulation and the toxins de-
stroyed, can be injected into animals without pro-
ducing tetanus. But if a culture of non-pathogenic
organisms be injected simultaneously with the spores,
or if there be an effusion of blood at the point of in-
jection or a previous bruising of the tissues, the ani-
mal will surely die of tetanus. It would seem, there-
fore, from these experiments, that a mixed infection
is necessary to the development of tetanus when the
infection is produced by spores. This fact is of the
greatest importance in natural tetanus, for here the
infection may be considered as being probably always
produced by the bacilli in their spore stage, and the
conditions favoring a mixed infection are generally
present.
Tetanus bacilli and their spores have been found
widely distributed in garden earth, hay dust, floors of
dwellings and hospitals, on splinters of wood, old
nails, in the air, etc. They have apparently been
observed more frequently in certain localities than in
others, as in some parts of Long Island and New
Jersey, but they are probably equally distributed
everywhere. This bacillus is the chief etiological
factor in the production, not only of trismus and
traumatic tetanus, but also of all the various forms
of tetanus — puerperal tetanus, tetanus neonatorum,
and idiopathic and rheumatic tetanus.
Tetanus Antitoxin. — Behring and Kitasato were the
fir-t to show the possibility of immunizing animals
against tetanus. Here the question of immunity
against infection does not consist in producing an
increased power of resistance against the development
of the infecting agent, but. similar to diphtheria, in
bringing about an immunity to the effects of the tet-
anus toxin. The methods originally proposed by
B hring and by Roux for producing a serum for the
treatment of the disease, consisted chiefly in weakening
the tetanus toxin by means of chemical disinfectant-
(iodine trichloride, Gram's solution, etc.), so that when
inoculated into the te-t animals they produced com-
paratively little reaction. At the present time pure
unaltered toxin is injected either alone in small
doses or along with antitoxin. After the first dose
of toxin the animals acquire a certain tolerance which
enables them to stand a dose of a less attenuated toxin
or of a greater amount of unchanged toxin. Then by
gradually increasing the doses or the strength of the
toxin administered, the animal- are finally ah
bear injections of large quantities of the
toxin.
These immunizing experiments in tetanus I
borne practical fruit, for it was through them thai
principle of serum therapeutics fu
It was thus shown that animal- could be protected
from tetanus infection by the previous or sum
in' itoxin, pi o 1 anti-
toxin was obtained froi oized
animal; anil from tin- it was assui
result could b
I'm unfortunately, the conditions in thi
disease are verj much less favorable, inasmucl
treatment i- usually commenced, not shortly after the
infection has taken place, but often only on the appear-
of tetanic symptoms, when tic' poison ha- al-
ready diffused itself through the body.
The tetanus antitoxin is prepared in the same
manner as the diphtheria antitoxin — by inoculatii g
the tetanus toxin m increasing doses into horses. The
toxin is produced in bouillon cultures grown
f ally. After ten or fifteen days the culture fluid is
filtered t hrough porcelain, an. I the germ-free Bltra
used for the inoculations. The horses receive 0.5 c.c.
as the initial dose of a toxin of which 1 c.c. kills
250,000 gm. of guinea-pig, and along with this a
sufficient amount of antitoxin to neutralize it. In
five day- this dose is doubled, and then every five to
day-, a- rapidly as the horses .1 it, until
they support 700-800 c.c. or more at a single <
After some months of this treatment the blond of
horse contains the antitoxin in sufficient amount for
therapeutic use. When the temperatures of the
horses are normal and they have recovered from the
dose of toxin last given, they are bled into sterile
flasks and the serum collected.
Tetanus antitoxin is tested exactly as is diphtheria
antitoxin, except that the standard unit is different.
The test toxin used in the German method is one i f
which 1 gm. destroys 150,000,000 gm. of mouse.
This is dissolved in 33J c.c. of ten-per-cent. sodium
chloride solution. Ten times the amount of antitoxic
serum which neutralizes 1 c.c. of this dilution of the
test toxin contains 1 unit of tetanus antitoxin. In the
French method the amount of antitoxin which is
required to protect a mouse from a dose of toxin
sufficient to kill in four days is determined, and the
strength of the antitoxin is stated by finding the
amount of serum required to protect 1 gm. of animal.
If 0.001 c.c. protected a 10-gm. mouse, the strength of
that serum would be 1 to 10,000. Guinea-pigs are
sometimes used instead of mice.
The dose of tetanus antitoxin for immunization is
10 c.c. of a serum of a strength of 1 to l. in in. m n
or about 1,500 units, unless the danger seem great,
when the injection may be repeated after seven or
eight days. For treatment it is well to begin with
50 c.c. or about 10.000 units, and then, according to the
-everity of the case, give from 20 to 50 c.c. each day
until the symptoms abate. The curative treatn
in man has not been followed by very satisfactory
results, owing to the fact already stated that the dis-
ease is generally too far advanced before treatment is
commenced. From statistics collected by Lambert
and others, however, of cases of tetanus treated with
antitoxin, the remedy would seem to have been of
undoubted practical use — so much so. at least, that
in all cases in which tetanus is suspected or in which
dirt has been ground into serious contusions, in
gunshot wounds, etc., preventive inoculations of the
serum should be given. In certain parts of France
where tetanus i- very prevalent among horses,
Xocard distributed tetanus antitoxin to sixty-three
veterinary surgeons, who treated with it. for the pre-
vention of the disease, 2,727 of these animals. Only
851
Bacteria
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
one of this number became affected, and this horse was
not inoculated until five days after being pricked in
shoeing. Although the delay was too great to prevent
the appearance of tetanus, yet the disease was of a
very mild nature. During the same period 259 cases
in animals that were not so treated were observed.
These striking results would certainly seem to indicate
that the remedy deserves a much more extensive
consideration in the treatment of patients with
immunizing doses of serum than has heretofore been
given it — at least in neighborhoods where tetanus
is not uncommon (fortunately it is a rare disease in
man), and when the dirty condition of their wounds
leads one to suspect the possibility of tetanus infection.
Good results have followed this practice in many
places. It is the custom at many dispensaries in
New York City and elsewhere to immunize all Fourth
of July wounds by injecting 1,000 units. None of
these cases have developed tetanus. Even the
eleven cases of human tetanus reported as occurring
in Europe after single injections of antitoxin prove the
value of immunizing injections, for the mortality was
only twenty-seven per cent. The recently proposed
method of injecting from 3 to 15 c.c. of tetanus anti-
toxin into the lateral ventricles has not so far shown
itself to be superior to the intravenous or subcutaneous
methods, and is not in general to be recommended.
No bad results have followed the injection of the
antitoxin when the serum was sterile and the operation
was performed aseptically.
The Bacillus of Ttphoid Fever (Bacillus typhi
abdominalis). — This organism was first observed by
Eberth, and independently by Koch, in 1880, in the
internal organs of typhoid cadavera. It was obtained
in pure culture by Gaffky in 18S4; and has also been
found during life in the blood, urine, and feces of
typhoid patients. Its etiological relationship to
typhoid fever has been somewhat difficult of demon-
stration from the fact that, although pathogenic for
many animals when artificially inoculated, it has not
been easy to produce infection or give rise to lesions
corresponding to those occurring in man. Still the
results which have been obtained under certain
conditions, together with the specific reactions of the
blood serum of typhoid patients, and the constant
presence of the bacillus in the spleen, blood, and
excretions of the sick during life, have finally estab-
lished, on a scientific basis, that this organism is the
chief cause of typhoid fever.
Microscopical Appearances. — As met with in the
organs of man and animals the typhoid bacilli are
short, plump rods with rounded ends. They vary
in size, being from 1 to 3 n long and 0.5 to 0.8 ft broad,
usually occurring singly, but sometimes growing
into long threads, especially in certain culture media,
as in potato. They are generally longer and some-
what more slender than the bacillus coli under
similar conditions. (See Plate VIII., Fig. 7.)
Motility. — Actively motile, especially the short
bacilli, each rod possessing from eight to fourteen
flagella attached to the sides and extremities of the
cells. The longer threads have a sinuous and more
sluggish motion. (See Plate VIII., Fig. 8.)
Spore Formation. — Does not form spores. In
stained preparations, particularly when grown on
potato, refractive granules may be seen at the ends
of the rods, which stain more intensely, and in the
body of the cells " vacuoles" which remain unstained.
These so-called Gaffky 's spores, however, are not true
spores, as the bacilli containing them show even less
resisting power than the homogeneous bacilli found
in other cultures, but are probably involution forms.
Staining Reactions. — The typhoid bacilli stain with
the ordinary aniline colors, but a little less readily than
do most other organisms, though this is not constant.
They are decolorized by Gram's solution.
852
Biological Characters. — The bacillus typhosus grows
most luxuriantly in the presence of oxygen but
oxygen is not essential to its development (facultative
anaerobic); it grows fairly well also in an atmosphere
of C0 2 . Its growth on the ordinary culture media
is similar to that of the bacillus coli communis, but
somewhat slower and not quite so abundant - in
contradistinction to most other pathogenic micro-
organisms, it grows well on slightly acid media. Be-
low 10° C. it does not develop, its optimum tempera-
ture being at 37° C; over 40° and below 30° C. it^
growth is retarded.
Growth in Gelatin. — In gelatin plates the deep
colonies are not characteristic; they are small,
punctiform, and sharply circumscribed, of a yellowish-
brown color and finely granular in structure. The
superficial colonies, however, particularly when
young, are quite characteristic; they form a bluish-
white, transparent, iridescent coating on the medium,
with irregular outline, denser in the center than at
the periphery, and exhibiting under a low power a
brownish color and wrinkled appearance. The
gelatin is not liquefied.
In gelatin stab cultures the growth is mostly confined
to the surface; it is thin, thready, often slightly
granular, extending along the track of the needle
and gradually reaching out to the sides of the tube;
white to yellowish brown in color, irridescent, and
transparent. There is no liquefaction.
Growth in Agar and Blood Serum. — Not distinctive.
Growth in Bouillon. — This medium is uniformly
clouded, but the clouding is not so dense as by the
colon bacillus. After eighteen to twenty-four hours'
growth a sediment is frequently developed, and a
film forms on the surface, with a slightly acid reaction.
Growth in Potato. — The growth in this medium is
generally considered to be very characteristic, but it
varies considerably. The typical growth is a slightly
moist, almost invisible, but luxuriant layer, usually
covering the surface of the potato, and when scraped
with the needle is tough and tenacious. Sometimes,
however, the development is restricted, not very
luxuriant, and of the same color as the medium.
Again, it may be quite heavy, of a yellowish-brown
color with a greenish halo, and similar to that of the
colon bacillus. These variations in growth are
thought to be due to the reaction (alkalinity) of the
potato.
Milk is not coagulated, but some acid is produced
by the typhoid bacillus. The Bacillus coli communis,
on the contrary, causes coagulation of milk in twenty-
four to forty-eight hours at 37° C.
Vitality. — The typhoid bacilli withstand desiccation
for months; according to Uffelmann in dried earth,
clothes, etc., for two months or more. In dust,
however, they do not seem to live so long. They
resist cold remarkably well; freezing and thawing
repeatedly under favorable conditions finally kills
them. They are destroyed by heating to 60° C. in
ten minutes and at higher temperatures still more
rapidly. In feces the bacilli retain their vitality for
weeks or months, depending upon the number of
putrefactive organisms present. In oysters they
have remained alive for a month. In water which
has been sterilized they live for many days; in
ordinary water they are destroyed, by the concurrence
of other bacteria, in about fourteen days; in running
water this destruction takes place more rapidly.
It thus appears that, under favorable circumstances,
protected from light and other deleterious influences,
l he typhoid bacilli may retain their vitality outside
of the body for a considerable length of time. But
they may live also in the human body for a long time;
Sahli has found them in the pleural exudate fifty
days from the beginning of the disease, and Heintze
observed them in a case of typhoid fever in periostitic
pus ten months after convalescence.
REFERENCE HANDBOOK OF THE MEDICAL S( ll\<
Bacteria
Chemical Effects. — The typhoid bacillus produces
no pigment or odorous substances. It reduces
litmus solutions; converts nitrates into nil rites, the
Kilter being gradually decomposed; forms luetic acid
from grape sugar, but does not produce gas from
carbohydrates; produces 11. S abundantly, but does
not produce indol. The cultures are rich in toxins
!i, when freed from germs by filtration, are
active disease producers.
Pathogenesis. — Although the typhoid bacillus is
pathogenic for mice, guinea-pigs, rabbits, goats, etc.,
which when inoculated with virulent cultures die,
showing symptoms of spasm, falling temperature,
and diarrhea, no experiments so far have produced in
animals the typical lesions of typhoid fever in man.
iin experiments have indicated thai the presence
oi other bacteria in the body, and of exposure to the
action of poisonous gases in lowering the natural
resistance of the individual, may render him more
ceptible to typhoid infection. But whatever
conclusions may be drawn from these results with
regard to the typhoid process in animals, in the
human subject typhoid fever is now generally recog-
ied as a true infection, caused by the invasion and
growth of typhoid bacilli in the body. This disease
belongs to the class of infections known as metastatic —
that is to say, diseases in which the specific infective
organisms do not abound in the circulation, as in
septicemia, nor remain localized in one situation,
but are distributed through the body in groups, the
characteristic lesions of typhoid fever being in the
lymphatic structures of the intestines, viz., the
solitary follicles and patches of Peyer, the mesenteric
glands, and the spleen; the liver and kidneys are less
commonly affected.
Outside of the body the typhoid bacilli have been
found so far only in comparatively few instances in
water and soil, which have become contaminated
with typhoid dejections; also in milk. They have
been found in healthy persons who have been in close
association with typhoid patients, and those con-
valescent from typhoid fever. (See section on Typhoid
Carriers, below.) In typhoid patients they have fre-
quently been detected in the spleen and other organs
(kidneys, liver, gall duct, etc.), the blood, urine, and
feces. They are most easily isolated from the spleen
and lymphatic glands; they are often difficult to isolate
from the excretions. The typhoid bacillus may give
rise to the most varied complications along with the
clinical symptoms of typical typhoid fever; it has
been demonstrated to be the cause of suppurative in-
flammations of the spinal cord, of the brain and its
membranes, of the lungs and kidneys, and of different
suppurative processes, erysipelas, abscess, etc., in
typhoid patients. The pyogenic functions of the
typhoid bacillus are indeed no longer disputed. But
at the same time in many cases of mixed infection in
typhoid fever, the other pus cocci (streptococcus,
staphylococcus, pneumococcus, etc.) are no doubt
concerned in the production of the complications of
the disease.
With regard to the mode of infection by the typhoid
bacillus, there is no doubt that it is principally by way
of the mouth and stomach to the intestines through
drinking water, etc. In a case reported by Mayer in
which death occurred on the second day of the disease,
there were found on autopsy lesions of the lungs,
spleen, kidneys, and intestines and great enlarge-
ments of the solitary follicles and patches of Peyer,
but nowhere a trace of necrosis or loss of substance
nor enlargements of the mesenteric glands. Microsco-
pically an extraordinary deposit of characteristic
typhoid bacilli was observed in the submucosa and
interstitial spaces of the muscular tissue. In other
cases, however, no intestinal lesions have been
present, only a localization of bacilli and changes in
the mesenteric glands and spleen revealing the nature
of the infect ion. I [ere ftb orpl probabl;
place more rapidly than usual, the bacilli not' multi-
plj ing to :m\ i iiivs. Hut not only
do tin. i : i which ha i e been examined bacterio-
logically and pathologically, but also the epidemiologi-
cal hi ioiv of typhoid fever, prove beyond que
that the chief i le of invasion of tin pecific bac-
illus is by way of the mouth. The infective matt rial
discharged in the feces and mine of typhoid 1
patient- in the latter of whii icilli
often persist for weeks or month coi I u unate the
water supply, articles of food, hand- of nurses and
attendants, etc., and thus spreads infection from
place to place. (In this account the disinfection of
tin- dejections of typhoid patients and convalescent
cannot I"' too carefully looked after.
Typhoid Carriers. — Examinations of convali cent
typhoid cases show that about one to five per cent, con-
tinue to pass typhoid bacilli for years, perhaps for life.
The focus of infection i.- believed to !»• in either the
gall-bladder, chronic ulcers of the intestines, or the
normal intestinal tract. The majority are women.
A remarkable case has been noted in New York of
a cook who carried typhoid infection to other persons
with whom she was associated for six years ll'.ltll to
1907). Another remarkable instance is one in which
some hundreds of cases of typhoid fever were t raced to
a milk supply produced at a farm looked after by
a typhoid carrier who had had typhoid fever forty-
i years before. .Medicinal treatment has so far
yielded only slight results (See Bacteria Carriers.)
Immunization. — Specific immunization against ex-
perimental typhoid infection has been produced in
animals by the usual method of injecting at first small
quantities of the living or dead typhoid culture and
gradually increasing the dose. The blood serum of
animals thus immunized has been found to acquire pro-
tective and curative bactericidal and possibly feeble
antitoxic properties against the typhoid bacillus.
These characters have also been observed in the blood
serum of persons who have recovered from typhoid
fever; and recently the attempt has been made to
employ the typhoid serum of immunized animals or
dead cultures for the cure and prevention of typhoid
fever in man, but no marked results have been obtained.
Vaccination against Typhoid. — The use of killed
typhoid bacilli as vaccine has been advocated by
Wright. Two injections are usually given. The first
of 500 millions and the second, ten days later, of 750
millions. If it is impossible to count the number, 0.1
c.c. and 0.3 c.c. of a bouillon culture can be given.
The bacilli are heated to 60° C. for thirty minutes
or killed by 1/2 per cent, lysol or carbolic acid. For
a day or two the injection produces a slight fever, a
local pain, followed by the development of bacteri-
cidal substances in the blood, apparently sufficient in
amount to give some immunity lasting for a year
or more. A second injection adds to the degree of
immunity. In 49,600 individuals under observation
in India and Africa, S,600 were thus treated. The
disease appeared in them to the extent of 2.75 per
cent, with a case mortality of 12 per cent. In 41,000
inoculated there was a case percentage of 5.75 per
cent, anc' a case mortality of 26 per cent. The use of
protective vaccine in the shape of dead cultures,
would therefore, seem to be advisable where dancer
of typhoid infection exists. This practice of vacci-
nation against typhoid has recently been introduced
into the 1". S. army.
Specific Reactions. — The following specific reactions
have oeen utilized for the differential diagnosis of the
fcyi l, aid bacillus from other similar organisms, and
as in aid to the clinical diagnosis of obscure cases
o typhoid fever:
1. The typhoid bacillus does not produce indol.
2. It does not produce fermentation or gas from
media containing grape sugar, milk, or cane sugar.
853
Bacteria
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
3. On lactose litmus agar it grows usually as pale
blue colonies, but occasionally causes slight redness of
the surrounding medium.
4. Widal's Serum Reaction. — This reaction is based
upon the fact, first observed by Pfeiffer, Gruber, and
Durham, but since practically applied on a more ex-
tended scale by Widal, that living and actively
motile typhoid bacilli if placed in the diluted blood or
serum of a patient suffering from typhoid fever,
within a very short time lose their motility and be-
come aggregated into clumps. Either dried blood or
serum may be used for the demonstration of the
reaction. The blood is obtained by pricking with a
needle the skin (previously disinfected) covering the
tip of the finger or ear, and allowing two drops to
fall on a glass slide, one near either end, when they dry.
Fluid blood serum may be obtained in two ways:
First, the tip of the finger or ear is pricked and the
blood as it issues is allowed to fill by gravity a capil-
lary tube havig a central bulb, the ends of the tube
being then sealed by heat and the serum allowed to
separate from the clot. Second, a small piece of
cantharides plaster is applied to the skin at some spot
on the chest or abdomen, and from the blister thus
formed in six to eighteen hours, the serum is collected
in a capillary tube, the ends of which are then sealed.
The latter method is the best, for the serum obtained
is clear, free from blood cells and fibrin, which some-
what obscure the field on examination in the hanging
drop, and is admirably suited to the test. Dried
blood, however, obtained as above described answers
all practical purposes of diagnosis.
The method of performing the serum test is as
follows: A dilution of the blood or serum is first
made in the proportion of one to ten. In the case of
dried blood, it is dissolved in a little water and then
mixed with the typhoid culture (eighteen to twenty-
four hours old), the degree of dilution being guessed
by the color. By previously making test solutions
of dried blood in water of known proportions and
noting the color the dilution may be approximately
gauged. If serum is used, which is preferable not only
because there is less fibrinous deposit but also be-
cause it is possible to make the dilution more accur-
ately, one part of serum is added to nine parts of the
broth culture. This should contain living and actively
motile isolated bacilli. If there is no reaction when
the mixture is observed in the hanging drop — that is
to say, if within five minutes no marked change is
noted" in the motility of the bacilli and no considerable
clumping occurs — the result may be regarded as
negative, and no further test of the specimen is neces-
sary. If complete clumping and immobilization of
the bacilli occur within five minutes, this is a marked
immediate typhoid reaction, and though this test is
ordinarily sufficient for a positive diagnosis, the
reaction may be confirmed with higher dilutions up to
one to twenty, or more, if desired. If, however,
upon examination of the mixture there is no marked
reaction, but the bacilli only show in the first few
minutes an inhibition in their motility and a ten-
dency to clump, not complete within five minutes,
it becomes necessary to test this with dilutions up to
one to twenty, in order to measure the strength of
the reaction. If in the one-to-twenty dilution a com-
plete, distinct reaction takes place within thirty min-
utes, the result may also be considered positive, that
is that the blood or serum has come from a case of
typhoid infection, while if a less marked reaction
occurs it should be regarded as only probably typhoid,
and another specimen should be requested. The
time allowed by many observers for the develop-
ment of the reaction with the higher dilutions is from
one to two hours, but thirty minutes, in our opinion,
is a safer and sufficient time limit. Positive results
obtained in this way may be accepted as conclusive
evidence of the recent or previous existence of typhoid
infection in the patient. A former attack of typhoid
fever within a period of several months or one or
more years exceptionally vitiates the value of the
reaction. On the other hand, the absence of reaction
in any one examination does not exclude typhoid-
so that, if the case remains clinically doubtful, re^
peated examinations should be made. If too 'con-
centrated a solution of dried blood from a healthy
person is employed a pseudoreaction is often obtained
which may be mistaken for a true reaction. Dis-
solved blood always shows a varying amount of
detritus, partly in "the form of fibrinous clumps, and
the bacilli, inhibited by substances in the blood, may
become entangled in these substances simulating a
reaction. This is an important point to bear in
mind. In pseudoreaction, however, it may be
noticed that many free bacilli are apt to be gathered
at the margins of the hanging drop. The Widal
reaction, though not infallible, when performed with
due regard to the avoidance of every possible source of
error, is as reliable as any other bacteriological tesl
at present in use, and is of inestimable value as an aid
to the clinical diagnosis of irregular or mild cases of
typhoid infection. It is simple and easy of per-
formance by any one versed in bacteriological tech-
nique. The serum reaction is never present in other
diseases or in healthy persons, if correctly made and
in the proper dilution, as is so often the case with
Ehrlich's diazo reaction. It is better adapted for
general employment than are any of the cultural
methods now in use for isolating the bacillus from the
feces or urine. It is certainly safer than spleen
puncture, and it is not so difficult as, though far more
reliable than, the leucocyte count. The reaction does
not appear, as a rule, during the first few days of the
disease, but it is usually manifest before the rose-
colored eruption appears, though occasionally it is
very late in appearance (that is, not till the fourth or
fifth week and sometimes only during a relapse), and
in rare cases may be entirely absent. Although a
negative result, therefore, has but little significance,
a positive reaction when present — previous typhoid
being excluded — is almost as strong evidence of the
existence of the specific infection as the actual
demonstration of the typhoid bacilli.
Ice Pollution in the Production of Typhoid Ferer.—
Although there have been a few cases of typhoid
fever which have been directly traced to ice infection,
the fact that freezing kills a large percentage of
typhoid bacilli in water makes the danger of the pro-
duction of the disease from ice pollution very slight,
except under extraordinary conditions. It is always
much less than the use of the water itself. Every
week that the ice is stored the danger becomes less,
so that at the end of four weeks it has become as
much purified from typhoid bacilli as if subjected to
sand filtration. At the end of four months the
danger is almost negligible and at the end of six
months quite so. The possibility, however, of even
slight danger of infection from freshly cut ice sugpi-i-
tlie advisability of condemning any portion of rivers,
etc., greatly contaminated by sewage, for harvesting
ice for domestic purposes — such ice to be used only
where there is absolutely no contact with food.
The Colon Bacillus (Bacillus coli communis).—
This type of organism was first described by Emmer-
ich (1885), who obtained it from the blood,_ organs,
and intestinal discharges of cholera patients at
Naples under the name Bacillus neapolitanus. It
has since been found to be a normal inhabitant of the
intestinal canal of man and many animals. A
number of similar bacterial species are now often
spoken of as the colon group of organisms. The colon
group has interest not only because it excites
disease at times in man and animals, but also because
it is an index of fecal pollution from man or animals.
854
ukfi:i:eni lobar pneumonia;
in one hundred and twenty-nine cases examined by
Weichselbaum the pneumobacillus was found in nine.
According to Netter and Weichselbaum the cases due
primarily to this organism are distinguished by their
peculiarly malignant type and by the viscidity of the
exudate produced. It is also probably concerned,
primarily or secondarily, under certain circum-
stances, in the production of pleurisy, abscess of the
lungs, pericarditis, endocarditis, otitis media, and
meningitis, in all of which diseases it has been found
at times. It has been met with in all the organs of
the body and also in the blood.
The Pus-producing Organisms. — Many bacteria
are capable of producing, under certain conditions,
inflammatory and suppurative processes, abscess,
cellulitis, septicemia, etc. The microorganisms
most commonly found associated with suppuration
are staphylococci, streptococci, pneumoeocci, and
tetracocci. The following species are also occasion-
ally met with: the colon bacillus and allied members
of that group, the typhoid bacillus, the influenza
bacillus, and the bacillus pyocyaneus. In so-called
"cold abscesses" the tubercle bacillus is usually the
only organism present. Besides these bacteria,
other species may sometimes cause circumscribed
suppurative processes.
Staphylococcus Pyogenes Aureus. — This is one
of the commonest pathogenic bacteria, being present
almost everywhere. It is the most frequent cause of
acute circumscribed suppurative inflammations.
Though first observed by r Pasteur (1880) in pus and
by Ogston (1881) in acute abscesses, it was not
obtained by him in pure culture but was isolated and
accurately described by Rosenbach in 1884.
Microscopical Appearances. — Small, spherical cells,
having a diameter of about 0.8/1, occurring singly or
in pairs, but usually' arranged in irregular masses
simulating clusters of grapes; hence the name, from
crracpvX-n, "grape." (See Plate IX., Fig. 3.)
Motility. — N on-motile.
Staining Reactions. — Stains easily in aqueous solu-
tions of the basic aniline dyes; is not decolorized by
Gram.
Biological Characters. — Aerobic and facultative
anaerobic, but produces pigment only in the presence
of oxygen. It grows readily at a temperature of
from 1N° to 20° O, but best at 25° to 35° C., on all the
ordinary culture media.
Growth on Gelatin. — Grown on gelatin plates at room
temperature, it develops within forty-eight hours
punctiform colonies, which, when examined under a
low-power lens, appear as circular discs of a pale or
yellowish brown color, somewhat darker at the center
and surrounded by -i transparent zone with well-
defined border. Immediately around the colonies,
which grow rapidly and are slightly granular in
structure, there is a deepening of the surface of the
gelatin, due to its liquefaction. Later, the lique-
faction becomes general, the colonies running to-
857
Bacteria
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
gether. In gelatin stab cultures a white confluent
deposit first develops along the line of puncture,
followed by liquefying of the medium in the form of
a stocking. At the end of two days the yellow pig-
ment begins to form, and this increases in intensity
until finally (after a week) complete liquefaction
takes place and the "golden staphylococci" fall as an
orange-colored deposit to the bottom of the tube.
Under unfavorable conditions the staphylococcus
aureus gradually loses its property of liquefying
gelatin and producing pigment.
Growth in Agar. — In streak and stab cultures on
nutrient agar a whitish growth is at first produced,
and this after a few days also becomes golden yellow
on the surface. Colonies found at the bottom of a
stab culture or under a layer of oil remain white;
showing the inability of this organism to produce
pigment in the absence of oxygen.
Bouillon is densely clouded by the luxuriant growth.
Milk is coagulated in from one to eight days with
the production of acid.
Chemical Effects. — The production of an orange-
yellow pigment, but only in the presence of oxygen;
agar cultures smell like glue or spoiled paste; gas and
acid production from carbohydrates; the production
of H,S abundantly and a little indol; the decom-
position of urea by certain species — these are the
chemical effects of the staphylococcus.
Vitality. — Several cases of osteomyelitis have
been reported in which staphylococci have been found
alive in the body in the centers of infection after many
years, during this time having been encapsulated
apparently. In cultures they retain their vitality for
a year or more. The staphylococcus is distinguished
from most other pathogenic bacteria by its greater
power of resistance to all outside influences, desicca-
tion, heat, chemical agents, etc. It does not, how-
ever, form spores, as far as we know. In dried pus,
according to Hiigler, it stands desiccation for from
fifty-six to one hundred days. But it is rapidly
killed by moist heat at 70° C. It retains its vitality
in ice sixty-six days (Prudden). Disinfectants act
on it slowly. Meade Bolton found that a one-per-
cent, carbolic acid solution destroyed it in two hours;
mercuric chloride 1 to 1,000 killed it in five to ten
minutes. But there is a considerable difference in
the resisting power of the micrococci.
Pathogenesis. — The pathogenic effect of the Staph-
ylococcus pyogenes aureus on test animals varies much
according to the mode of application and the viru-
lence of the culture employed. Experiments have
shown that this organism as found in suppurative
processes in the human subject is not as infectious
for animals as it is for man. The order of suscep-
tibility seems to be as follows: man, horses, dogs,
cattle, goats, sheep, rabbits, guinea-pigs, mice. In
man a simple rubbing of the unbroken skin with pus
from an acute abscess is usually sufficient to produce
purulent inflammation. Cutaneous inoculation of
animals is negative, but subcutaneous injection
causes a local abscess in rabbits, guinea-pigs, and
mice, and intravenous injection in rabbits sometimes
produces pyemia and, after injury to the cardiac
valves, ulcerative endocarditis.
The filtrates from bouillon cultures contain highly
virulent toxic substances. Injection of these into the
peritoneal cavity of dogs causes serosanguineous
peritonitis, and ecchymoses in the serous and mucous
membranes of the intestines, finally resulting in
death with bloody diarrhea. Immunity against
staphylococcus infection may be produced by the
injection of gradually increasing doses of the pure
culture either living or previously sterilized by boiling.
The blood serum of animals which have been thus
immunized possesses slight protective and curative
effects in other animals, but no practical use of this
scrum has been attempted in man.
858
Staphylococcus aureus occurs outside the body
in milk, water, soil, air, etc. Ten per cent, of the
microorganisms present in the air of surgical clinics
consist of staphylococci (Ullmann). It is found on
the healthy skin, in the mouth, vagina, cervix uteri
and milk of nursing mothers. It is trie chief cause
of all acute inflammatory suppuration, in many cases
the sole cause. It is commonly found, however, in
association with streptococci, pneumococci, colon
bacilli, typhoid bacilli, etc. The following affections
particularly are frequently caused by the Staphylo-
coccus aureus and other species: acne, sycosis.
impetigo, pemphigus, conjunctivitis, furuncle, abscess,
periostitis, osteomyelitis, parotitis, tonsillitis, manmii-
l is, ulcerative endocarditis, pyelonephritis, etc.
It is the principal etiological factor in the production
of pyemia in the various pathological forms of that
condition.
Not all persons, however, are equally susceptible to
infection by the staphylococcus; those who are in a
cachectic condition or suffering from constitutional
diseases, like diabetes, are especially liable to infection.
In healthy individuals certain parts of the body, as
the back of the neck and seat, seem to be more
subject than others to attack by furuncles, carbuncles,
and the like. In persons in whom sores are readily
produced in consequence of disturbances of nutrition,
the micrococci find a suitable resting place at the
points of least resistance, as in the bones of weakly
children, in fractures, and injuries in general.
Staphylococcus pyogenes albus is morpho-
logically identical with S. pyogenes aureus, and is
probably a variety of the same organism winch has
lost its power of producing pigment. On the average
it seems to be somewhat less pathogenic.
Staphylococcus pyogenes citreus is also proba-
bly identical with the above-mentioned species,
except that it forms by its growth a lemon-yellow
pigment. It is found in about ten per cent, of cases
in the pus of acute abscesses, usually in association
with other pyogenic cocci.
Staphylococcus epidermidis albus is another
variety no doubt of S. pyogenes albus, but found
on the surface of the body and often in parts of the
epidermis deeper than can be reached by any known
means of cutaneous disinfection except by heat.
According to Welch it is far less virulent than S.
pyogenes aureus. It is frequently present in aseptic
wounds, but does not seem to interfere with their
healing, although sometimes it may cause suppuration
along the drainage tube, and is the common source
of "stitch abscess."
Micrococcus Tetragenus (Tetracoccus).- — This
micrococcus was discovered by Koch in 1884 in a
phthisical lung cavity. Gaffky made a further study
of it and described its pathological properties for
various test animals. Biondi found it in human
saliva; here, however, it is sometimes simply an
evidence of mouth contamination, not of lung
infection. In pulmonary tuberculosis it is commonly
associated with other pathogenic bacteria, which,
though playing no part in the etiology of the primary
affection, contribute no doubt to the progresshe
destruction of the lung tissue. Its pyogenic character
is shown by its not infrequent presence in the pus of
acute abscesses, empyema, etc.
Microscopical Appearances. — When obtained from
the animal body it occurs mostly in groups of four
surrounded by a capsule. In cultures the cocci are
seen in various stages of division as large round,
undivided cells, in pairs of oval elements, and in
groups of three or four. When the division is com-
plete they remind one of sarcina in appearance,
except that they divide in four instead of in three
REFERENCE HWDBoiiK OF Til It MEDICAL S( [ENCE8
Bacteria
directions and arc not built up like, cotton bale .
(See Plate 1\ , Fig. 4.)
Motility. — Non-motile.
Stain iiui Reactions. — Stains readily with the ordi-
nary aniline dyes; is not decolorized by Gram.
Biological Characters. — Grows both in the presence
and in the absence of oxygen, bul best with oxygen,
in the usual culture media. It may be cultivated al
room temperature (20° ('.); the optimum being I"
tween 35° and 38° ('. The growth is slow under all
conditions.
Growth in Gelatin. — On gelatin plans small, white
to grayish-yellow, shiny, prominent, round, or lemon-
sbaped colonies develop. In gelatin stab cultures it
ts equally as well on the surface as along the
. of the needle; forming on the surface a thick,
white, shiny iii:bs and tilling out the fissures along
the line of puncture. The gelatin is not liquefied.
On agar and blood serum the growth on the sur-
is moist and glistening. The colonies appear as
small, transparent, round points of a grayish-yellow
color and slightly elevated.
Pathogenesis. — Subcutaneous injections of a cul-
ture of this micrococcus in minute quantity are usually
fatal to white mice in from three to six days. The
organisms are found chiefly in the spleen, lung-,
liver, and kidneys, few in the blood. Gray mici
generally immune. Rabbits and dogs are also little
■ptible. In guinea-pigs only a local reaction or
abscess sometimes follows inoculation, and again
they die from septicemia; intraperitoneal injections
produce purulent peritonitis, groups of micrococci
being found in the exudate.
Streptococcus Pyogenes (Streptococcus erysipe-
loid*). — This microorganism was first observed by
Koch in stained sections of tissues attacked by septic
processes, and by Ogston in the pus of acute abscesses
(1882). It was obtained in pure cultures by Fehleisen
(1SN3) from a case of erysipelas, and its pathological
properties proved. Rosenbach (1884) and Krause
and Passet ( 1885) isolated it from pus and gave it the
name of streptococcus pyogenes. It has since been
shown to be the chief cause of many suppurative
inflammations. Formerly the streptococci of ery-
sipelas, acute abscess, septicemia, puerperal fever,
etc.. were thought to belong to different species,
because they possessed certain differences in their
pathological effects and morphological peculiarities,
according to the source from which they were derived.
But now it is recognized that these slight differences
are not sufficient to constitute separate species, but
only varieties of the same species. At the same
time, however, there would appear to be some strep-
tococci, which, in so far as their specific reaction in
the presence of a protective serum is concerned, are
as distinct from the streptococcus pyogenes as is the
pneumococcus. This question is of practical impor-
tance, for upon its solution depends our ability to
select a suitable protective serum in different cases
of streptococcus infection.
Microscopical Appearances. — Spherical micrococci
from 0.4 to 1 p. in diameter, usually larger than the
staphylococci, characteristically arranged in chains
of eight, ten, twenty, or more elements, but also
associated in pairs and sometimes in irregular masses.
(See Plate IX., Fig. 2.)
Motility. — Non-motile.
Staining Reactions. — Stains easily with all the basic
aniline dyes and by Gram's method.
Biological Characters. — Facultative anaerobic, grow-
ing in both absence and presence of oxygen, and on
the various liquid and solid culture media. The
growth is slow, developing best at from 30° to 37° C,
but also at room temperature (18° to 20° C). There
is no growth over 47° C.
Growth on Gelatin.— In gelatin plates small, white to
yellowish or brownish granular round colonies de-
velop, which do not liquefy the gelatin; though
occa tonally, with unusual variel ies, a amount
of liquefaction has been observed. Under a high
power, chains of streptococci may l>e seen projecting
from the sides of the discs. In gelatin slab cultures
the growth i not confluent, bul individual colonies
are arranged beside one another along lie- Iii,.
punei up .
Growth an Agar. — (in agar plates the colo
visible after t - hirty hours' growth, and when
magnified sufficiently show beautiful chain cocci
"i!e N iii i he form of twisti d loops. 1 lie colonii
circular in shape when thinly scattered over the plates,
but irregular when crowded together.
Gro . — The growth iii thi- medium is
variable in different varieties; in slightly alkaline
bouillon at -u " C. reaching their full development
within thirty-six to forty-eighl hours. Streptococci
which grow in long chains usually give an abundant
floerulent deposit and leave the liquid clear; I he
deposit may, however, he granular, in Larger Hake- or
in tough masses; sometimes the broth i- clouded.
Those growing in short chains, as a rule, cause dil
clouding of the bouillon, with a granular deposit at
the bottom of the tube. The development in a
mixture of ascitic fluid and bouillon, which is t In' bi '
medium for the growth of the streptococcus, is more
abundant than in plain bouillon.
Growth in Solidified Blood Serum. — This is also an
excellent medium for the cultivation of the strepto-
coccus. Tiny grayish colonies appear after twelve
to eighteen hours. Milk is usually coagulated with
the production of acid, but not always.
The growth on potato is scanty.
Development of Hemolytic Substances. — Most strep-
tococci produce these. This is especially true of
those from human septic infections. As pneumococci
and some types of streptococci produce them in a
much less degree, blood agar plates are a very useful
means for a probable identification. If 1 c.c. of
fresh or defibrinated blood is added to 6 c.c. of melted
agar at 40° to 45° C, well shaken, inoculated with
characteristic streptococci and poured in a Petri dish
there will appear in twelve to twenty-four hours tiny
colonies surrounded by clear zones of about J to J
inch in diameter. Pneumococci and many other varie-
ties of streptococci, which occur together with char-
acteristic forms in the throat, lungs, etc., on the other
hand produce only narrow zones of a green pigment.
Vitality. — Cultures of the streptococcus die much
sooner than those of the staphylococcus, very few
living over a month and the majority dying within a
few days; they live longest in serum bouillon or a
mixture of ascitic fluid and bouillon, and may be
kept thus for a considerable time in small sealed glass
tubes in the ice chest. When dried in blood or pus,
the streptococci retain their vitality for several
months at room temperature, and still longer in the
refrigerator. The thermal death point, according to
Sternberg, is between 52° and 54° C, the time of
exposure being ten minutes.
Chemical Effects. — As products of their growth the
streptococci form but little pigment, no indol, a little
H 2 S, and as a rule no acids or gases from carbohy-
drates. From albuminous culture media they pro-
duce toxins which are precipitated by alcohol but are
soluble in water. To obtain these toxins the cultures
are killed by r chloroform or filtered through porce-
lain. Introduced into animals in considerable quan-
tities they cause suppuration and fever and even
death; they seem to belong to the class of so-called
toxalbumins.
Pathogenesis. — The majority of test animals are not
very susceptible to infection by the streptococcus,
and hence it is difficult to obtain any definite pat holog-
ical changes in theirtissues by inoculations of cultures.
859
Bacteria
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
White mice and rabbits are the most susceptible, and
these animals are, therefore, usually employed for ex-
perimentation. The virulence of streptococci, how-
ever, varies greatly for animals and is different from
their virulence for the human subject. The most viru-
lent cultures, when injected in small quantity into the
circulation or the subcutaneous tissues of a mouse or
rabbit, produce death by septicemia. Less virulent
varieties require the injection of large quantities to
produce a similar result, while some produce only
abscess or erysipelas when injected subcutaneously,
and others have no effect at all when introduced
directly into the circulation. Many of the strepto-
cocci obtained from cases of cellulitis, abscess,
empyema, and even septicemia belong to this group.
A number of varieties of streptococci have thus
been discovered, differing in virulence and in their
growth in culture media; but all attempts to separate
them into classes, until recently through the use of spe-
cific serum, have failed, because the differences ob-
served, though often marked, are not constant.
Knorr has enunciated the following important facts
with regard to the virulence of streptococci: All
varieties when cultivated for any length of time on
artificial media gradually lose their virulence. By con-
tinuous passage through certain susceptible animals,
as mice, a streptococcus is obtained which is very
pathogenic for those animals, but at the same time
has lost its virulence for others, as rabbits. The
more virulent any variety of streptococcus is for an
animal, the more certainly it kills without suppura-
tion, which is produced only by less virulent forms.
There seems also to be a strong tendency for a strepto-
coccus to produce the same kind of inflammation, when
inoculated, as the one from which it was derived; for
example, streptococci from erysipelas tend to pro-
duce erysipelas, from septicemia to produce septice-
mia, etc. Streptococci, however, obtained from
different sources (abscesses, puerperal fever, sepsis,
erysipelas, etc.) are sometimes capable of producing
erysipelas when inoculated into the ear of a rabbit,
provided they possess sufficient virulence. By con-
tinued passage of fatal doses through susceptible
animals Marmorek has obtained cultures of strepto-
cocci of such virulence that 0.0001 c.c. subcutaneously
injected into mice almost invariably killed them,
while 0.000001 c.c. sometimes produced death — i.e.
in amounts which contained but a verv few organisms.
According to this investigator, the virulence may be
retained by cultivation in mixtures consisting of two
parts of serum and one part of bouillon, or one part of
ascitic or pleuritic fluid and two parts of bouillon,
such cultures being kept for two months or more
without transplantation to fresh media.
Streptococci have been found outside the body in
the soil, in water, and in the air of surgical clinics, etc.
In healthy persons they have been observed in the
mouth, nasal cavities, vagina, and infrequently in the
cervix uteri, sometimes in virulent forms. The
Streptococcus pyogenes may give rise in man to a
number of inflammatory and suppurative processes.
It is frequently the primary cause of infection in
erysipelas, acute abscesses, cellulitis, lymphangitis,
tonsillitis, bronchitis, pneumonia, sepsis, puerperal
fever, impetigo contagiosa; less commonly in pleuritis,
pericarditis, meningitis, periostitis, osteomyelitis,
otitis media, mastoiditis, empyema, etc. Associated
with other bacteria in diseases of which they are the
specific cause, streptococci have also been found
contributing to secondary or mixed infection in
pulmonary tuberculosis, bronchopneumonia, scarlet
fever, and septic diphtheria, playing an important part
in these affections in the production of septicemia and
fever. So uniformly present are streptococci in the
pseudomembranous inflammations of scarlatina that
some authorities -have claimed that a certain variety
of streptococci (Streptococcus conglomcratus of Kurth
8G0
and Klein) is the specific cause of this disease. The
same is true for smallpox. Their abundance in scar-
let fever and smallpox is most probably due to their in-
crease in the injured mucous membrane and entrance
into the circulation when the protective properties of
the blood have been lowered. 5. pyogenes is further
the probable cause of a number of cases of nephritis
arthritis, and myelitis, being frequently found in the
blood and urine, with or without sjmiptoms of general
intoxication.
In animals such as horses, asses, cows, sheep, goats
and dogs, the streptococcus also produces diseases
similar to those observed in man. These organisms
have not infrequently been found in the vaccine
lymph of stations where this is prepared, though
generally they are the non-virulent varieties.
Almost all of the diseases above mentioned have
been produced experimentally in animals, the result
depending upon the susceptibility of the animals
employed, the virulence of the streptococci and the
amount of infective material injected. The causal
relation of this organism to disease has also been
demonstrated in man. Fehleisen has inoculated
cultures obtained from the skin of patients suffering
from erysipelas into persons with inoperable malig-
nant growths — lupus, carcinoma, and sarcoma — and
has produced a typical erysipelatous inflammation in
from fifteen to sixty hours. Persons who had
recently recovered from an attack of erysipelas proved
to be immune. In such persons also it was observed
that malignant tumors apparently improved or
entirely disappeared after inoculation. This fact has
been made use of in the treatment of cancers by the
artificial production of erysipelas through inoculation
of pure cultures or of their toxic products, and in
some cases of spindlecelled sarcoma, according to
Coley, with considerable success; in carcinomata the
results have been very slight.
Susceptibility and Immunity. — As with the staphylo-
coccus, the streptococcus is more liable to invade the
tissues and produce inflammation and suppuration
when the standard of health is reduced from any cause,
and especially when by absorption or retention toxic
products are present in excess in the body. Thus
local streptococcus infections are more likely to occur
as complications or sequel® in various specific
diseases, in chronic alcoholism, in constitutional
affections in those exposed to septic emanations from
sewers, etc., and in cases in which there is absorption
of toxic products formed in the alimentary canal as
the result of the ingestion of improper food, of con-
stipation, etc.
Just as in persons who have recovered from an
attack of erysipelas there has been observed a slight
immunity to further infection, so it has been found
that animals, after recovering from artificial inocu-
lation of the toxic products of the streptococcus,
acquire a moderate immunity, which may be increased
by the administration of gradually increasing doses
of the culture. In this way Knorr has immunized
rabbits against an intensely virulent streptococcus
by injections of slightly virulent cultures; Pasquale
has partially immunized these animals against sep-
ticemia; and Marmorek has protected sheep, asses,
and horses against very large doses of a streptococcus
which though but slightly virulent for them was
intensely so for rabbits.
In none of the streptococcus infections in man,
however, are there apparently produced lasting im-
munizing substances in the blood after a single attack.
In cases of erysipelas, cellulitis, and abscess, recovery
after periods varying from a few days to several
months would seem to indicate the presence of slight
or transitory protective substances; but the severe
forms of infection, such as septicemia following
operations and puerperal fever, show little tendency
to recovery when once well established.
REFERENCE HANDBOOK OF THE MFDICAL SCIENCES
Bacteria
Marmorek was the first to attempt to produce a
curative antistreptococcus serum obtained from
immunized animals (asses and horses) for the treat-
ment of streptococcus infections. The re ults re-
ported from the use of this serum since his first c -
munication in 1895 have been very variable. The
protective power of antistreptococcus serum is un-
doubtedly specific, but it soon loses this power and
often is practically useless six weeks after its prepare
tion. Definite protection, however, from the serum
has been obtained by many reliable observers since
Mannorck's first reports. It has been shown that
the same serum does not always confer immunity to
other varieties of streptococci than the one which
was originally employed in the immunizing inocula-
tion. But the results of numerous investigators
would seem to indicate that the majority, though not
all. of the streptococci met within cellulitis, erysip-
elas, and abscess will be influenced by the same serum,
while those obtained from cases of pneumonia and
endocarditis and other exceptional infections are apt
to have individual characteristics. In order, there-
fore, that the scrum may have specific antibodies
for the variety of streptococcus causing each separate
infection it is now customary to prepare a polyvalent
scrum by injecting each horse with a large number
of different varieties of streptococci. This serum,
though not quite so efficient as if made by the strep-
tococcus infecting each ease, will be fairly efficacious
in all cases. As already mentioned, the results so
far from the use of the antistreptococcus serum,
therapeutically, have been somewhat variable. In
some cases the disease has progressed in spite of
large injections. In other cases apparent improve-
ment has been noticed. With the exception of rashes.
no deleterious effects have been observed, although in
very large doses albuminous urine, for a short time,
has followed. Thus the serum is certainly worth
trying in suitable cases, even though no very striking
results are to be expected. Care should be taken,
however, to get the most reliable preparation, as much
on the market is worthless. Full doses (30-50 c.c.) of
serum should be given if the case is at all serious.
Intravenous injections seem to give better results
than those administered subcutancously.
The following varieties of streptococci have been
described by some authors:
Streptococcus Brevis. — Develops in bouillon
slightly curved, short chains; the bouillon is clouded.
Gelatin is liquefied immediately around the colonies.
There is a distinctly visible growth on potato. Grows
at 10° to 12° C. Is usually non-virulent.
Streptococcus Lonous. — Develops in bouillon
long twisted chains, with a granular or flocculent
sediment, the supernatant liquid remaining clear.
Gelatin is not liquefied. There is no visible growth
on potato. No growth under 14° to 1G° C. Is usu-
ally highly virulent.
The following subdivisions of this streptococcus
have also been described: (1) Streptococcus turbidus
with clouded bouillon culture; (2) Streptococcus vis-
cosus with clear bouillon culture and slimy sediment;
(3) Streptococcus conglomeratus with clear bouillon
culture and granular sediment.
The Pneumococcus (Micrococcus Lanceolatus;
Diplococcus Pneumonia). — This micrococcus was first
observed by Sternberg, and almost simultaneously
by Pasteur (18S0), in the blood of rabbits inoculated
from human saliva. It was subsequently described
by Talamon (1SS3) and demonstrated by him to be
capable of producing fibrinous pneumonia in rabbits
when introduced directly into the lung of these
animals. In 1885-1886 this microorganism was sub-
jected to an extended series of investigations by
Fraenkel, Weichselbaum, Sternberg, and others,
and proved to be the chief cause of lobar or croupous
pneumonic in man. Several dial incl varietii
pneumococci have been recognized, showing quit a
wide range of variation in morphology
I'lie -c, called Strep In, 0i - . m < U
(Schottmuller) and other capsulated chain bacteria,
formerly classed as streptococci, e i red
to be varieties of the pneum
Besides the different varieties of pnei :occi the
following bacteria are capable of exciting pneu ma:
Streptococcic pyogen, , Stap) ,' . , , , Bacil-
lus pneumonia}, Bacfflu ftuei
BaciUus diphtherial, Bacillus typhi, Bacillus colt,
Bacillus lulu rculosis.
Microscopical Appearances. — Very irregular; oci
typically as spherical or oval and lancet- taped » i
usually united in pairs (diplococci), but sometimes
as short chains consisting of four to six clem
and resembling streptococci. In stained specimens
from sputum, the fibrinous exudates of croupous
pneumonia, the blood of inoculated animal-, ami cul-
tures on blood serum, the lancet-shaped cells are com-
monly surrounded by a gelatinous capsule. Varia-
tion in form and arrangement is characteristic of
the pneumococcus, then? being great differences
according to the source from which it is obtained.
(See Plate IX., Figs. 5 and 6.)
Motility. — Non-motile.
Staining Reactions. — Stains readily with ordinary
aniline dyes; is not decolorized by Gram's solution.
The capsule may be demonstrated in cover-glass
preparations either by Gram's or Welch's (glacial
acetic acid) method.
Biological Characters. — Aerobic and facultative
anaerobic, grows equally well in the presence and
absence of oxygen. It develops on almost all culture
media having a slightly alkaline reaction; but the
growth is slow and scanty, and the virulence and
power of reproduction are soon lost. Grows very
slowly, often not at all at room temperature; opti-
mum 37° C, maximum 42° C.
Growth on Gelatin. — The growth on this medium is
slow, often none at all, owing to the low temperature
(22° to 25° C.) at which gelatin has to be kept. The
gelatin is not liquefied.
Groioth on Agar and Blood Scrum.- — At the end of
forty-eight hours in the incubator, there appears on
agar a thin colorless layer of non-confluent colonies.
If blood serum or ascitic fluid be added to the agar
the colonies are larger and closer together, the
growth being more luxuriant. The growth of Loef-
fler's blood-serum mixture is very similar to that on
agar, but is somewhat more vigorous, appearing on
the surface as small, fairly granular dew-drop-like
colonies.
Grouih in Bouillon. — At the end of twelve to
twenty-four hours in the incubator a slight clouding
is produced, due to the development of the organisms,
which on microscopical examination are seen to
consist of pairs or longer and shorter chains. After
two or three days the medium again becomes trans-
parent, the cocci sinking to the bottom of the tube.
The best fluid medium for the cultivation of the pneu-
mococcus is a mixture composed of bouillon two
parts and ascitic or pleuritic fluid one part. In this
medium the organisms grow well, and cultures kept
in a cool place and prevented from drying retain
their vitality for a number of months.
Milk is a favorable medium, and in some cases
coagulation takes place.
Vitality. — In cultures the pneumococcus soon loses
its vitality; it lives longest in media containing blood
or serum. Pneumonic sputum attached to cloths,
air-dried and exposed to diffuse daylight, retained
its virulence for rabbits for periods of nineteen and
fifty-five days in different experiments. Exposed
to direct sunlight the same material retained its
861
Bacteria
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
virulence after twelve hours' exposure (Bordoni-
Uffreduzzi). This resistance of the organism for
so long a time under these conditions is attributed in
part to the protective influence afforded by the
albuminous envelope surrounding the micrococci in
the sputum.
Chemical Effects. — Three varieties of pneumococci
have been isolated which produce a brick-red pig-
ment. Filtered and dead unfiltered cultures contain
toxins as products of growth. For other chemical
effects, see Streptococcus.
Pathogenesis. — The pneumococcus is quite patho-
genic for some animals, especially mice and rabbits;
rats are less susceptible, and guinea-pigs, sheep, dogs,
and birds are almost immune. In mice and rabbits
the subcutaneous injection of small quantities of
pneumonic sputum in the early stages of the disease,
or of a pure, virulent culture of the micrococcus,
usually results in the death of these animals in from
twenty-four to forty-eight hours. The course of the
disease produced and the post-mortem appearances
indicate that it is a typical form of septicemia — so-
called sputum septicemia. The most marked patho-
logical lesion is the enlargement of the spleen. The
blood after death often contains large numbers of
pneumococci. True localized pneumonia does not
usually result from subcutaneous injections into
susceptible animals, but injections made through the
thoracic walls into the substance of the lung may
induce a typical fibrous pneumonia. Attenuated
cultures produce, according to the point of inocula-
tion, pneumonia and pleurisy, peritonitis, etc. Atten-
uation of the virulence of cultures of the pneumococ-
cus may be produced artificially by the action of heat
or several days' growth in the incubator, by continued
Eassage through unsusceptible animals (guinea-pigs),
y cultivation in unsuitable media, etc. Virulence
is restored and increased by passage through highly
susceptible animals of the same species from which
the organism was originally obtained.
The pneumococcus has not been found outside the
body, except in sputum. It is frequently present in
the saliva of healthy individuals. In diseased per-
sons it is one of the most important pathogenic bac-
teria. It is associated with various inflammatory
Erocesses, especially of the mucous and serous mem-
ranes; and is the chief etiological factor in the pro-
duction of lobar and catarrhal pneumonia, pleurisy,
pericarditis, endocarditis, empyema, peritonitis, otitis,
meningitis, conjunctivitis, and keratitis; less fre-
quently of nephritis, parotitis, metritis, pyosalpinx,
strumitis, amygdalitis, arthritis, osteomyelitis, perio-
stitis, etc., abscesses, and general septicemia. Erysio-
elas can also be caused by it. In many of these aii :c-
tions the organism is found not only locally, but also
in the blood. Very often the pneumococcus is asso-
ciated with and acts as a synergist of other pus-
producers, as the staphylococcus, streptococcus, etc.
It is carried from its original seat in the lungs to
distant organs of the body by means of the circula-
tion, being often found in the lymphatios and the
blood both during life and after death. Knowing
that the saliva and nasal secretions under normal
conditions so frequently afford a resting place for
the pneumococci, we have only to assume the pro-
duction of a suitable medium for these parasites in
the body, brought about by an abnormal condition
of the mucous membranes from exposure to cold, or
a reduction of the vital resistance of the tissue cells
in an interior organ, by disease, traumatism, excesses
of various kinds, alcoholism, etc., readily to com-
prehend how an individual may become infected
primarily or secondarily with pneumonia.
Immunity. — Fraenkel has shown that subcutane-
ous injections of rabbits with virulent cultures of the
pneumococcus produced infection in only a small
proportion of them; those which recovered were
862
found to be somewhat immune to a second infection.
Artificially attenuated cultures or material containing
naturally weakened micrococci have also been used
for inoculation. Another series of experiments were
based on the assumption that the protective sub-
stances are contained in the natural or artificial
products of the growth of the organisms. Thus cul-
tures freed from bacteria by filtration and emulsions
of pneumonic sputum, portions of pneumonic lung
pleuritic exudates, etc., were employed for inoculation
by different experimenters. But the quantity of
material required for inoculation by these methods
having been found inconveniently large, attempts
have been made to obtain the immunizing products
in a more concentrated form. Foa and Scabia, and
the Klemperer brothers prepared glycerin extracts,
after the manner of Koch's tuberculin, calling their
product "pneumotoxin." At present, however, a
protective serum is obtained from horses by the
repeated injections of fully virulent pneumococci in
exactly the same way as in the production of anti-
streptococcus or diphtheritic antitoxic serum.
Curative experiments in man have been recently
made with this antipneumococcus serum obtained
from immunized animals. The most successful of
these were conducted by the Klemperers. They hold
that in man during the pneumonic process there is a
constant absorption into the circulation of the toxic
substances produced by the bacteria. This contin-
ues until eventually the same antitoxic substance is
produced naturally in the body as is seen to occur
experimentally. It is then, they think, that the
crisis takes place. The bacteria are neither destroyed
nor is their power to produce pneumotoxin lessened;
but the third factor, the antitoxin, now exists and
neutralizes the toxin. These authors state that they
have been able to show that the blood serum of
patients after the crisis contains antitoxic substances,
and is capable, in a fair number of cases, of curing
the disease when injected into infected animals.
They have also made observations upon patients with
a view of inducing the crisis by the injection of the
blood serum of immunized animals and of persons
convalescent from pneumonia. Somewhat favorable
results have been reported in a certain number of
cases thus treated by the Klemperers, Jansen, De
Rienzi, Weisbacker, Washburn, Pass£, Ugheti, Mennes,
Lambert, and others, but nothing definite so far has
been accomplished. It may, therefore, be concluded
that the curative treatment by antipneumococcus
serum, like that of antistreptococcus serum, is still
in the experimental stage. All that can be said
about the results obtained is that the cases treated
have, as a rule, done better than was expected,
though no striking curative effects have been pro-
duced. In many instances there was no develop-
ment of pneumococcus blood infection; and even if
the serum does not hasten the crisis and bring about
a positive cure, yet it may be able to prevent a
general infection. It is known that there are several
varieties of the pneumococcus, as of the streptococcus,
possessing different biological and pathological
properties and varying virulence. Possibly it may
be found that pneumococcus serum obtained from
animals immunized against a certain variety of
pneumococcus protects only fully against that variety,
as with the streptococcus serum, and that large intra-
venous injections of 50 c.c. of a polyvalent serum
may be of value. But whether that be so or not,
the injections, at any rate, of the serum have been
shown to be practically harmless, and the benefits to
be derived from the discovery of a curative remedy
for pneumonia are so great that these experiments
are certainly worth continuing.
The Meningococcus (Diplococcus intracclhrfaris
meningitidis). — This organism was isolated by
Hill I'.IM'.XCK HANDlsniiK < >F Till: MFIHCAL SCIENCES
Bacteria
Weichselbaum (1887) from the exudate of cerebro-
spinal meningitis, both when complicating pneumonia
unci in uncomplicated cases, and from its usual pres-
ence in the interior of pus cells he called it D
acellularis. It has since been found (1895) by
Jager and Schcurer in the nasal secretions and sputum
ol persons suffering from tins affection during an
epidemic. The frequency of its occurrence in and
restriction to this disease afford sufficient evidence
of its being concerned at times, at least, in the
production of cerebrospinal meningitis, though the
pneumococcus is probably the most common cause.
Motility. — Non-mo! ile.
Staining Reactions. — Stains with the ordinary
aniline colors, but best with Loeffier's alkaline methyl-
blue. It is readily decolorized by Gram's
solution.
Microscopical Appearances. — Occurs as coffec-
i-shaped micrococci usually united in pairs
(diplococci), but also in groups of four, and in small
masses; sometimes solitary and smaller apparently
degenerated forms are found. It has no well-defined
ule. In the exudate it is generally found, like
the gonococcus, to which it bears a close resemblance
morphologically, in the interior of the pus cells and
extranuclear. According to some authors it is
sometimes indistinguishable in form from the pneu-
mococcus, streptococcus pyogenes, and tetracoccus.
Plate IX., Fig. S.)
Biological Characters. — The meningococcus does not
grow at room temperature but only between 25° and
40° C, best in the incubator at 3G°-37° C. Its devel-
opment is usually scanty on the surface of agar,
though sometimes a few colonies grow luxuriantly.
It does not grow at all or very poorly in bouillon or
bouillon mixed with one-third blood serum. It
develops best on Loeffier's blood-serum mixture as
used for diphtheria cultures.
When grown on nutrient or glycerin agar, at the end
of forty-eight hours in the incubator a tolerably
good growth develops, appearing as flat, grayish
colonies, viscid and usually non-confluent. On
Loeffier's blood serum the growth forms round, whitish,
shining, viscid-looking colonies, with smooth, sharply
defined outlines. The colonies tend to become
confluent, but do not liquefy the serum.
Cultivated in artificial media the meningococcus
soon loses its vitality (in six days), and must therefore
be transplanted every two or three days to fresh
media.
Pathogenesis. — Not very pathogenic for animals;
most for mice and guinea-pigs, less so for rabbits and
dogs. Subcutaneous injections of animals give nega-
tive results; intrapleural or intraperitoneal inocula-
tions in mice and guinea-pigs, in large doses, are
generally successful. The animals usually fall sick
and die within thirty-six to forty-eight hours, showing
slight fibropurulent exudation. In the blood and
enlarged spleen diplococci are found in small numbers
and mostly free; in the pleuritic exudate they are
present in considerable quantities and then are found
in the interior of the pus cells. Meningitis, corre-
sponding to the disease as occurring in man, has
been artificially produced in dogs by subdural inocula-
tions of recent cultures.
Under natural conditions in the human subject the
meningococci probably gain access to the brain and
meninges by way of the nose, ear, and upper air
passages. They have been found not only in menin-
geal pus but also in the nasal mucous secretions, the
sputum, and the urine of patients suffering from
meningitis, and occasionally in the nares of healthy
persons coming in contact with patients. A mixed
infection of the meningococcus, pneumococcus, and
streptococcus pyogenes is often met with.
Serum Treatment. — Numerous experiments, having
for their object the production of a protective serum
for this di been made since 1905 by variou
investigators; Kolle and \\ . , Park, Joch-
mann, I lexner, and others. The Bu
use of an immune serum in cases of human cerebro-
spinal meningitis, however, by the intraspinal method,
may properly be accredited fo Jochmann and
physicians who employed bis serum in 1005 and I
This serum wa pr injecting hoi
increasing doses of meningococcus, killed al about
58° C. The doses were given every eight d;
beginning with a loopful and increasing until the
growth on the surface of ascitic agar covering two
Petri dishes was used. After this do ched
living cultures were given. The serum a to
possess both bactericidal and opsonic power. Forty
were reported treated, but detail- were given
of only seventeen patient-, five of whom died and
twelve recovered, a tahty of 29 per cent. Joch-
mann directed that after lumbar puncture, 20 to
.">0 c.c. of fluid should be removed and then 2(J
of immune serum injected. These injections were
to be repea or twice if the fever did not abate
or returned. A general betterment of the headache,
stiffness of neck, and mental condition was noticed.
Although the serum prepared in different labora-
tories in Europe was regularly used after Jochmann's
report, it did not receive much attention in this
country until Flexner, at the Rockefeller Institute for
Mei Ih.i1 Research, through his important experiments
on infected monkeys, which demonstrated the value
of the intraspinal injection of the serum, aroused a
general medical interest in the subject, shortly
after this, Flexner and Jobling published their report,
which fully corroborated the earlier results of Joch-
mann. From a large number of eases of the disease,
which have now been treated, in which the bacterio-
logical diagnosis was made, it appears that the aver-
age mortality at all ages was about 31.5 per cent.,
the highest mortality being 42.3 per cent, which
occurred in the first two years of life. The mor-
tality, however, at this age period, under the older
mode of treatment, was formerly 90 per cent, and
over. The best results have been obtained in the
first-to-third day injections, the poorest after the
seventh day. It would seem to be evident, therefore,
that the intraspinal injections of antimeningococcus
serum are of undoubted value in the majority of
cases and should always be given — the sooner the
better — not even waiting necessarily for a bacterio-
logical examination to give the first injection. No
ill effects have been observed from the use of the
serum.
A bacteriological diagnosis of cerebrospinal menin-
gitis may often be made by means of lumbar puncture
to obtain a specimen of the fluid from the spinal canal,
and microscopical examination and cultivation on
Loeffier's blood serum. The clinical value of this is,
that about forty per cent, of the cases due to the
meningococcus recover, while almost all of those
caused by the pneumococcus and streptococcus die.
The Gonococcus (Micrococcus gonorrhoea;). —
First observed by Neisser (1S79) in gonorrheal pus
and described by him under the name of " gonococ-
cus." It was obtained in pure culture by Bumm
(1885), and its infective nature proved by inocula-
tions into men.
Microscopical Appearances. — Micrococci usually
united in pairs (diplococci) or groups of four. The
bodies of the diplococci are shaped like coffee beans
or a Vienna roll, having an unstained division or
interspace, in stained preparations, between two fiat
surfaces facing one another. They are from 0.8 to
1.6 /i long and 0.6 to 0.8 /( broad. In gonorrheal
discharges the diplococci are found mostly in small,
irregular groups in or upon the pus cells and extra-
nuclear. Occasionally round, single, and undivided
863
Bacteria
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
cells are observed, and again irregular forms, parti-
cularly in old cultures, and in chronic gonorrhea of
long standing. (See Plate IX., Fig. 7.)
Motility. — Non-motile.
Staining Reactions. — Stains readily with the basic
aniline dyes, especially with methyl violet, gentian
violet, and fuehsin; not so quickly with methylene
blue, which, however, is the best staining agent for
demonstrating its presence in pus. The gonococcus
is decolorized by Gram's solution, which enables it
to be distinguished from other pus cocci; but this
method cannot always be depended on to differen-
tiate it from all diplococci found in the urethra and
vulvovaginal tract, some of which are morpholog-
ically similar to the gonococcus and are also decolor-
ized by Gram's solution.
Biological Characters. — Aerobic and facultative
anaerobic. Does not grow at room temperature,
best at 37° C. Growth on ordinary culture media
is so scanty that special media have been devised
for its cultivation.
Human Placenta Serum Agar. — Wertheim has suc-
ceeded in developing luxuriant and virulent cultures
to many generations on a mixture consisting of pla-
centa blood serum and two per cent, peptone agar.
His method is as follows: Several loops of gonor-
rheal pus are diffused through liquid placental blood
serum warmed to 40° C. in a test tube. Two dilu-
tions are made from this, and an equal quantity of
melted two-per-cent. peptone agar cooled to 40° C.
is added to the three tubes, and the contents poured
into Petri dishes. At the end of twenty-four hours
in the incubator there will have developed on at
least one of the plates distinct colonies, which are in
appearance translucent and finely granular with
scalloped margins. By transferring such a colony
to slant cultures of serum agar, pure cultures of the
gonococcus are obtained; these are somewhat shiny
in appearance and of a grayish-white color.
Human Chest Serum Agar. — Heiman, and almost
simultaneously, Kiefer and Menge, proposed a cul-
ture medium made from hydrothorax, ascitic, or
hydrocele fluid, obtained from the human subject.
This medium as prepared by Heiman consists of a 2
per cent, agar +2 per cent, peptone +0.5 per cent,
salt +2 per cent, glucose; of this mixture two parts
are added to one part of "chest serum," obtained
from a patient suffering from hydrothorax, acute
pleurisy, or hydrocele, which, if necessary, is steril-
ized. The chest serum agar should have a neutral
reaction. The growth in this medium is thus de-
scribed: "In plate cultures streaked on the surface,
growth abundant, colonies circular in shape, edges
somewhat irregular, shading off into yellowish-white;
texture finely granular in periphery, presenting punc-
tuated spots of higher refraction in and around the
center of yellowish color."
Pig Serum Nutrose Agar. — Wassermann recom-
mends a culture medium for the gonococcus con-
sisting of 15 c.c. pig serum diluted with 30-35 c.c.
water, to which is added 2-3 c.c. glycerin, and finally
about 2 per cent, nutrose (casein sodium phosphate).
This is thoroughly mixed and boiled and sterilized
by the fractional method. To the mixture is now
added an equal quantity of 2 per cent, agar cooled
to 40° O, for the inoculation of cultures, and then
Eoured into Petri dishes. The growth is favored
y admission of air, and is similar in appearance
to that already described for plate and streak
cultures.
Toxins. — Wassermann has obtained on his serum
nutrose agar virulent cultures of the gonococcus,
which after being killed still possessed toxic action.
The gonotoxin produced was found to be very
resistant to heat and the action of alcohol; it killed
mice, and in rabbits gave rise to caseous infiltration
often passing into necrosis, and in large doses pro-
864
duced general toxemia. Injected into the human sub-
ject the gonotoxin seemed to produce no curative effect
on an existing chrome gonorrhea, the intense reaction
caused not becoming less on repeated inoculations.
The production of gonotoxin would seem to ac-
count for the gonorrheal secretion. It also renders
more comprehensible several obscure points in the
history of chronic gonorrhea: for example, the fact
that gonococci may be apparently absent from, or
only isolated organisms present in, the gonorrheal
discharge, and yet a purulent secretion be kept up
containing few bacteria; but if, owing to some in-
jury to the tissues, the organisms increase in number
an acute exacerbation of the disease is again set up
and masses of gonococci are then found in the pus.
Vitality. — The gonococcus has but little resistant
power against outside influences. It is killed by
weak disinfecting solutions and by desiccation in
thin layers. In comparatively thick layers, however,
as when gonorrheal pus is smeared on linen, it has
lived for forty-nine days, and dried on glass for
twenty-nine days (Heiman). No development takes
place below 25° C. or above 39° C; it is killed by a
temperature over 42° C.
Pathogenesis. — Gonorrhea as occurring in man is
non-transmissible to dogs, monkeys, horses, and rab-
bits, whether inoculations be made into the urethral,
vaginal, or other mucous membranes. Large doses
of virulent cultures produce in animals toxic inflam-
mations, similar to that produced by the gonotoxin,
without any multiplication of cocci. Although
animal inoculations have been thus followed by
negative results, the etiological relation of the gon-
ococcus to human gonorrhea has been demonstrated
beyond question by the infection of healthy men
with the disease by inoculation of pure cultures by
Bumm, Wertheim, Kiefer, and Heiman.
The gonococcus has never been found outside the
body, except in articles of clothing, etc., which have
become contaminated by those affected with the
disease; nor has it ever been met with in healthy per-
sons. In those suffering from gonorrhea it has been
found in the urethra and prostate of the male and
in the urethra, vagina, and cervix uteri of the female,
as the cause of the disease. Besides gonorrheal
urethritis and vaginitis, the gonococcus is the cause
of certain cases of endometritis, metritis, salpingitis,
oophoritis, peritonitis, proctitis, cystitis, and prob-
ably also of epididymitis; also of gonorrheal
ophthalmia neonatorum, and rarely of diphtheritic
conjunctivitis in children (Fraenkel). The gonococ-
cus produces in adults severe conjunctivitis, sel-
dom rhinitis and otitis. It is frequently the cause
of gonorrheal arthritis, also probably in some cases
of pleuritis, malignant endocarditis, parotitis, peri-
ostitis, and bursitis.
In the local affection squamous epithelium pro-
tects better than cylindrical epithelium. The para-
site penetrates gradually through the epithelium into
the connective tissue. In travelling to distant organs
of the body the gonococcus follows mainly the course
of the lymphatics and produces inflammation which
finally leads to fibrinous hypertrophy — stricture of
the urethra, hypertrophy of the prostate, etc. There
is no or very slight immunity produced after recovery
from an infection. The use of sera in acute gonor-
rheal joint inflammation has given in a considerable
percentage of cases good results and seems to be
worth trying. Vaccines (heated cultures) have also
been used with apparently real benefit in joint inflam-
mations and even in very localized chronic infections
of the urethra, bladder, and elsewhere. The dose is
from twenty to a thousand million given every three
to seven days.
There is practically no limit to the time during which
a man or woman may remain infected with gonococci
and infect others. A case has been under observa-
EXPLANATION OF
PLATE IX.
EXPLANATION OF PLATE IX.
Fig. 1. — Bacillus Coli Communis. Agar culture. Stained with fuchsin. X 1,000.
Photomicrography from Bowhill's "Bacteriology" by permission.
Fig. 2. — Streptococcus Pyogenes (Longus). X 1,000. Photomicrograph from Sternberg's
" Bacteriology" by permission.
Fig. 3. — Staphylococcus Pyogenes Aureus. X 1,000. Photomicrograph from Park's
" Bacteriology" by permission.
Fig. 4. — Micrococcus Tetragenus (Tetracoccus). X 1,000. Photomicrograph from Park's
" Bacteriology" by permission.
Fig. 5. — Diplococcus Pneumoniae (Fraenkel) in Sputum, x 1.000. Stained by Gram's
method. Photomicrograph from Sternberg's " Bacteriology" by permission.
Fig. 6. — Diplococcus Pneumonias (Fraenkel) in Blood. X 1,000. Photomicrograph from
Sternberg's "Bacteriology" by permission.
Fig. 7. — Micrococcus Gonorrhoeae (Gonococcus of Neisser) in Urethral Pus. Stained with
Loeffler's solution of methylene blue. X 1,000. Photomicrograph from Sternberg's
" Bacteriology" by permission.
Fig. S. — Diplococcus Intracellularis Meningitidis (Meningococcus). X 1,000. Photo-
micrograph from Park's " Bacteriology" by permission.
Refekence Handbook
OF THE
Mf.dical Sciences
Plate IX
Streptococcus pyogenes. *?•.**•••*<'
VII.
Gonococcus (Neisser).
vS- 1
V.
Diplococcus pneumoniae in
sputum.
9.
#'
in.
Staphylococcus pyogenes
aureus
Pathogenic Bacteria.
VIII.
I liplocoocus intracellularis
meningitidis.
REFEHKNCF HANDBOOK OK Till' MEDICAL SCIENCES
Bacteria
ion where twenty years luul elapsed since exposure
(i infect inn and yet the gonococci were still abundant.
It is now well established thai most of the inflam-
mations nf the female genital tract are due to gono-
rncci and the majority of such infeel ions are produced
in innocent women by their husbands who are suf
faring from latent gonorrhea.
In view of t lie fact i hat several non-specific forms of
urethritis exist, and also that diplococci morpholog-
ically similar to the gonococcus Neisser are often
found in the normal urethra ami vulvovaginal tract,
it becomes a matter of great importance to he able to
detect gonococci when present and to differentiate
these from the non-specific organisms. For the dem-
onstration of gonococci, they must be found as
diplococci lying in masses in the pus cells anil extra-
nuclear, when stained with methylene blue and
decolorized by Oram's solution. Organisms having
these characteristics microscopically may for all
practical purposes be considered as certainly gono-
cocci, if they are obtained from the urethral discharge
and confirmed by examination on three' successive
days. But if there still remains any doubt, and
especially if the organisms are obtained from the
vulvovaginal tract, plate cultures should be made
on one of the special media described (chest serum
agar, etc.), on at least three consecutive days.
Malta Fever (The Micrococcus rnelitensis). —
This organism was first discovered by Bruce in Malta
in 1887. The disease is confined to the shores of the
Mediteranean, but cases have been observed in Porto
Rico, China, Japan, and the Philippines. It does
not seem to be directly transmitted from person to
person. Prodromal symptoms follow an incubation
period of 5 to 14 days. Headache, sleeplessness, loss
of appetite, and vomiting accompany a high fever.
The spleen and liver are enlarged. Neuralgic pains
are severe. The fatal cases appear similar to severe
cases of typhoid fever. Micrococci are found abun-
dantly in the blood and all organs.
Microscopical Appearances. — Very small rounded
or slightly oval organisms, about 0.3 a in their greatest
diameter. It is usually single or in pairs. In old
cultures involution forms occur, almost bacillary in
shape.
Motility. — Absent.
Staining. — It stains readily with aniline dyes and
is negative to Gram.
Biological Characters. — Grows rather feebly at 37°
C. on nutrient gelatine and in broth. The colonies are
not usually visible until the third day. They appear
as small round disks, slightly raised with a yellowish
tint in the center. The broth is slightly clouded
after five or six days. The culture remains alive
for several weeks or months. In gelatin the growth
is very slow. Gelatin is not liquefied.
Pathogenesis. — Among animals, monkeys only are
infected. They pass through the disease much like
man. They can be infected by subcutaneous or mu-
cous inoculation. In Malta it has been found that
about half of the goats pass organisms in feces, and
so contaminate their milk, which is believed to be a
source of infection. By safeguarding the milk the
disease has been largely eliminated. Infections of
heated cultures have been thought to give good results
in treatment.
Diagnosis. — The diagnosis of Malta fever can fre-
quently only be made by bacteriological methods.
Cultures are made by spreading over the surface
of a number of agar plates freshly drawn blood.
Often no organisms develop. The agglutination test
is then required. The blood of persons suffering
from other infections frequently agglutinates the
micrococcus of Malta fever in low dilution, so that
1:500 or over is required for a positive diagnosis.
Animals injected with the coccus produce a serum
agglutinating in high dilution and this method can
sometimes be used, under suitable precaution . to
identify suspected cull un .
The Bacillus of Soft Chan< Ducrey' hoc-
ill" i. — This bacillus was first specifically
and obtained in pure culture by Ducrey in Iss'J.
An experimental inoculation is followed iii one or
two days by a small pustule. This soon rupl
and a small round depressed ulcer is lefl . Aboul this
other pustules develop which tend to become con-
fluent. The base of the ulcer is covered with a gray
exudate and its edges are undermined. There i no
induration as in the Byphilitic chancre. The secre-
tion is seropurulenl and very infectio
Microscopical Appearances. — About 1.6 p long
and o.l fi thick, growing often in chains, sometimes
twisted together in dense masses.
Staining. — It stains best with carbol-fuchsin, and
shows polar staining.
Biological ammeters. — Grows best in blood-agar
1 1 \\o pails agar liquefied at 50° C. and mixed with one
part human, dog, or rabbit blood) or in condensation
water of blood-agar, at 35" to 37° C. It grows also
in coagulated rabbit blood. In 24 to 48 hours, on
the surface of the media, well-developed, shiny,
grayish colonies, about 1 mm. in diameter, may be
observed. The calonies remain separate, but only
become numerous after further transplantation. The
best results are obtained when the pus is taken close
to the walls of the abscess. Glass smears show iso-
late,! bacilli or short parallel chains with distinct
polar staining. The organisms are especially char-
acteristic in the water of condensation from' blood-
agar, the bacilli being thinner and shorter, with
rounded ends; sometimes long, wavy chains are
found.
After the eleventh generation of the culture, and
upon all old cultures, on inoculation the character-
istic soft chancre is produced in man.
The bacillus lives several weeks in blood-agar at
37° C. but it soon dies in coagulated serum. All
other ordinary culture media so far tried have given
negative results and even with the media described
development is difficult and often fails. The chancroid
bacillus possesses but little resistance to deleterious
outside influences. Hence the antiseptic bandages,
etc., used in treatment of the affection soon bring
about recovery by preventing the spread of the
infection.
The Bacillus Pyocyaneus (Bacillus of green and
blue pus). — This bacillus is found in green or blue
colored pus which occasionally accompanies the
discharges from open wounds, and is the cause of the
pigmentation produced. It was first obtained in
pure culture by Gessard.
Microscopical Appearances. — Delicate, slender rods,
about 0.4 u broad and 1.5 to G /( long, often united in
pairs or in chains of four to six elements, and occa-
sionally growing into long threads.
Motility. — Actively motile, possessing only one
flagellum.
Spore Formation. — Absent.
Staining Reactions. — Stains readily with the ordi-
nary aniline colors; does not stain with Gram's method.
Biological Characters. — Aerobic and facultative
anaerobic, but produces pigment only in the presence
of oxygen. Grows readily on all artificial culture
media at room temperature, but best at 37° C. On
gelatin plates flat, irregular colonies with radiating
borders are rapidly developed, imparting to the
medium a fluorescent green color; liquefaction begins
at the end of two or three days, and in five days the
gelatin is completely' liquefied. In gelatin stab cul-
tures liquefaction takes place rapidly at first near the
surface and gradually extends downward; a greenish
color is produced in that portion in contact with the
air. On agar plates a wrinkled, moist, whitish layer
Vol. I.— 55
865
Bacteria
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
is developed, the surrounding medium being at first
bright green, later darker in color, and finally blue
green or almost black. In bouillon a green fluores-
cence is produced, the medium being clouded, and a
floceulent sediment forms. Milk is coagulated and
peptonized. On potatoes a greenish-yellow or brown-
ish growth occurs, the surrounding surface being
green.
The Bacillus pyocyaneus produces two pigments —
one of a fluorescent green (bacterio-fluorescin, soluble
in water) and the other of a blue color (pyocyanin,
soluble in chloroform) formed only in the presence of
oxygen. A faint aromatic odor is produced in recent
cultures; in old cultures a disagreeable ammoniacal
odor. No indol or I-LS is formed by this bacillus, and
very little acid from grape sugar; no gas. Nitrates
and nitrites are converted into free nitrogen. The
bacillus pyocyaneus produces poisons by its growth.
It has but little resistance to outside influences.
Drying kills it rapidly; exposure to the action of
direct sunlight for four hours partly destroys its
power of producing pigment.
Pathogenesis. — Pathogenic for rabbits and guinea-
pigs. Subcutaneous or intraperitoneal injections
of 1 c.c. of a bouillon culture cause the death of these
animals in from twenty-four to thirty-six hours,
with the production of extensive inflammatory
edema and purulent infiltration of the tissues. The
bacilli multiply in the body, and may be found in the
serous or purulent fluid as well as in the blood and
organs. Smaller amounts do not kill the animals,
but render them immune to doses fatal to those not
thus immunized. In rabbits inoculated with a
culture of the bacillus anthracis a fatal result may be
prevented by soon after inoculating the animal with
a pure culture of the Bacillus pyocyaneus. It has
been suggested that the protective action is due to
the chemical products of the growth of the bacillus,
and not to an antagonistic effect of the living bacteria.
Though widely distributed in nature, the bacillus
f>yocyaneus has not so far been found outside the
iving body. It has been observed occasionally in
the mouth and intestines of healthy individuals, on
the unbroken skin and in the purulent discharges of
open wounds, also in bandages and dressings, at times
epidemically in hospitals. Usually the organism
appears only in association with the common pus
cocci, coloring the pus blue or green. In some cases,
however, it has been found alone in disease processes,
as in otitis media, ophthalmia, bronchopneumonia,
pericarditis, etc., especially in children, so that we
have reason to believe that this bacillus, although
ordinarily non-pathogenic for man, may under certain
conditions become a source of infection. In general
its presence in wounds delays the process of repair
and may give rise to a depression of the vital powers
from the absorption of its toxic products.
The Bacillus Proteus Vulgaris. — This is the
most important of a group of similar bacteria, known
as the "Proteus group," which are among the com-
monest and most widely distributed putrefactive
organisms. They were formerly included by the
earlier observers under the name of "Bacterium
termo," which they applied to all minute motile
organisms found in putrefying substances. It was
discovered by Hauser in 1885.
Microscopical Appearances. — Small, slender rods
varying greatly in size, but on the average about
0.6 /t broad and 1.2 /x long, generally occurring in
pairs but sometimes arranged in filaments, which
may be more or less twisted. It is to its great vari-
ability in form that it was given the name of proteus.
Motility. — Actively motile.
Spore Formation. — Absent.
Staining Reactions. — Stains readily with aniline
dyes, especially fuchsin or gentian violet; also stains
with Gram's solution.
Biological Characters. — Aerobic and facultative
anaerobic. Grows on almost all culture media
developing most rapidly at room temperature, but
also in the ice box and in the incubator. Toxin
production seems to be favored by admission of air.
The growth on gelatin plates containing five per
cent, of gelatin is very characteristic. At the end of
ten to twelve hours at room temperature, small, round
yellowish colonies with thick centers and irregular
edges develop, from which brush-like offshoots are
thrown out. Other colonies are surrounded by a
zone of threads which, partly in circular, partly in
irregular twisted figures, surround the central opaque
mass. Straight and twisted offshoots, which fre-
quently become detached from the parent colony,
grow into the surrounding medium and continue
moving about in the liquefied gelatin, sometimes
called "swarming islands." When the consistency
of the medium is more solid, as in ten-per-cent.
gelatin, the liquefaction and migration of these sur-
face colonies are more or less, retarded. In gelatin
stab cultures the growth is less characteristic — lique-
faction takes place rapidly along the line of puncture,
and soon the entire medium is liquefied. Upon
nutrient agar a rapidly spreading, thin, moist, grayish-
white coating appears, and migration of the colonies
also occurs. Milk is coagulated with the production
of acid. On potato a dirty grayish coating develops.
Bouillon is uniformly clouded.
Culture media containing albumin or gelatin are
decomposed by the proteus vulgaris with the pro-
duction of a disagreeable putrefactive odor and
alkaline reaction. It produces gas and acid from
carbohydrates, thus giving off no odor. It also-
produces indol and H,S. Urea is decomposed into
carbonate of ammonium. It forms toxins, which may
be obtained by filtration of the cultures through
porcelain. The proteus vulgaris possesses consider-
able resistance toward chemical and thermic influ-
ences, but is killed at 60° C. in half a minute.
Pathogenesis. — This bacillus is pathogenic for
rabbits and guinea-pigs when injected intravenously,
intraperitoneally, or subcutaneously in large quan-
tities, death of the animal being produced with symp-
toms of intoxication. The effects are much more
readily produced when other organisms, as the strep-
tococcus, are introduced simultaneously into the body.
Less virulent species of pathogenic bacteria (staphy-
lococcus, streptococcus) also gain in virulence when
they are injected along with living or dead proteus
cultures.
The proteus vulgaris is found very commonly out-
side the body in putrid meat and other decaying
substances, such as foul water, etc. It is found also in
the digestive tract of healthy persons. In disease, it
is the organism chiefly concerned in the production
of cystitis with ammoniacal urine, either alone or in
conjunction with the Bacillus coli communis, and is
so an etiological factor in many other genito-urinary
affections. The Urobacillus liauefaciens septicus of
some authors is probably identical with the proteus
vulgaris. Although this bacillus, however, occurs
quite frequently, along with other bacteria in various
diseases, it has seldom been positively shown to be
the specific cause of infection. Booker, who has
made extended investigations into the etiology of
cholera infantum, concludes that the proteus vulgaris
plays an important part in the production of this
affection. He found the bacillus present in eighteen
cases of cholera infantum examined by him, but not
in the feces of healthy infants. Levy believes that
in so-called "meat or sausage poisoning" bacteria
of this group are chiefly concerned, and that the
pathogenic effects are due to toxic products evolved
during their development; though others attribute
this affection to an anaerobic organism, the Bacillus
botulinus of Van Ermengen, the symptoms being
see,
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Ba< i' i i.i
escribed as botulism. According lo .Jiigcr, certain
irms of icterus accompanied with fever, pain in the
mscles, and enlarged liver and spleen, known as
Weil's disease," are produced by the proteus.
hus il would seem that, though ordinarily a harm-
'SS parasite, the proteus vulgaris may at times
.nine pathogenic to man. Considering the very
ide distribution of t li i-s organism in nature, the
onder is that with its poisonous properties so few
iseases apparently are produced by it.
The Bacillus op Malignant Edema (Bacillus
dematis maligni). — This bacillus is widely dis-
puted, being found in the superficial layers of the
oil especially in garden earth, manure, filth of all
inds, and house drains; also in the blood and intes-
uies of animals, it was discovered by Pasteur
1877), and later carefully studied by Liborius and
v.n-h.
Microscopical Appearances. — Rather large rods,
imilar morphologically to tetanus and symptomatic
nthrax bacilli, but showing a greater tendency to
out into long filaments; in size from 0.8 to 1 ft
iroad and 2 to 10 ft long.
Motility. — Motile, but not very actively so except
he short forms, having three to twelve flagella
1 1 ached to the ends and sides of the rods.
Spore Formation. — Forms spores generally in the
niddle of the rods and oval in shape.
Staining Reactions. — Stains readily with the ordin-
iry aniline dyes, especially when obtained from the
iniinal body; decolorized by Gram's method.
Biological Characters. — Strictly anaerobic, growing
n all the usual culture media in the absence of oxygen.
Development takes place at room temperature, but
nore rapidly and abundantly at 37° C.
This bacillus grows on nutrient gelatin, but more
ibundantly on glucose gelatin containing one to two
>er cent, of glucose. Gas is formed and the gelatin
s liquefied.
On agar plates the colonies appear as dull, whitish
mints, irregular in outline, and when examined under
i low power they are seen to be composed of a thick
network of threads radiating irregularly _ from the
enter to the periphery. Blood serum is rapidly-
liquefied, with the production of gas. Bouillon is
louded from the formation of gas. Milk is not
coagulated. Cultures of the bacillus of malignant
edema give off a peculiar odor.
Pathogenesis. — Especially pathogenic for mice,
guinea-pigs, and rabbits, although horses, cats, dogs,
goats, sheep, calves, pigs, chickens, and pigeons are
also susceptible, and occasionally man. Cattle are
immune. A small quantity of a pure culture sub-
cutaneously injected into a susceptible animal gives
rise to general hemorrhagic edema which extends
over the entire surface of the abdomen and thorax
and results in the death of the animal. There is no
odor developed, and little, if any, gas. In infection
with garden earth, owing to the presence of associated
bacteria, gas is produced having a putrefactive odor.
Malignant edema is chiefly confined to the domestic
animals, but cases have also been reported in man.
Infection takes place most readily when, as in the
natural disease, other bacteria are simultaneously'
introduced, such as B. proteus and B. prodigiosus.
Animals which recover from malignant edema are
subsequently immune. Artificial immunity may be
induced in guinea-pigs by the injection of filtered
bouillon cultures which have been previously ster-
ilized.
Bacillus Aerogenes Capsulatus. — Found by
Welch in the blood-vessels of a patient suffering
from aortic aneurysm; on autopsy made in cool
weather eight hours after death, the vessels were
observed to be full of gas. Since then it has been
found in a number of other cases. These cases, as a
rule, showed marked symptoms of delirium, rapid
pulse, high temperature, and the develop m of
emphysema and discoloration of the di eased area,
or of abdominal distention when the peritoneal
cavity was involved.
Microscopical Appearand Straight or slightly
curved rods, with rounded or somel quare-cut
ends, somewhat thicker than the anthrax bacilli and
varying in length, occasionally growing out into long
threads. In the animal body, ami sometimes in
cult ores, the bacilli are i in lo ed in a tin
capsule.
Motility. — Non-1 not ili'.
,Sjiori Formation. — Absent.
Staining Reactions.- Stains with the ordinary
aniline dyes and by < barn's method.
Biological Characters. — Anaerobic, growing at room
temperature, but more rapidly at '.'•' ('. in the usual
culture media in the absence of oxygen, with
production. Gelatin is not liquefied, but is gradually
peptonized. On agar grayish-white colonies are
developed in the form ol llattened spheres, oval or
irregular masses, beset with hair-like projections.
Bouillon is diffusely clouded, and a white sediment is
formed. .I////,- is rapidly coagulated.
Pathogenesis. — Usually non-pathogenic in healthy
animals, although Dunham found that the bacillus
taken freshly from human infection i- sometimes
very virulent. When quantities up to 2.5 c.c. of
fresh bouillon cultures are injected into the circula-
tion of rabbits and the animals killed shortly after-
ward, the bacilli develop rapidly with abundant
formation of gas in the blood-vessels and organs,
especially the liver. Welch suggests that in some
cases in which death has been attributed to the
entrance of air into the veins the gas found at autopsy
may have been produced by this or some similar
microorganism entering the circulation and develop-
ing shortly before or after death. The bacillus had
been found in the dust of hospital wards.
The Anthrax Bacillus (Bacillus anthracis). —
This organism is always present in the blood of ani-
mals affected with anthrax or splenic fever, an acute
disease very prevalent, in certain parts of Europe and
Asia, among sheep and cattle. In this country it is
comparatively rare. The disease also occurs in man
as the result of infection, either through the skin,
the intestines, or, in rare instances, through the
lungs, in the form of external anthrax or malignant
pustule, and internal anthrax or wool-sorter's disease.
Those persons are most subject to infection who
come in contact with animals, hides, wool, etc.
Owing to the fact that anthrax was the first infec-
tious disease which was shown to be caused by a
specific microorganism, the study of this bacillus
has probably contributed more to our general knowl-
edge of bacteria than any other living organism.
It was first observed by Pollender in 1S49 in the
blood of animals affected with anthrax. In 1S63
Davaine showed by inoculation experiments that it
was capable of producing the disease. Then finally
in 1879, Pasteur, Koch, and others demonstrated
that the bacillus could be isolated in pure cultures
on artificial media, and that when susceptible animals
were inoculated with portions of these cultures con-
ditions similar to those found in the animal from
which the original cultures were obtained were
produced.
Microscopical Appearances. — In the blood of ani-
mals it occurs as large rods of variable size, from 1 to
1.2.5 ft broad and 3 to 10 ft or more long, often arranged
in flexible filaments twisted and plaited together.
In unstained specimens examined in the hanging
drop the ends of the rods appear to be slightly rounded,
while in stained preparations they seem to be square
cut. Under a high magnification, especially in
867
Bacteria
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
cultures, the ends are seen to be a trifle thicker than
the body of the cell, and occasionally somewhat
indented and concave, giving to the rods the appear-
ance of joints of bamboo cane. At one time much
stress was laid upon these morphological peculiar-
ities as distinguishing marks of the anthrax bacillus;
but it has been found that they are the effects of
artificial cultivation, staining, etc., and not neces-
sarily characteristic of the organism under all con-
ditions. The bacilli, when obtained from the blood
of affected animals and certain culture media (liquid
blood serum), are enclosed in a capsule, which in
stained preparations may be distinguished by its
taking on a lighter stain than the rods themselves
which it surrounds. (See Plate X., Fig. 1.)
Motility. — Non-motile.
Spore Formation. — Forms spores under aerobic
conditions at temperatures from 12° C. up to 37° C.
The spores are elliptical in shape and once or twice as
long as broad; they first appear as small refractile
granules distributed at regular intervals, one in each
rod, and as the spores develop the mother cells
become less and less distinct until they finally dis-
appear altogether, the complete oval spore being
set free by its dissolution. Spores are never formed
in the living animal or in unopened carcasses, owing
to lack of oxygen, but in slaughtered animals, bloody
dung, etc., where the conditions necessary for their
production exist. This fact is practically important
with regard to the disposal of the carcasses of animals
dead of anthrax. In fresh culture media the germina-
tion of spores takes place in a few hours. In old
cultures which have been repeatedly transplanted the
power of spore formation is often spontaneously lost.
Certain varieties of anthrax bacilli soon become
asporogenous. All agencies which decrease the
virulence of the bacilli (as, for instance, cultivation
at 42° C.) act unfavorably upon the function of spore
formation. (See Plate X., Fig. 2.)
Staining Reactions. — Stains easily with the ordinary
aniline colors, also by Gram's method.
Vitality. — Anthrax bacilli free from spores retain
their vitality in cultures for months, probably by
spore production; in water they soon die; in the soil
fresh anthrax blood is rendered germ free by exposure
to sunlight in twelve to twenty-four hours. Accord-
ing to Koch, when exposed to desiccation, anthrax
bacilli retain their vitality only for five weeks; in
dried blood they withstand a temperature of 92° C.
for one and one-half hours, but in the presence of
oxygen they are killed by exposure to light in nine
hours and in a vacuum in eleven hours. Pickling
fails to destroy anthrax bacilli in meat in fourteen
days, but kills them after six weeks. They are
rapidly destroyed by moist heat at 60° C. Exposed
to cold from 1° to 24° C. the bacilli in agar cultures
were destroyed for the most part in twelve days, and
the few surviving organisms yielded colonies of dim-
inished pathogenic action and power of liquefying
gelatin.
Dried anthrax spores retain their vitality inde-
finitely; in a moist condition in water, earth, putrid
spleen, etc., the spores have lived for one and one-half
to two and one-half years. They also resist a com-
paratively high temperature. Exposed to dry heat
they require a temperature of 140° C. maintained
for three hours to kill them, but in moist heat they
are destroyed by a temperature of 100° C. in four
minutes. Anthrax spores in a desiccated condition
are killed by the action of direct sunlight in four
hours, by diffuse daylight in several weeks.
Biological Characters. — Aerobic and facultative
anaerobic, growing best in the presence of oxygen
but also in its absence. Under the latter condition,
however, this bacillus no longer liquefies gelatin, and
the presence of oxygen is absolutely necessary for the
formation of spores. The anthrax bacillus grows
rapidly on a variety of nutrient media at a temper
ature from 14° to 43° C, but best at 37° C.
Growth on Gelatin. — On gelatin plates small, white
opaque colonies are developed on the surface at the
end of. twenty-four to thirty-six hours at 24° C.
while the deeper colonies are of a greenish color!
Under a low power the colonies exhibit a charac-
teristic appearance, consisting of a light-gray tangled
mass of threads projecting beyond the edges in
curly hair-like tufts, which have been likened to a
Medusa's head. Liquefaction of the gelatin takes
place in three or four da3's, a white pellicle floating
on the surface. In gelatin stab cultures at the end of
twelve to twenty-four hours a thick, white central
thread appears along the line of puncture, from which
other white threads and irregular projections radiate
Eerpendicularly into the medium. After two days
quefaction commences on the surface and gradually
extends downward.
On agar plates the growth is similar to that on
gelatin and is equally characteristic, but the colonics
are not so compact. At the end of twenty-four hours
in the incubator a grayish-white coating is formed
on the surface, which spreads rapidly and consists of
masses of long threads matted together.
In bouillon the growth is characterized by the
formation of flucculent masses which sink as a seoi-
nient to the bottom of the tube, leaving the liquid clear.
Pathogenesis. — Especially pathogenic for mice,
guinea-pigs, and rabbits, somewhat less for cattle and
sheep (except the Algerian sheep, which are immune:,
and considerably less for horses; rats, cats, dogs,
chickens, pigeons, and frogs are but little susceptible.
Man, though subject to local infection (malignant
pustule) from accidental inoculation of wounds,
and occasionally to intestinal or pulmonary infection
(wool-sorter's disease) as the result of inoculation
through dust charged with anthrax spores and the con-
sumption of meat from anthrax animals, is not as
susceptible to this disease as the lower animals.
Subcutaneous injections in susceptible animals result
in death in from one to three days. Little or no
change can be observed at the point of inoculation,
but the subcutaneous tissue for some distance over
the abdomen and thorax is found to be edematous,
with small ecchymoses scattered throughout theeldem-
atous portion; the underlying muscles are pale in
color. The intestinal viscera show no marked micro-
scopical lesions, except the spleen, which is enlarged,
soft, and dark colored. The liver may present the
appearance of cloudy swelling. The lungs are red or
pale red in color, while the heart is usually filled with
blood. The anthrax bacillus produces in susceptible
animals a true septicemia, and after death the capil-
laries throughout the body always contain the bacilli
in larger or smaller number. It is difficult to produce
infection by the ingestion even of spores, but by
inhalation it may be readily caused in animals. Infec-
tion is most promptly brought about by introduction
of the bacilli directly into the circulation, but inocula-
tion by contact with the abraded skin may also pro-
duce infection.
Many theories have been advanced to account for
the occurrence of intestinal anthrax in cattle and
sheep, the form of the disease which is most common in
these animals. It has been thought that infection
was produced mainly by the eating of food contami-
nated by anthrax spores derived originally from the
bodies of affected animals; but, as we have seen, it is
extremely difficult to cause infection in this way.
By some authors it has been supposed to be a mias-
matic infection and likened to malaria; and occur-
ring as it does in the summer months and in low
swampy places, there would seem to be a possible
analogy in this respect between the two infections.
But anthrax occurs in epidemics, being present at one
time in a certain place and absent in another. Pas-
868
REFERENCE HANDBOOK OF THE MEDK \l. SI II W I -
li. M terla
■ ur is of the opinion that the earth-worms play an
uportant part in conveying the spines from one
icality i" anotlier from the buried carcasses of af-
:cted animals; but Koch has shown this hypothesis
) be untenable, as the bodies of earth-worms offer
n unsuitable medium for the growth of spores, even
' they arc taken up and carried in this way. The
lost plausible explanation so far suggested for the
ilution of the problem is the supposition that under
atural conditions unfavorable to the development
f the bacilli an attenuation of their virulence takes
ilace, and then again as the conditions become
e favorable the virulence is restored — a result
hich ran be artificially produced in cultures by
bemieal agents, heat, etc. Nuttall has recently
st d that perhaps the disease may be conveyed
a the bodies of insects, under certain conditions, as
it li malarial infection; but here, too, the bacilli
indergo attenuation, according to the same author.
nation of Virulence and Immunity. — The
,-irulence of anthrax cultures may be artificially
tttenuated by the action of chemical agents and
icat. Pasteur has succeeded in effecting considerable
mmunity against anthrax in regions where this
lisease is prevalent, by the inoculation of cattle and
-heep with cultures attenuated by heat. Two vac-
lines are employed of different degrees of strength,
irepared from virulent cultures reduced in virulence
by cultivation at temperatures between 42° and 43°
According to statistics collected by Chamber-
land from the results of twelve years' experience with
this method of protective inoculation in France, out of
three million sheep thus treated only one per cent.
have died of anthrax since its introduction, whereas
the mortality previously was over ten per cent. In
cattle the mortality percentage has been reduced
from five per cent, to 0.3 per cent. The method,
however, is not unattended with danger, and some-
times the animals succumb to the effects of the
inoculation.
The Bacillus of Symptomatic Anthrax. — Like
the bacilli of anthrax, of malignant edema, and teta-
nus, to all of which it bears a certain resemblance,
the bacillus of symptomatic anthrax is an inhabitant
of the soil. It is the specific cause of the disease in
animals, principally cattle and sheep, known as
"black-leg." "quarter-evil," or symptomatic anthrax,
which prevails in certain localities, and is character-
ized by a peculiar emphysematous swelling of the
tissues of the leg and quarters, accompanied with
the formation of gas. On section of the affected
parts the muscles and cellular tissues are found
saturated with bloody serum, while the tissues them-
selves are dark, almost black in color. The bacillus
can always be found in the affected parts, in the bile,
and after death in the internal organs.
Microscopical Appearances. — Long rods, with
rounded ends, from 0.5 to 0.6 ,u broad and 3 to 5 n
long; mostly isolated, also occurring in pairs, joined
end to end, but never growing out into long filaments.
as the anthrax bacillus does in culture media and the
bacillus of malignant edema in the animal body.
Motility. — Actively motile, flagella being attached to
the bodies of the cells.
Spore Formation. — Forms spores elliptical in shape,
usually thicker than the bacilli, lying near the mid-
dle of the rods, but rather toward one end, giving
them a spindle shape.
fining Reactions. — Stains with the ordinary
aniline dyes, but not with Grain's method or only
when the staining is much prolonged.
Biological Characters. — Strictly anaerobic, growing
only in the absence of oxygen, best in an atmosphere
of hydrogen but not in CO,. Develops at room tem-
perature in the usual culture media, but best in
media containing 1.5 to 2 per cent, glucose or 5 per
cent, glycerin and at 37° C.
On gelatin, irregular, slightly tabulated colonies
develop and the gelatin is -oon Liquefied. On ";/'""
the colonies are similar to those of malignant edema
but somewhat more compact, after twenty-four to
forty-eight hours in the incubator. In agar -tali
ires growth occur- i ielow the sur-
face, and is accompanied by the production of gas
having a peculiar, disagreeable, rancid odor.
Patho .—Pathogenic for cattle (which are im-
against malignant edema), sheep, go
guinea-pig-, and mice; less so for horse: and i
i . pigs, cats, dogs, chickens, and pigeons arc,
as a rule, immune. Infection lias never been pro-
duced in man.
When susceptible animals are inoculated Bubcu-
taneously with pure cultures of this organism, with
- or with bits of diseased tissue, death occurs
in from twenty-four to thirty-six hours. At
autopsy a bloody serum is found iii the subcutaneous
tissues extending over the entire surface of the abdo-
men, and the muscles present a dark red or black ap-
pearance, even more intense in color than in malignant
edema, and there is considerable development of gas.
The ordinary manner of natural infection in cattle
is by wounds which not only tear the skin, but pene-
trate the subcutaneous tissues. The disease is also
produced by the ingestion of forage contaminated
by the bacilli or their spores, and by the inhalation of
dust containing the organisms.
Immunity. — It is well known to veterinarians that
natural recovery from one attack of symptomatic
anthrax protects an animal from a second attack.
Artificial immunity can also be produced in various
ways: by intravenous inoculation; or in guinea-pigs,
by inoculations with bouillon cultures which have
been kept for a few days and have lost some of their
virulence, or with cultures kept in the incubator at
42° to 43° C; or by inoculations made into the end
of the tail; or by injection of filtered cultures sterilized
by heat. Arloing, Cornevin, and Thomas recom-
mend for the production of immunity in cattle the
use of a dried powder of the muscles of animals dead
of the disease, which has been subjected to a tem-
perature sufficient to attenuate its virulence. Two
vaccines are prepared, as in anthrax one by exposure of
the powder to 85°-90° C. (the stronger vaccine 1 , and
the other to a temperature of 100°-104° C; the weaker
vaccine is first used, and then the stronger. The
inoculation is made into the cellular tissue of the ear
or on the end of the tail; fourteen days are allowed to
elapse between the two inoculations. Kitt recom-
mends a single vaccine from infected flesh heated for
six hours at 100° C. and given in decigram doses.
The results obtained from these methods of prevent-
ive inoculation against symtomatic anthrax would
seem to have been fairly satisfactory.
The Spirillum of Asiatic Cholera (Koch's
comma bacillus). — In 1SS3 Koch isolated from the
dejecta and intestines of patients suffering from
Asiatic cholera a characteristically curved organism
— the so-called "comma bacillus" — and showed that
these bacteria were exclusively found in cases of the
genuine disease. Other observers have since de-
scribed morphologically similar organisms of non-
choleraic origin. Finkler and Prior, for instance,
observed such organisms in the diarrheal stools of
patients with cholera nostras; Deneke found others
in old cheese. .Miller met with others again in cari-
ous teeth, and Metehnikoff observed others in fowls.
But all of these organisms differ in many respects
from Koch's comma bacillus, and none of them is
affected by the specific serum of animals immunized
to Asiatic cholera. Though varying somewhat in
different epidemics, this spirillum is now generally
recognized by bacteriologists to be the chief etio-
logical factor in the production of true Asiatic
cholera.
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Bacteria
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Microscopical Appearances. — Curved rods, with
rounded ends which do not lie in the same plane,
from O.S to 2 /i in length and about 0.4 u in breadth.
The curvature of the rod may be very slight, like
a comma, but sometimes it forms a half-circle, or
two contact rods curved in opposite directions may
form an S-shaped figure, and under unfavorable con-
ditions of growth, as in old cultures and on the addi-
tion of chemical antiseptics, etc., they may develop
into long spiral filaments consisting of numerous
turns of a spiral in which it is impossible to recognize
any connection between the individual elements of
which they are composed. These latter, the true
spirilla, are considered to be involution forms. Under
favorable conditions of growth and in fresh cultures,
the slightly curved or almost straight forms are com-
monly observed. (See Plate X., Fig. 5.)
Motility. — Actively motile, the movements being
undulatory and due to one or two flagella attached
to the ends of the rods.
Spore Formation. — Absent; the arthrospores de-
scribed by Hueppe have not been confirmed by other
observers.
Staining Reactions. — Stains with the ordinary anil-
ine colors, but not as readily as many other bacteria;
an aqueous solution of carbol fuchsin gives the best
results with the application of heat. It is decolor-
ized by Gram's method.
Biological Characters. — Aerobic and facultative ana-
erobic, growing on all the usual culture media at
room temperature, but best in the presence of oxygen
at 37° C. There is no development below 8° C. or
above 42° C. The culture media must be distinctly
alkaline, as the spirillum is very sensitive to acid.
On gelatin plate cultures at 22° O, at the end of
twenty-four hours, small, round, yellowish-white to
yellow colonies may be seen in the depths of the me-
dium, which later grow toward the surface and cause
liquefaction of the gelatin, the colonies sinking to
the bottom of the pockets thus formed. Examined
under a low power they appear granular in structure
with more or less irregular outlines, the surface
looking as if covered with little fragments of glass.
An ill-defined halo is first seen to surround the colo-
nies, which has a peculiar reddish tint by transmitted
light. In gelatin stab cultures at the end of twenty-
four to thirty-six hours a small funnel-shaped depres-
sion appears on the surface of the medium, which
soon spreads out in the form of an air bubble above,
while below this a whitish, viscid mass is seen. The
funnel .now increases in depth and diameter, and in
from four to six days may reach the edge of the tube;
in from eight to fourteen days the upper two-thirds
of the gelatin is liquefied; and in a few weeks com-
plete liquefaction takes place.
Upon agar plates the growth is not so character-
istic, a moist, shining, grayish-yellow coating develop-
ing on the surface in the incubator.
Blood serum is rapidly liquefied at brood tempera-
ture.
In bouillon the growth is rapid and abundant, the
liquid being diffusely clouded, and on the surface a
wrinkled membranous film is often formed.
On potato having an acid reaction no growth, as a
rule, takes place; but if the potato be rendered alka-
line with a solution of soda or cooked in a three-per-
cent, solution of common salt, development takes
place in the incubator as a thin, semi-transparent
brown or grayish-brown layer.
Milk is a favorable culture medium, but is not
changed, as a rule, though it is coagulated by some
varieties of cholera spirilla.
Vitality. — The comma bacillus does not usually ex-
hibit much resistance to outside influences. In pa-
tients suffering from the disease the organisms have,
as a rule, disappeared from the contents of the intes-
tines in from four to eight, or more rarely in from ten to
870
fifteen days; though in a few cases living spirilla have
been found after forty-seven days. They have been
observed in cholera dejections for from one to three
and occasionally from twenty to thirty days; in one
recorded case after one hundred and twenty days.
Even in cultures the spirilla of Asiatic cholera are
rather short-lived. They have been found, however,
to retain their vitality in pure bouillon cultures for
three or four months and in agar cultures for six
months or more, when protected from drying. I Q
unsterilized water they may live for a considerable
time apparently, though the observations on this
vary from one day to one year. In sterile water
they develop to some extent and retain their vitality
for several weeks. Low temperatures, absence of
light, and presence of salt in the medium would
seem to favor their preservation. In well or river
water they usually die in from three to eight day-.
In food they retain their virulence for a period
varying from a few hours to a few days.
The comma bacilli are rapidly destroyed by
desiccation. Exposed in cultures on a cover glass to
the action of the air at room temperature they are
killed in two or three hours unless spread in a very
thick layer. This fact indicates that infection is
probably not usually produced through dust or other
dried objects contaminated with cholera bacilli.
They are destroyed by moist heat at 60° C. in ten
minutes. They resist cold fairly well, withstanding
repeated freezing without being killed, though their
growth is inhibited. They have but little resistance
to the action of chemicals, especially mineral acids,
which have thus been employed for the disinfection
of waterworks to which these germs have gained
access. For disinfection on a small scale 0.1 per cent,
solution of bichloride of mercury or two to three per
cent, solution of carbolic acid may be used. Milk of
lime is a good general disinfectant on a large scale.
The wash and linen of cholera patients, floors of
dwellings, etc., may be disinfected by a five per cent,
solution of carbolic acid and soap water.
Chemical Effects. — The spirilla of cholera produce
pigment in small amount only on potato. The
peculiar disagreeable odor given off from cholera
cultures in bouillon has been thought by some to be
of diagnostic value, but it is not specific. Milk
sugar is decomposed with the production of lactic
acid without gas. In lactose-litmus agar the cholera
spirillum forms on the surface of the medium a blue
film, below this a red coloration, while lower down the
medium is decolorized.
When a small quantity of chemically pure sulphuric
acid is added to a twenty-four-hour-old bouillon cul-
ture of the cholera spirillum containing peptone, a red-
dish-violet color is produced — known as the " nitroso-
indol reaction" — which is due to the production of
indol and the reduction of nitrates in the culture to
nitrites. Brieger separated the pigment thus formed,
called " cholera red." For a long time it was believed
that the nitroso-indol reaction was peculiar to the
cholera spirillum, and great weight was placed upon
its production as a diagnostic test. But it has been
shown that it is by no means specific, many
other bacterial species giving the same reaction
under similar conditions. The reaction, never-
theless, is a constant and characteristic property of
this bacillus, and is of undoubted value in differen-
tiating this from other similar organisms which do
not give the reaction. For the test it is best to
employ a culture not of bouillon, but a distinctly
alkaline solution of peptone (1 per cent, peptone +
0.5 per cent, sodium chloride — Dunham's solution),
from which more constant results are obtained.
Several toxins have been obtained from cholera
cultures, but all of them much less poisonous than
the original cultures. According to Pfeiffer these
toxins are to be considered as secondary products
i;i I i;i:i:\i i: nwiHionK <>r Tin: MKDIC'AL SCIENCES
Bacteria
modified by the action of the chemical reagents em-
ployed in separating them. Very much more power-
ful toxic products have ln.ii obtained from tin- bodies
of the bacilli cultivated on agar and carefully killt d
by chloroform or heat. Three times the minimal
fatal dose thus obtained from an agar culture (about
0.5 ingiii.) kills a guinea-pig in from sixteen to eight-
een hours, when injected into the peritoneal cavity.
tin- effect being exactly t lie same as that produced
by the living organisms, viz., rapidly beginning
symptoms of the algid stage, muscular weakness,
collapse, and death.
Pathogt in six. — None of the lower animals being
naturally subject to Asiatic cholera, there is little
reason to expect that inoculations of pure cultures of
the spirillum should give rise to typical cholera
infection. It has been shown, moreover, that the
comma bacillus is extremely sensitive to the action
of acids, being quickly destroyed in the stomach by
the acids of the gastric juice. Nevertheless, numer-
ous attempts have been made to produce cholera
in test animals by inoculation of pure cultures of
the organism, usually with negative or unsatisfac-
tory results. Koch, however, succeeded in producing
an approximation, at least, to the symptoms of
cholera in man by the infection of guinea-pigs by the
following method: First, o c.c. of a five per cent.
solution of sodium carbonate is injected into the
stomach by means of a pharyngeal catheter, in order
to neutralize the gastric contents; and then, after a
while, 10 c.c. of a liquid containing one or two drops
of a bouillon culture of the bacillus is administered
in a similar manner, and at the same time the animal
receives int raperitoneally 1 c.c. of laudanum per
200 gm. weight, to control the peristaltic movements.
As the result of this treatment the animals are nar-
cotized for about half an hour, but recover without
showing any ill effects from the opium. _ In about
twenty-four hours the temperature begins to fall,
weakness and paralysis set in, and, as a rule, death
occurs within forty-eight hours. On autopsy the
intestines are found to be congested and filled with
watery fluid containing large numbers of spirilla.
Unfortunately, however, other morphologically simi-
lar spirilla (the spirilla of Finkler-Prior, Deneke, and
Miller) act very much in the same way, though
somewhat less powerfully. Intraperitoneal injec-
tions of large quantities of cholera cultures also often
produce death in rabbits and mice with similar
symptoms.
With regard to the pathogenic properties of the
cholera spirillum for man, there are quite a number
of cases on record of accidental infection by pure
cultures, which furnish the most satisfactory evidence
of its being capable of producing the disease. In 1884
a student in Koch's laboratory in Berlin became ill
with a severe attack of true Asiatic cholera while
working with cholera cultures at a time when there
was no cholera in Germany. In 1S92 Pettenkofer
and Emmerich experimented on themselves by
swallowing small quantities of fresh cholera cultures,
with the result that both of them were taken, sick
with typical cholera, one with mild and the other
with severe symptoms. Since then other similar
experiments have been reported, most of the persons
taking the cultures having neutralized the acidity
of the stomach previously by means of soda solution;
and several fatal cases have occurred from accidental
infection. At the same time, however, some negative
results from experiments on the human subject have
also been recorded — which only goes to show that in
cholera, like other infectious diseases, an individual
susceptibility is required, in addition to the presence
of the germs, to produce infection.
According to Pfeiffer, cholera in man is an infective
process due to the destruction of the epithelial layers
of the intestines by the spirilla and the products of
their growth, whereby intoxication results from
absorption of the poisonous i ' ' . The larger
the surface of the mucous membrane affected, tie-
more abundant will be the development of bacilli
and the production Of toxins, and the more pro-
ed, iu consequence, will be the intoxication.
The cholera spirilla have been frequently found in
water (wells, water pipes, rivers, harbors, etc.) which
has become contaminated with the evacuations of
cholera patients. Hut to prove their presence beyond
question in water is by do means easy, as there are o
many other water bacti ria imulating cholera bacilli
from which they mii-i be differentiated; hence - e of
the reported findings may not have been genuine
cholera spirilla. The comma bacillus has been quite
often observed in the feces of healthy per-.. us without
producing, apparently, any pathogenic symptoms
whatever. Abel and Claussen thus found cholera
spirilla present in the stools, for days at a time, of
fourteen out of seventeen healthy persons in the
families of seven cholera patients. Jn Hamburg,
during the last epidemic of cholera in Germany,
twenty-eight such cases were observed in which the
stools were absolutely normal.
The cholera spirillum, however, has been found in
no other disease than true Asiatic cholera, occurring
in this affection chiefly in the contents of the intestinal
canal and especially in the mucous flakes of so-called
" nee-water" stools, existing in pure culture fre-
quently, and usually present in greatest, numbers at the
height of the attack. The spirilla are not, as a rule,
found in the interior organs in recent cholera ca
except perhaps occasionally in the intestinal glands.
In rare instances, nevertheless, both in cholera
patients and in inoculated animals, they have been
met with in the organs — lungs, liver, kidneys, spleen
and occasionally the heart's blood. The more
virulent the organism is, the more apt, apparently,
is it to gain access to the interior organs.
Immunity. — Recovery from an attack of cholera
produces a certain degree of immunity to the disease.
Lazarus in 1S92 observed that the blood serum of
persons who had recently had cholera possessed the
power of protecting guinea-pigs from infection by the
cholera spirillum; while the serum of healthy persons
or those affected with other diseases had no such
effect. He attributed this to the presence, in the
serum of convalescents from cholera, of antitoxic
substances which neutralized the action of the toxins
produced by the growth of the spirilla, in the same
manner as the antitoxins of diphtheria and tetanus
neutralize their respective toxins. Pfeiffer, on the
other hand, maintained that this serum contained
bactericidal substances which killed the spirilla so
rapidly when injected into the animal that they were
not able to produce their specific poisons, and that
thus the animal was protected. It is now generally
admitted that the serum is strongly bactericidal and
feebly antitoxic.
These specific substances present in the blood of
cholera-immune men and animals act only upon
organisms similar to those with which they were
originally infected — producing immobilization and
agglutination of the bacilli. Pfeiffer, who first
observed this peculiar reaction in cholera serum, has
shown, however, that the specific relation existing
between the antibacterial and protective substances
produced during immunization and the bacteria
employed to immunize the animals is not confined
alone to cholera. This discovery has given us an
apparently reliable means of distinguishing the
cholera and typhoid bacilli especially from all other
similar organisms, and the diseases which they
produce from other infections which may be mistaken
for them, which has proved to be of great practical
value as an aid to clinical diagnosis.
There are two methods, known as Pfeiffer 's and
Bacteria
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Gruber's reactions, whereby genuine cholera spirilla
may be differentiated from other similar vibrios:
1. Pfeiffer's reaction is produced as follows: The
blood serum of an animal rendered immune to cholera,
by inoculation of attenuated or dead cholera cultures,
is mixed with ordinary bouillon in the proportion of
1 to 100, and in 1 c.c. of this mixture a platinum
loopful (about 2 mgm.) of the species under investiga-
tion is added, and this then injected into the periton-
eal cavity of a guinea-pig weighing about 200 gin.
Every five minutes some of the peritoneal effusion is
removed by means of a capillary pipette and examined
microscopically both stained and unstained. If it is
the true comma bacillus, the bacilli will be observed
to become at first non-motile, then agglutinated into
clumps, and finally (in about twenty minutes) to
become disintegrated and loosened. When the above
phenomena are absent, the organism belongs to
another species. A control experiment should be
made with a known cholera culture to avoid possible
error.
2. Gruber's reaction is founded upon this, but he
deserves the credit of having determined the amount
of dilution required to agglutinate and immobilize the
cholera spirilla when mixed with cholera-immune
serum for microscopical examination in the hanging
drop, without injection into guinea-pigs, thus simpli-
fying the method for practical use. For this purpose
the blood serum of a person suffering from a case of
suspected cholera, or of an animal immunized against
the species to be investigated, is mixed with a pure
cholera culture in the proportion of 1 to 50 and
upward, and the mixture at once examined in the
hanging drop. If the spirilla become immobilized
and agglutinated into clumps within twenty or
thirty minutes, then they are genuine cholera spirilla;
if not, the result is negative.
Immunity. — Within the last few years Haffkine in
India has succeeded in producing an artificial im-
munity against cholera infection in man by means of
subcutaneous injections of dead cultures of the cholera
spirillum; and Nolle has found that the blood serum of
persons thus inoculated gave a reaction similar to that
of persons who had recovered from cholera, showing
bactericidal and agglutinative substances from the
fifth day, but most distinctly on the twentieth day
and for months after the protective inoculation.
In over 200,000 persons inoculated with Haffkines' vac-
cine the results obtained would seem to show a distinct
protective influence in the preventive inoculations.
Spirilla Resembling the Spirillum Cholera
Asiatic.e. — When Koch's comma bacillus was first
discovered its properties seemed so characteristic
that it was considered an easy matter to distinguish
it from all other bacteria. Since then, however,
more and more similar organisms have been met with
by various investigators, until now they have ceased
to be designated even by special names. The
following are among the best-known species:
1. Spirillum or Finkler and Prior (Vibrio pro-
teus). — This organism was obtained by Finkler and
Prior from the dejections of patients with cholera
nostras which had been allowed to stand for some
days. It has since been found to bear no etiological
relation to the disease, and is of interest only on
account of its resemblance in some respects to the
cholera spirillum.
It occurs as more or less curved rods, usually some-
what longer and thicker than the cholera spirilla and
not so uniform in diameter. Involution forms are
common in unfavorable culture media. It is actively
motile, a single flagellum being attached to one cud
of the rods. It does not form spores. (See Plate N.,
Fig. 6.)
It grows equally well, in the presence and absence
of oxygen, on the usual culture media at room
temperature. On gelatin plates small, white, punc-
tiform colonies are developed at the end of twenty-
four hours, which under a low power are seen to be
finely granular and yellowish in color; liquefaction
of the gelatin around the colonies progresses rapidly
and is usually complete in forty-eight hours. Isolated
colonies on the second day form cup-shaped depres-
sions. In stab cultures on gelatin liquefaction proceeds
much more rapidly than with the cholera spirillum,
a stocking-shaped pouch appearing in two days,
while the entire gelatin is liquefied in about a week;
a whitish film forms on the surface. Upon agar a
moist, shining layer covering the entire surface is
quickly developed. Blood serum is rapidly liquefied.
On potato at room temperature a shining, grayish-
yellow layer is formed, soon spreading over the
surface. The cholera spirillum, on the other hand,
produces no growth on potato at room temperature.
The cultures of the Finkler-Prior spirillum give off
a strong putrefactive odor; in media containing sugar
they produce acid; they do not form indol, and they
have a greater resistance to desiccation than the
cholera spirilla. The absence of the agglutinative
reaction with a dilution of the serum of an animal
immunized to cholera is a valuable differential sign.
This organism is pathogenic for guinea-pigs when
introduced into the stomach after previous injection of
soda solution and tincture of opium, similar symptoms
being produced, only somewhat less marked, as with
the cholera spirillum. Although originally observed
in the dejections of persons affected with cholera
nostras, it probably has no relation to this disease,
having been seldom found since under such conditions
by subsequent observers.
2. Miller's Spirillum. — In 1SS4 Miller observed
a curved bacillus in dental caries which, from its
microscopical appearances in cultures and from
animal experiments, has been thought to be identical
with the Finkler-Prior spirillum. The Vibrio helio-
genes of Fischer and the Vibrio lisbonensis o/Pestana,
and other similar spirilla met with from time to time,
are also probably identical.
3. Deneke's Cheese Spirillum (Vibrio tyro-
genes). — This organism was obtained by Deneke from
old cheese, but has since been rarely observed.
Morphologically and culturally it shows greater
resemblance to Koch's comma bacillus than does the
Finkler and Prior spirillum. It occurs in curved rods
and long spiral filaments, the diameter of the segments
being uniform throughout. On the other hand, it is
somewhat more slender than the comma bacillus and
the spiral turns are closer together. In its power of
liquefying gelatin it stands between the cholera
spirillum and the vibrio proteus, and its other char-
acters are also so intermediary between these two
species that they are scarce worth describing. It is
said to form a thin, yellowish coating upon the surface
of gelatin and agar stab cultures, and not to give the
indol reaction; but these characteristics are not
constant. The chief means of differentiating it from
the cholera spirillum is by the serum reaction.
4. Spirillum Metchnikovi. — This spirillum was
discovered by Gamaleia in 1SSS in the intestinal
contents of fowls dying of an infectious disease com-
mon to certain parts of Southern Russia, and pre-
senting symptoms like those of fowl cholera. It has
since been found by Pfeiffer in the waters of the Spree
and by Kutcher in those of the Lahn. In the affected
animals it is almost always found in the intestines,
but also in the blood, producing septicemia. This
interesting microorganism cannot be morphologically
distinguished from the cholera spirillum; it occurs as
curved rods somewhat thicker, shorter, and often
EXPLANATION OF
PLATE X.
EXPLANATION OF PLATE X.
Fig. 1. — Bacillus Anthracis from Cellular Tissue of Inoculated Mouse. Stained with gentian
violet. X 1,000. Photomicrograph from Sternberg's "Bacteriology" by permission.
Fig. 2. — Anthrax Spores from a Bouilion Culture. Double-stained preparation — with
carbol-fuchsin and methylene blue. X 1,000. Photomicrograph from Sternberg's
" Bacteriology" by permission.
Fig. 3. — Bacillus of Tetanus from an Agar Culture. X 1,000. Photomicrograph from
Sternberg's " Bacteriology" by permission.
Fig. 4. — Bacillus of Glanders. X 1,000. Photomicrograph from Sternberg's "Bacteri-
ology" by permission.
Fig. 5. — Spirillum of Asiatic Cholera (Comma Bacillus). From a culture upon starched
linen at end of twenty-four hours, stained with fuchsin. X 1,000. Photomicrograph
from Sternberg's "Bacteriology" by permission.
Fig. 6. — Spirillum of Finkler and Prior with Flagella. Agar culture. X 1,000. Photo-
micrograph from Bowhill's "Bacteriology" by permission.
Fig. 7. — Bacillus of Bubonic Plague from Agar Culture, showing Irregular Forms. X 1,000.
Photomicrograph.
Fig. 8. — Bacillus of Bubonic Plague from Bouillon Culture, Showing Rods in Chains with
Polar Staining. X 1,000. Photomicrograph.
Reference Handbook
OF THE
Medical Sciences
Plate X
J ,- ■-■
Bacillus Anthracis
VI.
Spirillum Finklcr Prioi
<-: .
*x-
Anthrax Bacillu
with Spores
V
,*
4,
Cholera Spirillum
III.
Tetania Bacillus.
VIII.
Plague Bacillus.
(Broth Culture)
Pathogenic Bacteria.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Bacteria
,,, iv decidedly bent than the comma bacillus. It
queues gelatin, as a rule, much more rapidly than
he cholera bacillus does, but this varies. It gives
lie nitroso-indol reaction without the addition of
litrites, and coagulates milk with acid reaction. It
[oes not give the serum reaction with cholera-
mmune serum.
The Spirillum mclchnikori is characterized by its
>athogenic action for chickens and pigeons; a minute
[uantity of a culture injected into the breasl muscles of
hese animals causes their death with the local and gen-
;ral symptoms of fowl cholera, except thai I he contents
)f the intestines have more the appearance of cholera
md the spleen is rather diminished than enlarged.
la the blood and edematous fluid about the necrotic
loint of inoculation, the organisms are present in large
iiumbers. Gamaleia has claimed that by passing the
aolera spirillum of Koch through a series of pigeons,
upon which this organism is said to act similarly to the
Vibrio metchnikovi, by successive inoculations, its
pathogenic power may be greatly increased, and thai
when sterilized cultures of this virulent variety of
bacillus are injected into pigeons they become immune
to the Vibrio metchnikovi, and vice versa. But
PfeifTer denies this — and the negative results obtained
from the serum reaction with Metchnikoff's spirillum
and cholera-immune serum show that the organisms
are not identical.
The Spirillum op Relapsing Fever (Spirochosta
or Spirillum obermeieri*) . — First observed by Ober-
meier (1873) in the blood of a patient suffering from
febris recurrent. Bacteriologically very little is
known of this microorganism. It occurs as long,
slender, flexible, motile spirals or wavy filaments, with
pointed ends usually from 20 to 30 /< long. Flagella
and spores have not been observed. Typically the
organisms are found only in the blood and spleen, not
in the secretions of patients with relapsing fever, and
chiefly at the height of the disease, seldom or never
during the intermissions. They stain readily with
the ordinary aniline colors, especially with fuehsin
and Loeffler's methylene blue solutions; they do not
stain by Gram's method.
They have never been cultivated in artificial media.
When preserved in blood serum and 0.5 per cent, solu-
tion of salt, they retain their vitality for a considerable
time.
Inoculation experiments have been successfully
made on man and monkeys. Monkeys when inocu-
lated with human blood containing the spirilla take
sick after about three and one-half days, but exhibit
only the initial febrile attack; no relapse such as is
characteristic of the disease in man occurs. Extirpa-
tion of the spleen renders the disease more dangerous
for these animals. Infection may be transmitted by
inoculation also from one monkey to another. Al-
though so little is known of this organism from a bacte-
riological standpoint, the fact of its constant occurrence
in relapsing fever and of the communicability of the
disease from man to monkeys by inoculation of the
blood gives us grounds for assuming that this is the
cause of the affection.
Spiroch/ETA Pallida (Treponema pallidum). — This
organism is found in large numbers in syphilis or
infectious diseases of human beings, characterized by
its long course and by the definite stages of its clinical
history. It was first observed by Schaudinn working
together with Hoffmann, in 1905, in the fresh exudates
of chancre, and as it possessed many of the characteris-
tics of the spirochetes he named it Spirochata pallida.
♦These organisms are classed with the spirochetes as pro-
tozoa by Schaudinn, Hartmann, and others, but by Norris,
Novy, and others they are still placed with the bacteria. In
this article, therefore, the two most important of the group,
only, will be described, viz., Spirochceta obermeieri and Spiro-
chmta pallida.
Later, because it showed individual characteristics
(.having no undulating membrane, though possessing a
flageUum), he classed it as a separate genus, Trepo-
nema pallidum. Since the investigations of Schau-
dinn and Hoffmann, extensive studies on human
and experimental syphilis have abundantly corrobor-
ated their findings, and this organism IS OOW recogn-
ized to be the specific can c of the disease.
Microscopical Appearances. — Very delicate in struc-
ture. 4 to 20 /! long (average, 10 p) and | to * /«
in diameter. It has four to twenty sharp deep spirals.
I lagella like anterior and posterior prolongations
are often seen. The double flagella occurring rarely
at one end are interpreted by Schaudinn aing
Longitudinal division, which then takes place very
quickly. In the living condition tin' organism is not
very refractive and is seen at first with difficulty.
Motility. — Its characteristic vements are rota-
tion on its long axis which is comparatively rigid,
slight forward and backward motion, and bending of
the entire body. By the use of the ultramicroscope
the motility of the organism is clearly seen.
Stamina'. — It stains red by Gram's method, while
most- of the oilier spirochetes stain blue.
Biological Characters. — Cp to 1909 numerous
attempts were made to cultivate this organism in
artificial media without success. Schereschewsky,
Miihlens, and others, now employ as media (1) collo-
dium sacs in tubes of fluid horse serum, (2) horse or
human serum heated to 75° C. The spirochetes are
not obtained in pure culture, but in what are termed
"pure-mixed cultures," as with amebae.
Pathogenesis. — So far as known, syphilis in nature
appears only in man. Kle.bs in 1879, and since then
others, have reported that syphilis could be produced
in monkeys by the inoculation of human virus, show-
ing many of the lesions characteristic of the disease.
Sehaudinn's spirochetes have been demonstrated
in practically all lesions of syphilis in man (primary,
secondary, and tertiary), including the congenital
types, in such numbers and position as to make the
majority of workers in this field look upon them as
the true cause of the disease.
Immunity. — After the development of the primary
lesions in syphilis man is usually insusceptible to
reinoculation during the active stage of the disease,
but during all the stages both man and monkeys can,
in some cases, be reinoeulated.
Efforts to obtain an attenuated virus to be used for
inoculation have been unsuccessful. Fresh material
loses its virulence in six hours, and the results of
inoculation with such virus have been entirely nega-
tive. Passage through monkeys does not attenuate
the virus. The injection of large quantities^ of the
serum of syphilitics into monkeys has failed to
produce definite immunity, although some animals
after such treatment did not take syphilis.
Wassermann, Neisser, and Bruck, have applied the
so-called "Bordet-Gengou phenomenon" as a diag-
nostic test for syphilis, usually spoken of as the
" Wassermann reaction." This test will be described
in detail elsewhere.
The Glanders Bacillus (Bacillus mallei). —
This bacillus was discovered by Loeffler and Schiitz
(1882) in the tissues of animals affected with glanders.
It was isolated in pure culture by several bacteri-
ologists, almost simultaneously, and was proved to
lie The cause of the disease with which it is associated.
Microscopical Appearances. — Small bacilli (2-3 a
long and 0.4 ft broad) with rounded or slightly pointed
ends; they usually occur singly, but sometimes in pairs,
and they rarely grow out to long filaments. Involu-
tion forms are common in old cultures. (See Plate
X., Fig. 4.)
Motility. — Non-motile.
Spore Formation. — Absent.
873
Bacteria
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Staining ReactioJis. — Stains with difficulty with the
ordinary aniline colors; does not stain by Gram's
method. The bacilli often exhibit a granular appear-
ance (metachromatic bodies) which are especially
visible with Neisser's stain.
Biological Characters. — Aerobic and facultative
anaerobic, growing both with and without oxygen,
but best in the presence of oxygen and at brood tem-
perature, though it develops slowly at 2.5° C; does
not grow at over 40° C. It may be cultivated on
all the usual artificial media, but best on five per cent,
glycerin agar.
On glycerin agar at the end of twenty-four to forty-
eight hours it forms whitish, transparent colonies
which in six or seven days may attain a diameter of
7 to S mm. On blood serum a moist, opaque, shiny
layer of a yellowish or dirty-brown color is developed.
The serum is not liquefied. On potato the growth is
very characteristic. At the end of twenty-four to
thirty-six hours at 37° C, a moist, yellow, transparent
coating develops, becoming deeper in color and
denser in consistence until it finally presents a reddish-
brown color, and the surrounding surface of the potato
acquires a greenish-yellow tint. The cultures often
exhibit long, felt-like, interlaced filaments not unlike
the threads of the bacillus anthracis, and finally club-
like enlargements. In bouillon a diffuse clouding
takes place, a tenacious, ropy sediment being ulti-
mately formed. Milk is coagulated with the produc-
tion of acid.
Vitality. — The resistance of cultures of the bacillus
of glanders is not very great. They lose their viru-
lence quickly by natural weakening as early as the
fourth or fifth generation; therefore in order to retain
virulence it is necessary after two or three generations
of cultures to pass the virus through a susceptible
animal. According to Bonome the glanders bacillus
dies in ten days when exposed to a temperature of 25°
C; but other authorities find that it may live for three
months under similar conditions. Exposed to heat
the bacilli are killed at 80° C. in five minutes, and at
100° C. in three minutes.
Corrosive sublimate solution (1 to 1,000) destroys
the bacilli in fifteen minutes, and five per cent, car-
bolic acid in one hour. The virulence is quickly lost
in distilled water (six days); it is not destroyed by
putrefaction.
Pathogenesis. — Among domestic animals, horses,
asses, cats, dogs, goats, sheep are the most susceptible;
less so pigs. Cattle and birds are immune. Among
test animals, the field mouse, wood mouse, and guinea-
pig are the most susceptible, the rabbit being less so,
while white mice and house mice are comparatively
immune. When pure cultures of the Bacillus mallei
are injected into horses and other susceptible animals
true glanders is produced. The disease in the horse is
characterized by the formation of ulcers upon the
nasal mucous membrane. These ulcers have irregu-
lar, thickened margins and secrete a thin, virulent
mucus; the submaxillary glands become enlarged and
form a tumor; other lymphatic glands also become
inflamed, and some of them suppurate and open ex-
ternally, leaving deep ulcers; the lungs are finally in-
volved and the breathing becomes rapid and irregular.
In farcy, which is a more chronic form of the disease,
circumscribed swellings appear in different parts of the
body, especially where the skin is thinnest, which sup-
purate and leave angry-looking ulcers with abundant
purulent discharge. Pure cultures can be obtained
from the interior of the suppurating nodules and
glands which have not yet opened to the surface; but
the discharge from the nostrils or from an open ulcer
contains comparatively few bacilli, and these are asso-
ciated with so many other bacteria which grow more
readily than the glanders bacilli on culture media that
it is difficult to obtain pure cultures in this way by the
plate method. Here test animals are useful
874
In guinea-pigs subcutaneous injections are fol-
lowed in three or four days by swelling at the point of
inoculation, and a tumor with caseous contents soon
develops, then ulceration of the skin takes place.
The lymphatic glands become inflamed, and in from
two to three weeks symptoms of general infection
appear. In male animals orchitis and epididymitis
are present, while the internal organs (lungs, kidneyB,
spleen, and liver) are generally the seat of character-
istic nodular formations. From these pure cultures
may be obtained. The specific ulcers produced upon
the nasal mucous membranes of the horse are rarely
present in guinea-pigs. The process is often prolonged,
and the animals may live from six to eight weeks
after inoculation; or it remains localized in the skin.
Intraperitoneal injection of guinea-pigs is usually
followed by death in from eight to ten days, and in
males the testicles are invariably affected. In female
animals the disease may be communicated to the fetus.
The bacillus of glanders has never been found out-
side of the animal body nor in healthy individuals.
The disease occurs as a natural infection only in
horses and asses, but it may be communicated to man
by contact with affected animals, and usually by
inoculation through wounds of the skin or mucous
membranes. In man, where the virus enters, a local
swelling appears, which spreads rapidly, accompanied
by suppuration and cording of the neighboring
lymphatics. Multiple abscesses are formed in the
skin, muscle, and internal organs, and there are often
suppurative changes in the joints, the disease at this
stage resembling pyemia. Characteristic glanders
nodules a,ppear in the mucous membranes, particu-
larly of the nose, which soon disintegrate, forming
ulcers. The disease not infrequently terminates
fatally, death resulting from general infection carried
by means of the lymph circulation.
It is transmissible from man to man. Washer-
women have been infected from the clothes of a patient.
Among horses it is by no means an uncommon disease,
particularly in Southern countries, sometimes taking a
mild course and remaining latent for a considerable
time. Horses apparently healthy, therefore, may
possibly spread infection.
It is often difficult to demonstrate microscopically
the presence of the glanders bacillus in the nodules
which have undergone purulent degeneration, or in
the discharge from the nostrils, ulcers and glands.
Strauss has proposed the following rapid method of
diagnosis by inoculation of test animals: Some of the
suspected material or culture is introduced into the
peritoneal cavity of a male guinea-pig, making the
inoculation directly in the middle line of the abdomen,
to avoid introduction into the vesiculae seminalis.
If it is a case of glanders, the testicles begin to swell
within thirty to forty-eight hours, and the skin over
them becomes hyperemic, shiny, and finally degener-
ates and shows evidences of pus formation. The
diagnostic symptom is the tumefaction of the testicles.
The diagnosis of glanders in horses, in which the
clinical symptoms of the disease may be obscure, as in
chronic or subacute cases, may often be made by the
use of mallein. Mallein consists of the filtered pro-
ducts of the glanders bacillus — albuminous com-
pounds bearing a similar relation to glanders that
Koch's old tuberculin bears to tuberculosis — pre-
pared by evaporating a six-weeks'-old culture in
five per cent, glycerin nutrient veal broth to ten
per cent, of its original bulk. The dose of mallein is
about 1 c.c. subcutaneously injected, which usually
gives good reactions. An injection of mallein under
the skin of a healthy horse has no effect or at most
produces a slight local swelling and rise of temperature.
Following an injection of mallein into a glandered
horse two reactions are produced: a large and painful
swelling at t lie point of inoculation and a rise of tem-
perature to 104° or even 106° F. The rise of tempera-
REFERENCE II WDI'.ot )|< • )K THE MEDICAL SCIENCES
Bacteria
ture, however, should not be taken alone as con-
clusively iiuliciiting glanders; it must be considered
iii connection with the local swelling and the general
condition of the animal which is profoundly affected
by the injection. The practical value of this test has
been demonstrated by numerous experiments by
veterinarians. No ill effects have been found to
result from the injection of mallein in healthy horses.
On the contrary, not only production of immunity,
but some cures have been reported from its use.
An agglutination test may also be made for glanders
by the macroscopic or microscopic method.
In the macroscopic method (Mcissner and Schultz)
a forty-eight-hour glycerin agar culture of Bacillus
mallei is washed off with normal salt solution, to which
sufficient carbolic acid has been added to make a 5 per
cent, solution. This is incubated for two hours at
60° C, then filtered and enough of the earbolized
normal salt solution is added to give the emulsion a
slight, milky appearance. The serum is then made
up into the required dilution, 1:50, 1:100, etc., and
1 c.c. of each dilution is pipetted into stoppered sterile
tubes, an equal amount of the emulsion being added
to each tube. The tubes are incubated at 37° C.
for twenty-four to forty-eight hours. If a reaction
occurs the upper part of the fluid will be clear and a
fine granular sediment will be found at the bottom or
fine clumps clinging to the sides of the tubes.
In the microscopic or hanging-drop method a
twenty-four-hour glycerin broth culture which has
been heated to 60° C. for one minute, is used and the
test is made as in the Widal test for typhoid fever.
The cover glass and slides must be sterilized and the
hanging drops made carefully and quickly to avoid
contamination. The slides are left at room tempera-
ture or at 22° C. for eighteen to twenty-four hours
and then examined microscopically. In this method
the reaction can be observed earlier than in the tubes,
and it is not necessary to wait for precipitation which
at times takes place slowly. The microscopic
method also gives a higher reading than the macro-
scopic method and includes more horses which are
doubtful. The agglutination is 1:500, but many
apparently healthy horses will agglutinate the
Bacillus mallei in dilutions as high as 1:5,000 to
1 :10,000. The cause of this is not understood. Such
horses then should be subjected to the mallein test
from time to time, with a view to the possibility of a
slight infection taking place. Very rarely a horse
in the last stages of glanders will fail to give a reaction,
but the disease symptoms will then be well defined.
The agglutination reaction has been found also to be
a valuable guide to the use of mallein. In human
cases the reaction of 1:100 and above is considered
positive, the normal blood not reacting above 1 :50.
The Bacillus of Bubonic Plague (Bacillus
Testis bubonica?). — This organism was discovered by
Kitasato and Yersin, independently, during an
epidemic of the bubonic plague at Hong-Kong,
China, in 1891. This disease, like anthrax and
leprosy, has a long historical record behind it. It is
probably the disease which under the names of "Black
Death" or "The Great Plague" decimated the
population of Europe in the Middle Ages.
Microscopical A p pearances. — Short rods, with
rounded ends, about twice as long as broad, occurring
singly, in pairs, or in short chains (especially in bouillon
cultures), and often surrounded by a capsule. Involu-
tion forms are common. (See Plate X., Figs. 7 and 8.)
Motility. — Non-motile, possessing no flagella ; though
Kitasato claims that it has very sluggish, scarcely
perceptible movements, and Gordon states by a
special method of staining (Van Ermengen's method)
he found polar flagella.
Spore Formation. — Absent.
Staining Reactions. — Stains with the ordinary
aniline dyes, but in preparations made from ;
cultures the character) tic bipolar staining, which is
observed in preparations fr blood and pus, is not
readily obtained. Hoes not .-tain by Gram's method,
Biological Character Strongly aerobic, growth
being inhibited in the all I nee "I oxygen. Develops
on i he u uaJ culture media, but be I on bl I erum
al 37° C; also fairly well at room temperature.
( >n gelatin plates small, darkly defined granular
colonies of a grayish-yellow to greenish color develop;
the gelatin i not Liquefied, in gelatin stab cult
it grows slowly on the surface and along the track of
the needle. On glycerin agar it grows rapidly, form-
ing a moist, grayish-white coating on the surface.
i in blood ■ i r a in in the incubator, at the end of twenty-
four to forty-eight hours, white, moi I tran parent,
and iridescent colonies are formed. Bouillon becomes
diffusely clouded, but if inoculated with a cohesive
mi of bacteria from an agar culture the bacilli
develop as a granular or grumous deposit on the walls
and bottom of the tube, the upper portion of the
liquid remaining clear, similarly to what is observed
in the growth of some varieties of streptococci.
There is a scanty growth on potato and milk; milk is
not coagulated.
The Bacillus of bubonic plague forms no gas in
media containing sugar, and but little indol. It
produces toxins, and the serum of animals immunized
against the bacillus yields antitoxic substances.
Vitality. — The bacilli of bubonic plague withstand
desiccation for from three to seven days: in water
they die in from three to eight days according to its
composition; in buried cadavera they retain their
vitality for twenty-eight to thirty-eight days. Ex-
posed to the action of direct, sunlight they are de-
stroyed in from three to four hours. They are killed
by heating at 55° C. in ten minutes, and at 80° C. in
five minutes. Corrosive sublimate (1 to 1,000) de-
stroys the bacilli immediately.
Pathogenesis. — This bacillus is pathogenic for
almost all animals, only pigeons being immune.
Guinea-pigs, rats, and mice are the most suceptible
animals; somewhat less so are monkeys, rabbits, cats,
and horses; and still less so are dogs and cattle.
Guinea-pigs when injected intraperitoneally with pure
cultures die in about two days of acute septicemia,
few bacteria being found in the tissues. At the
point of inoculation there will be seen a hemorrhagic
infiltration and edema, with enlargements of the
mesenteric glands and parenchymatous congestion of
the organs. The spleen sometimes shows minute
nodules resembling miliary tubercles, which contain
zooglea-like masses of the bacilli. Guinea-pigs are
also easily infected through the digestive tract.
Flies, bedbugs, fleas, and other insects take up the
organisms with the blood of plague-infected animals,
and the disease is frequently transmitted through
them, especially fleas, to man.
Hankin and Yersin have repeatedly found non-
virulent plague bacilli in the dust of infected houses
and in the soil. They have never been found in
healthy individuals. Among animals the bubonic
plague is known to occur spontaneously in rats,
which often are affected previously to human epi-
demics. Ground squirrels in California have been
shown also to be susceptible to infection and they are
supposed to help spread the disease. In patients
suffering from plague the bacilli are found chiefly in
the pus of the characteristic buboes and also in the
sputum from the pneumonic forms of the disease;
more rarely in the internal organs and the blood.
This organism is the specific cause of true Oriental
bubonic plague, the mortality from which is from
fifty to eighty per cent, of cases. It gains access to
the body (1) through the skin. Here the bacilli
may remain localized and multiply at first in the
neighboring lymph glands; frequently at the point
S75
Bacteria
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
of inoculation a pustule is formed which takes on
the nature of a furuncle or carbuncle containing
many bacilli. Death may occur without further
diffusion of the organisms, but ordinarily they are
distributed throughout the entire body, producing
death by septicemia. (2) Through the lungs. This
constitutes the so-called pneumonic form, or plague
pneumonia. The bacilli are present in the sputum
and sometimes in the blood; other pus cocci are found
in association. (3) Through the digestive tract.
This mode of infection has been demonstrated in
animals, but is uncertain in man.
Immunity. — Yersin. Calmette, and Borrel have
succeeded in producing passive immunity against
the plague bacillus in animals, and also to a certain
extent in man, by subcutaneous inoculations with the
serum of horses which were previously immunized by
intravenous inoculation of dead cultures. Such
serum possesses also some curative effect in men and
animals suffering from the plague, if inoculated with
large quantities and within twelve hours after infec-
tion. Roux maintains that this serum contains only
antitoxic, not bactericidal, substances. Active immun-
ity may also be produced, and apparently without
danger, by Haffkine's method of preventive inocula-
tion in the same manner as with cholera. This
method consists in the subcutaneous injection of
2.5-3 c.c. of a fully grown bouillon culture heated for
one hour at 70° C. to kill the organisms. The reac-
tion caused (fever and pain) is usually slight, and the
injection is best repeated after ten days. This treat-
ment is essentially protective rather than curative,
and although the immunity afforded is not absolute and
lasts only for a month or two, the majority of those
inoculated are protected or have the disease only in a
mild form and recover. By means of these two methods
of inoculation, along with strict quarantine regulation
and the destruction of rats and fleas, it is to be hoped
that this disease which, under the name of Black Death,
once decimated the population of the earth and which
in the East still causes a great mortality may be finally
exterminated or greatly restricted.
The German Plague Commission considered puncture
of the unopened bubo for diagnostic purposes some-
what dangerous, on account of possible infection of the
blood; but the English physicians in India make a
long incision in the affected gland, which is afterward
dressed with antiseptics. In this way material is
obtained for cover-glass specimens, plate and other
cultural methods. The pus of the buboes, and es-
pecially the sputum in the pneumonic forms, contain
numbers of bacilli. In these cases microscopical
examination alone suffices often to make a probable
diagnosis of the plague from the peculiar bipolar
staining of the organisms. Microscopical examination
of the blood is attended with success only in cases of
general infection, and here cultures yield better results.
It is recommended to make streak cultures on gelatin
plates at 22° O, at which temperature the plague
bacillus grows fairly well, while the streptococcus and
other associated bacteria usually exhibit only scanty
growth. According to Hankin, wdien the bacilli are
grown on agar containing 2.5 to 3.5 per cent, of salt at
31° C, in twenty-four to forty-eight hours inoculation
forms, consisting of pear-shaped bodies and spheres.
are developed, which he considers characteristic
enough to form a means of diagnosis. Finally, the
serum of men and animals affected with the plague
possesses the power of agglutinating the bacillus pestis.
This reaction is said to be present in the second week,
and is most pronounced in the second and third weeks
of the disease. Arthur R. Guerard.
Reff.rentf.s
Park and Williams: Pathogenic Bacteria and Protozoa.
Sternberg: Text-Book of Bacteriology.
Fliigge: Die Kficroorganiamen.
Lehmanii utul Neumann: Bacteriologische Diagnostik.
876
Bacteria Carriers. — It has been known for several
years that persons convalescent from certain acute
infectious diseases may thereafter carry and excrete
the exciting organisms from their bodies for a variable
length of time. Almost coincidently it was discovered
that not only those who have suffered from a specific
infectious disease may harbor the causative organisms
but also others who have been in direct contact with
either such patient or the infectious material. These
persons are apparently in normal health, or do not
show any symptoms of the specific disease. Recently
the general term "bacteria carriers" or "bacilli
carriers" has been applied to such persons.
It is difficult to define strictly what constitute
true bacteria carrier. The term is subject to broad
interpretation, but, as commonly understood at the
present time, certain restrictions may be made to fix
proper limitations. Therefore we may say provi-
sionally that a "bacteria carrier" is one who, while
apparently in good health, or at least not showing
any symptoms of a particular specific infectious
disease, is harboring and excreting the infectious agent
of such virulence that, when transmitted directly or
indirectly to a second person, or to an experimental
animal, it is capable of causing the disease in question.
The carrier may or may not have given a history
of a previous attack of the disease. According to
Novy, carriers may be classified under three types—
convalescent, chronic, and healthy carriers. But, as
he points out, perhaps the so-called healthy carriers
in most instances are individuals who have had the dis-
ease unknown to themselves at some previous time,
therefore they are really "chronic carriers''. In other
cases, while apparently healthy, the individual may
be in the incubation stage of the disease which de-
velopes later. After excluding these possibilities a
group remains which may fulfill the required qualifi-
cations for a strictly healthy carrier. As evident,
the term "healthy carrier" is one which can not be
correctly applied in certain cases, so must be used
with reservation.
The first observations upon carriers were made in
connection with epidemics of cholera, diphtheria, and
cerebrospinal meningitis. This list of infectious
diseases is being constantly added to as investigations
continue along this line.
Asiatic Cholera. — It has been found by a number of
workers in epidemiology that in cholera epidemics
there are healthy persons in the infected district who
carry virulent vibrios in their intestines, but who are
themselves apparently insusceptible to the disease.
Abel and Claussen reported an extreme case in which
they found cholera vibrios in the dejecta of fourteen
out of seventeen persons belonging to families wherein
there were cholera patients. In some instances the
organisms persisted as long as fourteen days. In the
Hamburg epidemic there were reported twenty-eight
cases of healthy persons with normal stools containing
cholera vibrios. Cholera vibrios are usually found in
the dejecta of patients for only a few days, but Kolle
found virulent organisms in the stools of convalescents
up to forty-eight days. A case has been reported in
which the organism was found one hundred and
twenty days after the attack.
It is evident from the above that the dissemination
of cholera comes about not only through contamina-
tion of water, food, etc., from the discharges of those
acutely ill of the disease, but also from the discharges
of certain convalescents and healthy "carriers,"
who may play an important role in spreading the
ili-ease. For efficient quarantine purposes laboratory
examinations of the feces, as well as clinical examina-
tions, must be directed toward those who have come
from infected regions, or have been exposed »ther-
wise to the disease.
Diphtheria. — As early as 1S94 Park and Beebe ex-
amined the throats of three hundred and thirty
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Bacteria Carriers
healthy persons. In eight subjects virulent diph-
theria bacilli were found, and two of those afterward
developed the disease; twenty-four subjects in this
aeries showed non-virulent or attenuated forms of the
organism. In further studies upon the persistence of
the virulent organisms in the throats of convale cent
a large series of consecutive cases were examined. It
was found that in approximately fifty per cent, of the
cases tin' bacilli disappeared within three days after
loss of the pseudomembrane. A majority of the
remaining patients showed the disappearance of the
organisms in rapidly decreasing numbers over the
following two weeks. But in a few cases the bacilli
persisted from the fourth to the ninth week. Park
later reported the ease of a patient who carried fully
virulent organisms for eight months. Prip reported
a case in which the virulent organisms persisted for
twenty-two months.
IVnnington has published the results of his ex-
amination of the throats of a large number of well
school children in Philadelphia. The summary of his
findings is very interesting in this connection. He
found that approximately ten per cent, of these
children harbored in their throats bacilli which cor-
responded morphologically with the organism of
diphtheria. One-half of these organisms were without
effect upon guinea-pigs. About thirty per cent.
behaved like attenuated forms, and fourteen per
cent, killed the animals with a fair degree of prompt-
ness.
In the examination of the throats of well persons in
contact with diphtheria patients, Kober found that
eight per cent, carried virulent bacilli. It is generally
considered that the bacilli found in well persons
recently exposed are more likely to be virulent than
others.
.Many more studies along these lines have been
made which confirm the findings just mentioned. All
these observations point to the fact that not only
convalescents but apparently well individuals may
serve as carriers of virulent diphtheria bacilli, and
under favorable conditions can infect others.
Specific antitoxic serum, likewise medicinal treat-
ment, apparently exerts little if any influence in
correcting this condition in diphtheritic convalescents.
Cerebrospinal Meningitis. — The Diplococcus intra-
cellularis meningitidis of Weichselbaum is another or-
ganism which is found in normal persons. In the
examination of twenty-seven healthy persons Schiff
found in the nasal secretions of seven an intracellular
diplococcus; in three cases of this group Weichsel-
baum identified the organisms as being meningococci.
Weichselbaum and Ghon isolated the same organism
from three persons who had been in contact with
the disease. Goodwin and von Scholly found the
meningococcus present in about ten per cent, of the
people who were in close contact with patients suffer-
ing from the disease. Others have found the menin-
gococcus in the throat and nasal cavities of healthy
persons, during an epidemic of meningitis. The
organism may persist a considerable length of time
in convalescents. Goodwin found the organism per-
sisting sixty-seven days after the onset of the
disease.
Evidence seems to indicate that cerebrospinal
meningitis is not highly contagious. Those who con-
tract the disease usually have had their general resis-
tance lowered by unhygienic environment, hardships,
exposure, etc. Individual susceptibility is an im-
portant factor. The organism may set up an acute
rhinitis without further invasion or harm. This
partly explains how the infection may be carried and
distributed, as it is well known that the organism
Eossesses a low degree of vitality; it is rapidly killed
y drying, sunlight, etc. Therefore, immediate or
mediate transmission of the infected secretions from
one person to another seems to be necessary in most
cases
in
Dwelling infections arc not proved The
fluence oi "bacteria carriers" in the spreading
of thi dises aci ounl foi the out bn afa and
finement to one family, -mall ana in a community, •«■
ingle regiment. P
cerebrospinal meningitis in ba
origin from "bacteria carriers." instances
arc on record which would indicate that tl
Influenza. — The influenza bacillus may be barb
in the respiratory and na al pa ages of mat ell
ons, « bo seem u o 1 heir act ii • iject 3
who have had the disease may harbor the bacillus for
I d ome ei i ca es n I In-
frequent, po ably due to an autoreinfection. They
maj also 11 ndary infection in many other
conditions. Williams quite early observed tnem in
sputum from pulmonary tuberculosis; they
present in great numbers in a large portion of the
• -i es, and in somi almo 1 pure cult u
Moreover, they were found not only during the wintx r
but also during the summer, when no influenza was
known to be prevalent. There is no doubt that
tuberculous patients act as influenza bacilli carriers.
■ certain healthy persons play a similar r61e.
Typhoid Fever. — Perhaps the most thorough
studies upon "bacilli carriers" have been carried out
in connection with typhoid. fever. Several exten
reports have recently appeared upon this subject.
Although these conditions have been recognized only
within the last few years, the investigations prom-
ise to throw much light upon certain outbreaks of
the disease of obscure origin. At the present time
considerable work upon this phase of the epidemio-
logy of typhoid is being pursued both in this country
and abroad.
It has been known for a number of j T ears that
typhoid patients and convalescents might carry pure
cultures of the bacillus in the bladder for an inde-
finite period of time. Petruschky in 1898 reported
typhoid bacilli in the urine of convalescents, as tongas
two months after the attack. Richardson soon after
mentioned a case, observed by Cushing, of a man
who had had typhoid fever five year-, previously, but
returned to the hospital for treatment of cystitis.
Bacteriological examination revealed a pure culture
of typhoid bacilli, which would indicate that the in-
fection had been carried five years, following the
typhoid-fever attack.
The above observations have been fully confirmed.
In certain cases typhoid convalescents carry the
bacilli a variable length of time as bladder infections,
and thus become a source of infection to others by
discharging the organisms in the outer world. Donitz
and others have reported cases which fully support
the claim that infections can originate from such a
source.
As early as 1902 Frosch suggested that convales-
cents from typhoid fever in some instances might
carry the bacilli in their bodies as saprophytes, and
their dejecta might give rise to new infections. In
this way the mystery of "typhoid houses" or "ty-
phoid localities" might be explained. Sound persons
might be "bacilli carriers" and be the source of
infection.
Drigalski and Conradi in the same year reported the
isolation of typhoid organisms from the dejecta of
four healthy persons who had been in contact with
cases of the disease. Drigalski in 1904 reported a
case in which the organisms were observed for nine
months in the stools. The next year Lentz and others
confirmed the supposition of Frosch and the findings
of Drigalski and others. Since then many more
contributions have been made on the subject winch
give further support to the views concerning " typhoid-
bacilli carriers."
Lentz (1905), in making an extensive review of the
877
Bacteria Carriers
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
results obtained at several laboratory stations engaged
in the investigation of typhoid fever, stated that out of
a large number of examinations ninety-eight chronic
"bacilli carriers" were found. At one station it was
found that about four per cent, of the cases examined
became bacilli carriers. In one instance Lentz found
that out of twenty-two carriers sixteen were women.
He observed that a definite relationship existed be-
tween gallstone disease and "bacilli carriers," as the
two conditions might be associated, and suggested
that gall-bladder infections might give rise to the
typhoid bacilli in the feces.
Neiter has called attention to the influence of
bacilli carriers in causing institutional epidemics.
In a certain German insane asylum were found thir-
teen " bacilli carriers, " all women. Friedel traced the
cause of a series of typhoid outbreaks in the institu-
tion, to a " carrier" who was a helper in the kitchen of
the asylum.
Kayser reported small outbreaks of typhoid fever
which could be traced to the milk in use. In two in-
stances the milk was traced back to the respective
dairies. In each case a "carrier" was found in
connection with the dairy, proof being furnished by
the isolation of typhoid bacilli from the feces. Kossel
describes a similar outbreak which had its origin from
milk supplied from a certain dairy. Upon investiga-
tion it was found that -one of the laborers was a
"bacilli carrier," although he was not aware that he
ever had the disease. He was removed from the dairy
work, with the result that no more cases developed
from the milk supply. Later, he returned to the
work and a second outbreak followed. Besides the
German cases cited, similar cases have been reported
in this country recently. These examples prove
very instructive, as they show the danger of em-
ploying "bacilli carriers" as workers about such
places.
Soper records a most interesting and instructive
case of a typhoid-bacilli carrier. He was called upon
to investigate a household epidemic of typhoid fever,
where, in close succession, six out of eleven were
stricken with the disease. The water and food sup-
plies were fully examined, with the result that they
could be excluded as sources of infection. Finally,
suspicion was directed to a cook who had been em-
ployed by the family shortly before the outbreak of
the disease. She left shortly afterward. Soper
succeeded in locating the cook again, but was unable
to derive any useful information from her. She was
a woman of apparently good health, about forty
years of age, of Irish descent, single, and had no
knowledge of ever having had typhoid fever. She
refused to give further information concerning her
past life, and the investigator therefore found it
necessary to look up her past history. During the
previous ten years it was possible to trace her where-
abouts with the exception of two years. It was found
that in the time accounted for she had been employed
in eight families, and in seven of these typhoid fever
had followed her. She had always escaped the
epidemics herself. In all, twenty-six cases and one
death occurred in the series of outbreaks. The last
position she held was with a family in New York City,
and the outbreak in this instance was followed by the
only fatality. Soper called the attention of the
Department of Health to the cook, who was suspected
of being a chronic carrier and a menace to public
health. She was placed in the Detention Hospital
March 19, 1907, where she was kept under constant
observation for almost three years. Bacteriological
examinations were carried out, under the directions of
Dr. Park of the Research Laboratory, by Goodwin and
Noble which showed that the urine was free from
typhoid bacilli, but the feces were rich with the
organisms. Examinations were continued during
the period of detention which showed that typhoid
878
bacilli were present in the stools (in varying numbers)
off and on at irregular intervals while under observa-
tion. The blood showed a positive Widal test early in
the course of the examination. This side of the' in-
vestigation was not followed along with the feces
examination, owing to the vigorous protests of the
carrier. It is not necessary to dwell upon this case
further than to call attention to the havoc which a
carrier can produce when coming in direct contact
with the food supply of non-immune individuals.
Klingler divides typhoid-bacilli carriers into two
groups: (a) those who have had typhoid fever at some
time or other, and (6) those who have no knowledge of
ever having had the disease. In a series of twenty-
three cases which came under his observation, he
found that six men and five women fell in the first
group, while in the second group there were three
men and nine women.
The discharge of typhoid bacilli in the feces of
carriers may be quite irregular in some cases, while
regular in others. This seems to depend on temporary
conditions in the intestinal tract. It has been
observed that sometimes the discharge of bacilli will
suddenly stop without recurrence. Also there may
be all degrees of gradation as to the length of time
the bacilli continue to be present in the feces after
the acute attack. They may not be found at all
after convalescence, or they may be present weeks,
months, or years thereafter. Lentz mentions one
case in which the organisms were present forty-two
years after the attack. From this we can easily see
that there may be no age limit. Klingler in his
series found bacilli carriers between the ages of
eighteen months and sixty years. The infant cases
may have been contracted through the mother.
The focus of infection is generally considered to be
in either the gall-bladder, chronic ulcers of the intes-
tines, or the normal intestinal tract. Wasserman and
Citron are of the opinion that a local immunity exists
in the gall-bladder and intestinal wall of the carrier,,
which protects the body from general infection. A
number of workers report that there is no raising in
value of the specific agglutinin, nor in specific .bac-
tericidal substances; but others have reported that
such substances are increased. It is desirable that
more work be done in regard to these particular
points.
Medicinal treatment or immunization, according to
Forster and Kayser, seems so far to have been
attended by practically no favorable results, in the
intestinal cases. But in the bladder infections
Richardson found urotropin very efficacious. The
use of this drug might be of service in the gall-bladder
infections in some cases. A successful use of urotro-
pin in gall-bladder infection was reported from the
Johns Hopkins Hospital soon after this type of
carrier was recognized. But, beneficial results have
not always followed its use.
When the infection in these cases can be localized
by such evidence as concomitant gall-stone disease,
operative means may in some cases lead to cure.
Dehler in 1907 operated upon a patient who was a
chronic bacilli carrier, with the purpose of relieving
the condition. Perhaps this is the first operation on
record which was undertaken for the cure of a typhoid
carrier. The patient, an insane woman, had infected
a number of persons before it was discovered that she
was a carrier. Previous to the operation typhoid
bacilli were found in the feces in thirty-seven out of
thirty-nine examinations. The operation consisted
in making a section, freeing the gall-bladder from
adhesions, opening it, and removing the gallstones,
then giving free drainage for some time. The patient
made an uneventful recovery, and with the exception
of once shortly after the operation, the stools were
reported to be free from typhoid bacilli.
Later on Dehler operated upon a second patient
REFERENCE HANDBOOK OF THE MEDICAL BCIENCES
Bacteria Canieri
i-ho was a bacilli carrier, and removed a lew small
tones from the gall-bladder. Subsequent examin-
tions of the feces showed the absence of typhoid
lacilli. In the same communication he reported
luil thr dejecta of I he previous case still remained
ree from typhoid organisms. Both patients showed
hi improvement in their general condition. Dehler
11 ■ It 1 the opinion that operative moans wore justifiable
ii those oasos in which no relief from the condition
an be brought about by medication or immuniza-
ion.
Albert in a recent study upon the subject of chronic
yphoid-bacilli carriers, stated that probably five per
■cut. of all typhoid patients become chronic carriers.
it her writers place the percentage from one to five per
int. Albeit also slated t hat ten per cent, of all cases
ire traceable to carriers, and called attention lo (lie
menace which chronic carriers are to public health.
The hitler fact is being more fully recognized by the
health authorities now, and attempts are being
made for the control of the problem in so far as is
i ical.
A number of eases have been reported in which the
dejecta of chronic carriers have shown a mixed
infection of the paratyphoid with the typhoid
bacillus. Also paratyphoid bacilli carriers have been
.. -ported by Gaehtgensand others.
Bacillary Dysentery. — As compared to typhoid
fever, a limited amount of work has been done which
will throw light upon the subject of bacilli carriers
among convalescents from dysentery or of healthy
carriers. But, taking up the closer study of certain
epidemics of this disease, it seems possible that there
are carriers in some instances. However, the
investigations of Shiga, Flexner, Goodwin, and others,
carried out in a large number of cases, have failed
to show the presence of B. dysertteriw in normal
Mi.nl-
In tivs disease, as in those discussed previously,
the so-called latent types apparently may be a means
of spreading the infection. Park is of the opinion
that paradysentery bacilli are distributed by carriers
and may in some cases give rise to epidemics. Duval
reported that he had found in two instances the
B. parady sentence in the normal stool of milk-fed
infants. Collins also found in a few cases the organ-
ism in the normal stools of babies.
Gonorrhea. — Many of the so-called cases of chronic
gonorrhea may be considered in the sense of being
gonococci carriers. A certain percentage of the so-
called chronic or latent cases do not show any clinical
manifestations after a certain length of time following
the acute infection. Yet these persons are quite
capable of infecting others, and there seems to be no
decrease in the virulence of the organism. Moreover,
the person is subject to superinfection from other
sources with acute clinical symptoms following.
Apparently there is no limit to the time a man may
carry the infection in chronic cases. Park mentions
a ease in which the organisms were abundantly
present after an exposure dating back twenty years.
Another class of carriers may be those who have
experienced slight if any clinical symptoms primarily,
but who carry the organisms and are able to infect
others.
Malta Fever. — Convalescents from malta fever in
some cases may carry, and excrete from the bladder
the Micrococcus melitensis for a considerable time
after an attack of the disease. Bruce quoting the
work of Kennedy states that theorganism is excreted
with the urine in ten per cent, of the cases. This is
continued in some instances as long as two years
after the patient is convalescent. Shaw also made
similar observations. The organism has been found
in the gall bladder of man (Horrochs and Kennedy).
Since the urine not infrequently shows the organism
for considerable time after the patient's convales-
cence, it is not improbable these carriers may be a
i: " toi in i he I"- ad of tin- disease; i he organ! m
tains its vitau'l j and \ irulem , • for
some I ime.
Plague— H is que tionable ii pe I bai illi can
in i In- en i- that we i on ider t\ phoid bai illi <
for example, are to be recognized. In the bul
type ol the 'ii ea e, com ale cent i nl Inue to
eliminate virulent organisms from the affected gk
for a .-,.,, iderable time after i he otl ptom
have abated. But such a condition could hard]
included under our definition of bacilli carriei ( In
1 be oi her hand, the pneu nic type of the disea e
may in some rare in tance afford examples which
simulate true bacilli carrier Got i hlicn reported
i hree except lonal ca e b hicb can oder hi obs
vation during the Uexandria pesl epidemic in 1899.
These cases were of the pneumonic type, and each
made a recovery; two were complicated with bul
while the third showed no bubo. The sputa from
these cases showed virulent pi- t bacilli fort v-ee
twenty and thirty-three days after complete di ap-
pearance of the fever. As evident, the one case in
particular without bubo, (3rd) might easily bave
escaped detection, without tl»- bacteriological exami-
nations, been discharged, and readily spread the infec-
tion. Padlensky states that in an epidemic of
plague of the pneumonic type, the specific organism
maj be found On the tonsils of well people, 1 1ms in-
dicating that heal l hy carriers may l bus exist. Bacilli
isolated from such carriers, wen- slightly virulent for
guinea-pigs, but after an animal passage I lie vi nil-
increased, lie called attention to the importance of
carriers in pest epidemics, and the need of further in-
vestigations. ( )l her observers have noted the presence
of pest bacilli in the sputum for some time after con-
valescence of the patient. While probably very rare,
the possibility still exists that in plague, among the
recovered, certain eases may be considered bacilli
carriers for a short time.
Other Infectious Diseases. — Pncumococci and strep-
tococci are quite frequently found in the throats and
air passages of normal persons. While these organ-
isms are nearly as virulent to susceptible animals as
when obtained from diseased eases, we are not yet
certain whether they are as capable of producing
disease in man. Many cases of pneumonia are
undoubtedly due to autoinfection.
Concerning the tubercle bacillus we need further
investigation. There may be certain persons who
may harbor the bacilli and still give no evidence of
any pathological condition caused by this organism.
But this supposition seems to be improbable.
As concerns the group of diseases caused by
filtrable virus little as yet has been done in relation
to the human carrier. The work of Osgood and
Lucas upon poliomyelitis, showed that in monkeys
the virus remained viable and infectious in the naso-
pharyngeal mucosa several months after the acute
paralytic stage of the disease. But the central
nervous system did not retain the virus, for the same
length of time, in a virulent condition. It is possible
that a parallel state may exist in the human con-
valescent from this disease, and may act as a source
of infection to others under certain conditions.
Bacteria carriers, or bacilli carriers, as stated, are
a constant, menace to public health when allowed
unrestricted freedom. It is imperative that such
cases bo recognized if possible, and the necessary
steps taken, so far as is feasible, to combat the con-
dition, or to prevent the spread of the disease by
prophylactic means.
Patients recovering from these diseases should be
thoroughly examined before being discharged in
order to a certain whether or not they are free from
virulent organisms. It is essential that more than
one examination should be made of fecal discharges
from suspected typhoid or cholera carriers, when the
lirst examination has given negative results. As the
879
Bacteria Carriers
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
organisms do not appear constantly in the dejecta
in many of these cases, it is evident that a single
examination will not always reveal the true condition.
Medicinal treatment, immunization, or surgical
intervention may relieve certain cases, but when
these means are not applicable it may be necessary
to quarantine the patient. In all cases in which the
dejecta carry infectious organisms complete steriliza-
tion should be employed. In safeguarding a water
supply these bacilli carriers must always be kept in
view.
When investigating the origin of an outbreak of an
infectious disease, it is always important to bear in
mind the possibility of a bacteria carrier as the source.
L. W. Fa.uulener.
Bacteriacese. — A family of Schizomyeetes, or fis-
sion-fungi, comprising cylindrical, more or less elon-
gated, straight (never spiral) forms, with or without
flagella, with or without endospores, dividing only in
one, the transverse, plane. It includes three genera:
1. Bacterium, without flagella: 2. Bacillus, with peri-
trichal flagella: 3. Pseudomonas, with polar flagella.
Bacteriological Technique. — The methods for the
artificial cultivation of bacteria are of fundamental
importance in bacteriology, and for that reason de-
serve very careful consideration. Nutrient media of
various kinds are used, but the three most commonly
employed are bouillon, gelatin, and agar. These in
turn may be variously modified as the needs of the
work may require. In addition, other media are
used, such as blood, serum, exudates, eggs, urine,
milk, potatoes, and the like. These will be severally
considered.
Bouillon. — To prepare beef tea, or bouillon as it is
called, 500 grams of lean, chopped beef (Hamburger
steak) are placed in a suitable enamelled vessel or in a
one-and-a-half-liter flask and 1,000 c.c. of ordinary
tap water are added, and the whole is thoroughly
mixed. This may now be set aside in an ice-box for
twenty-four hours so as to bring the soluble constitu-
ents into solution; or, what is preferable, it may be
placed in a water-bath and warmed at a temperature
not exceeding 60° C. for an hour. In this way the
nutrient substances are dissolved out and much time
is saved. It is not desirable at this point to heat
the fluid above the temperature given, inasmuch as
that would lead to the coagulation of the albuminous,
constituents, which, if they are allowed to remain in
solution, will facilitate the subsequent clarification of
the medium. When the digestion is completed,
whether carried out at a low temperature or in
the water-bath, the liquid is strained through well-
washed, starch-free muslin, or the juice may be
expressed by means of a meat press. The liquid thus
obtained is of a dark red appearance, due to the
presence of hemoglobin.
One thousand cubic centimeters of the meat extract
are then placed in a clean flask or vessel, and ten grams
of dry, powdered peptone ( Witte's) and five grams of
common salt are added and the whole is then warmed
at about 55° to 60° C. till the peptone has dissolved.
The next step is to render the medium suitably alka-
line, since bacteria as a rule require a slightly alkaline
soil. This manipulation requires special care, for,
if improperly done, the finished product may be
cloudy, or may have a deposit, or may even be
unfit for the growth of bacteria. The clouding
and the formation of a precipitate can be avoided
by boiling the meat extract after adding just enough
alkali to neutralize the fluid. For this purpose 5 c.c.
of normal sodium hydrate (four per cent, solution)
are added to the liter of meat extract. This amount
is usually sufficient to make the extract neutral to
litmus. The liquid is then heated in a boiling water-
880
bath or over a free flame for about fifteen minutes
after which it is filtered through a moist plaited filter
and allowed to cool to about 50° C. As stated
bacteria thrive best when the medium is slightly
alkaline. Hence 10 c.c. of the normal sodium hydrate
are now added to impart the desired alkalinity, after
which the liquid is again boiled for twenty to thirty
minutes, and finally filtered through moist paper.
Inasmuch as considerable water is usually lost by
vaporization during the preparation of the medium
it is advisable either to indicate the volume at the
beginning of the operation by a suitable mark on the
vessel, or, better, to take the weight of the fluid before
and after heating. The difference in the volume or
weight is finally made up by the addition of the corre-
sponding amount of distilled water. The finished
bouillon should make up to the original volume of
meat extract, that is, 1,000 c.c.
The beef tea thus prepared is now filled into tubes
or into flasks, as the case may be, and sterilized by
steam. This process will be described later. It is
hardly necessary to add that the bouillon after being
tubed and sterilized should be perfectly clear, without
a deposit, and should have a slight alkaline reaction.
For cultivating the gonococcus Thalmann recom-
mends using the ordinary bouillon, to which has been
added two-thirds to three-fourths of the amount of
alkali necessary to make it neutral to phenolphthalein.
Bouillon may be prepared by substituting meat ex-
tract in place of the meat infusion. The preparation
of the meat extract bouillon will be considered later.
Sugar-free Bouillon. — The bouillon as just prepared
always contains some sugar derived from the muscle
tissue employed. For many purposes this sugar con-
tent is undesirable, and must be removed in some way.
One procedure is to allow the meat extract to ferment
at a low temperature, 10° to 15° C, for two days.
Another is to place the meat extract at 37° C. for
twenty-four hours. Neither one of these methods will
give results which can be relied upon. The best
procedure is to add to the meat extract a rich fluid
culture of some acid-producing organism, such as
Bacillus coli (Smith), or B. lactis aerogenes (Dunham),
and then set it aside to ferment at 37° C. for twenty-
four hours or longer. The frothy liquid is then
carefully neutralized by the addition of normal
sodium hydrate, peptone and salt added, then boiled,
cooled, and rendered alkaline according to the
directions given under the preparation of bouillon.
The sugar-free bouillon thus prepared does not con-
tain indol, as might at first be supposed. It is pref-
erable to the Dunham peptone solution mentioned
below for testing for the presence of indol, since a
good reaction is given in sixteen hours, whereas the
cultures in Dunham's solution often require several
days before giving a positive test.
Martin's Bouillon. — The thoroughly mixed meat
suspension (500 grams of chopped beef and 1,000 c.c.
of water) is set aside at about 37° C. for twenty hours
so as to destroy the sugar normally present. The
liquid is then strained through well-washed muslin,
and to 1,000 c.c. of the filtrate five grams of common
salt are added, after which the liquid is neutralized
and finally rendered alkaline by the addition of 7 c.c.
of normal alkali per liter of bouillon. Ordinary
peptone is not added, inasmuch as it is likely to con-
tain sugar. Instead, Martin adds to this bouillon an
equal volume of a rich peptone solution made by digest-
ing the stomach of a pig. This latter solution is pre-
pared as follows: A pig's stomach is cleaned and cut
up into small pieces, and to 200 grams of this finely
divided tissue 1,000 c.c. of water and 10 c.c. of con-
centrated hydrochloric acid are added and the mix-
ture is set aside at 50° C. for about twelve hours.
The digested fluid is then decanted through a filter
of absorbent cotton and the strongly acid reaction
is reduced by the addition of 25 c.c. of a sixteen per
cent, solution of sodium hydrate. The liquid is then
RKIT.KI'.XCK HANDBOOK OF THE MEDICAL SCIENCES
Bacteriological Technique
carefully neutralized, after which ii is rendered alka-
line by the addition of 7 c.c. of normal sodium hydrate
per liter. The mixture of equal volumes of (lie sugar-
free bouillon and the peptone solution is heated,
filtered, and tubed or placed in flasks.
Peckliam's Bouillon. — This is made by taking finely
chopped beef, which must be as old as it can be
obtained in order that it may be free from muscle
sugar, ami adding 225 grams of it to 500 c.c. of water.
The mixture is rendered slightly alkaline with sodium
Carbonate, after which it is placed in a water-bath at
40° C, and four grains of trypsin are added. After
digesting for an hour the fluid is again rendered alka-
line with sodium carbonate. In from one to oik 1 and
a half hours the digestion should be arrested, other-
wise traces of indol may be detected. At the end of
this period the mixture is boiled and strained through
gauze and filtered cold through wet filter paper to
remove the fat. Five grams of salt and enough water
to make up to one liter are then added. The acidity
of the clear straw-colored filtrate is then reduced to
the desired point. The most suitable reaction for tin'
development of colon and like bacilli is when the
medium contains such an amount of free acid as to
require from 20 to 30 c.c. per liter of a decinormal
sodium-hydrate solution to bring it to a point neutral
to phenolphthalein.
Artificial digestion of muscle tissue by means of
pepsin and trypsin is resorted to in the preparation
of Deycke's agar.
Dunham's Peptone Solution. — This is prepared by
dissolving ten grams of Witte's peptone and five grams
of common salt in 1,000 c.c. of ordinary tap water. The
solution is then tubed and sterilized by steam. This
medium is used to detect the formation of indol by
bacteria, but inasmuch as many organisms fail to
grow in it and others require several days before
giving a reaction, it has not been found to be as
Suitable as the sugar-free bouillon given above.
Glucose Bouillon. — This is used to test for acid and
gas production. It is made by adding to the ordinary
bouillon, or better to that which is sugar-free, one
or two per cent, of glucose. The two per cent.
solution is most commonly employed. The steriliza-
tion of sugar-containing media by steam requires
special care to prevent oxidation of the carbohydrate
present. As a rule the steaming should not exceed
ten or fifteen minutes each day on three successive
days. Instead of glucose other carbohydrates, such
as lactose, maltose, saccharose, dextrin, etc., may be
added to the bouillon in one or two per cent, con-
centration.
Mannite-peptone Bouillon. — The alcohol mannite is
added to sugar-free bouillon in sufficient quantity to
give a one per cent, concentration. This medium is
especially useful in differentiating organisms which
otherwi. e closely resemble each other. For example,
the different varieties of dysentery bacilli may be
separated, since certain ones ferment mannite, while
others do not.
Glycerin Bouillon. — This is especially used for
cultivating the tubercle bacillus. It is made by
adding five per cent, of glycerin to the ordinary
bouillon. The mixture is then tubed and sterilized
in the usual way.
Carbolic Bouillon. — This is made so as to contain
0.1 per cent, of carbolic acid. One gram of acid may
be added to one liter of bouillon. The better pro-
cedure is to add 1 c.c. of a one per cent, carbolic acid
to 9 c.c. of bouillon. It is advisable to incubate the
tubes for several days so as to eliminate any possible
contamination. The medium is useful for examining
water for the colon bacillus, especially when the
bacterial contents are very high. The presence of
the antiseptic serves to check or prevent the growth
of many organisms which would otherwise develop.
It should be borne in mind that weak colon and
typhoid bacilli are likewise restrained.
Vol. I. — 56
i he tubes after inoculation with the water are Incu-
bated for twentj -four lenu al 3g i ■ , ft ft< r which
lai tose litmus agar plate in m uie, which are I
i camined for red colonies, < if com ,• all red colonies
are not to be regarded without further stu.lv OS the
colon bacillus.
Parietti's Bouillon. — A mixture of carbolic acid and
hydrochloric acid is first prepared l>v adding i c c.
of the latter to 100 r.v. of a li pel cent, carbolic
solul ion. I hi i olution after s tanding a fe
added in portions of o.l, 0.2, 0.3 c.c. to portioi
10 c.e. each of Sterile bouillon.
Nitrate Bouillon. — The Laboratory Committee of
the American Public Health \ ociation recommi
that this medium be prepared by dissolving one gram
peptone in one liter of tap water 1 amnion ia-ftv I , and
then add two grams of nitrite-free potassium nitrate.
Ten cubic ceiiti lei's of I he dium are placed in
test-tubes and sterilized in the usual manner. It is
be I to prepare the medium fresh before using.
Calcium-salt Bouillon. Bolduan found that the
addition of certain calcium salts to plain broth gave
a medium nearly equivalent to time containing
serum or ascitic fluid for the cultivation of the pneu-
mococcus, lueningococcu .etc. It has I he advantage
of being easily and rapidly prepared. Calcium
chloride can be used in solution of I to 2,000 in plain
broth, while calcium carbonate (marble) or calcium
sulphate (gypsum) is broken into small pier. .,
washed with water, added to broth in test-tubes,
and sterilized in the regular manner. Pneumococci
as a rule grow readily upon this medium, live approxi-
mately as long as upon ascitic broth, and retain
their virulence equally well. Hiss, working inde-
pendently of Bolduan, discovered the same advan-
tages of calcium broth when cultivating the above-
mentioned organisms, his publication appearing
later.
MacConkey's Bile-salt Media. — Bile salts and
various sugars enter into these media. A stock
solution may be prepared without sugar, then the
sugar may be added as desired. This solution is pre-
pared by dissolving twenty grams Witte's peptone in
1.000 c.c. distilled water heated to 00° C, then to
this are added five grams sodium taurocholate (com-
mercial product). For the medium one-half per cent,
of a freshly prepared one-per-cent. solution of neutral
red and the sugar are added. If glucose is used, one-
half per cent, is added; in the case of other sugars,
one per cent. The medium is sterilized in a steam
sterilizer at 100° C. on three consecutive days. Care
must be exercised in order not to overheat and split
the constituents in sterilizing. Instead of using
distilled water as a solvent for the ingredients, beef
broth may be used, thus giving a bile salt bouillon.
These media are especially applicable in the differ-
entiation of intestinal bacteria. The formation of
both acid and gas may be observed if the organisms
under cultivation possess such proper! ies.
Colored Bouillon. — Various coloring agents are
added to the nutritive media in order to bring out
the acid-producing or the reducing properties of
bacteria. The substances which are most commonly
used for this purpose are litmus, neutral red, fuchsin,
saffranin, and sodium indigo sulphate. The first two
are particularly useful, and are prepared the same as
the corresponding agar or gelatin media, which see.
Gelatin. — The ordinary nutrient gelatin is really
nothing more than bouillon to which ten per cent, of
gelatin has been added so as to impart solidity with
the additional advantage that the medium is trans-
parent. The method of preparation is as follows:
To 1,000 c.c. of the meat extract, prepared according
to the directions given under bouillon, 100 grams
of the best sheet gelatin are added; likewise ten grams
of Witte's peptone and five grams of common salt.
The whole is then warmed in a water-bath at 00° C.
881
Bacteriological Technique
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
until the gelatin has passed into solution. The liquid
is then neutralized and enough alkali added in excess
so as to impart a suitable alkalinity. As ordinarily
prepared the nutrient gelatin requires from 30 to
35 e.c. of normal alkali to effect neutralization. An
additional 10 c.c. will give the desired alkalinity.
Hence 40 c.c. of the normal alkali may be added at
once and the liquid tested with litmus paper. If the
liquid is not distinctly alkaline more of the reagent
may be added until the desired alkalinity is obtained.
The method of standardizing media by means of
phenolphthalein will be given later.
When the proper amount of alkali has been added
to the gelatin solution the latter is placed in a
water-bath, the water of which is then raised to the
boiling temperature. The gelatin is kept immersed
in the actively boiling water for about three-quarters
of an hour. Prolonged heating or sterilization at
high temperature (autoclave) lowers the solidifying
point of gelatin; therefore this must be avoided,
since it impairs the medium. The albuminous con-
stituents of the meat extract coagulate in flakes,
and at the same time clarify the liquid so that on
subsequent filtration the gelatin will be perfectly
clear. In case the coagulation of the albumin results
in minute particles, which cannot be readily removed
by filtration through paper, egg-albumin may be
added and precipitated by again heating. This is
brought about by allowing the medium to cool down
to 60° C. and to each liter add the whites of two eggs,
then thoroughly mix by stirring. Gradually bring
the temperature up near the boiling-point, without
stirring, and keep there about fifteen minutes. A
heavy coagulum results, the greater part of which
will rise to the surface. This may be removed by
straining through several thicknesses of cheese cloth
or a layer of absorbent cotton placed in a funnel.
The gelatin is then filtered through a plaited filter,
which should, however, be first warmed by passing
through it several hundred cubic centimeters of
boiling water. If the paper and funnel are sufficiently
warmed in this way there is no likelihood of the gela-
tin solidifying on the filter. The filtered gelatin
should be perfectly clear, should possess a slight alka-
line reaction, and should solidify when cooled under
running tap water. If it meets these requirements
it is then filled into sterile tubes to a depth of one
and a half to two inches, and finally the tubes are
sterilized by steaming for a quarter of an hour on
each of three consecutive days.
Whenever nutrient gelatin is mentioned in bac-
teriological work it is understood to be a ten per cent,
solution. This medium melts at about 23° C. That
is warm summer temperature, and for that reason
it is sometimes advisable to add more gelatin to the
preparation in order to make it more solid. A twelve
or even a fifteen per cent, solution of gelatin is used
under these conditions. Again, at other times it is
desirable to employ a gelatin which is relatively
quite soft, and in that case a five or eight per cent,
solution may be made use of. Obviously the amount
of alkali necessary to neutralize such media will vary
from that required for the ordinary gelatin. The
great value of the gelatin medium lies in the fact
that it can be readily melted and again solidified,
and in its transparency. Moreover, many bacteria
give rise to soluble ferments or enzymes which pep-
tonize or liquefy the gelatin, whereas others are not
able to do this. It becomes possible therefore to
divide bacteria into two large groups, according as to
whether they liquefy or do not liquefy gelatin.
Glucose Gelatin. — This is made by adding to the
clear filtered gelatin, prepared as above, two per cent
of glucose. The material is then tubed and sterilized
the ~ame as ordinary gelatin. This medium is par-
ticularly useful for the cultivation of anaerobic bacteria.
Glucose Litmus Gelatin. — To the glucose gelatin a
concentrated solution of litmus is added so as to
impart to the medium a deep blue color. This is
then tubed and sterilized. During the steaming of
this medium the litmus is usually decolorized, but
on subsequent cooling the blue color returns. If such
a medium is overheated in the process of sterilization
the sugar will be altered, and as a result the color of
the litmus will change to more or less of a red.
For special purposes other sugars may be added to
the gelatin, as in the case of bouillon. A lactose litmus
gelatin is very useful in differentiating various organ-
isms. The amount added is usually one or two percent.
Eisner's Medium. — The addition of gelatin to a
potato extract, instead of to a meat infusion, was first
resorted to by Holz. Eisner's medium is essentially
Holz's potato gelatin, to which one per cent, of potas-
sium iodide is added. It can be used to good advan-
tage in differentiating between the typhoid and the
colon bacillus, but at the same time it should be re-
membered that it does not afford an absolute means
of detecting the former organism. The method of
preparation is as follows: 1,000 grams of well-cleaned
potatoes are cut up into lumps which are then mashed
as fine as possible, best done by passing the material
through a fruit press. The fineh 7 mashed potatoes are
then placed in a meat press and pressure is applied.
In this way about -400 c.c. of a dark liquid is obtained
from the kilogram of potatoes. The potato juice is
then set aside in an ice chest overnight, after which
it is filtered through cotton. Ten per cent, of gelatin
and one per cent, of potassium iodide are then added
to the dark liquid, and the mixture is warmed at
about 40° C. until the gelatin melts. Inasmuch as
the reaction of this material varies considerably it is
necessary now to determine the exact degree of acidity
present, and then to reduce this by the addition of
the proper amount of alkali, so that the resulting
medium has an acidity such that it would require the
addition of 20 c.c. of normal alkali per liter to make
the solution neutral. The acidity of the gelatin is
determined by titrating a portion, say 10 c.c, with
decinormal sodium hydrate, using litmus paper as an
indicator. If, for example, 10 c.c. require 3.2 c.c.
of the decinormal alkali, it will be necessary to reduce
the acidity by adding 1.2 c.c. of decinormal alkali,
or better 0.12 c.c. of normal alkali for every 10 c.c.
of gelatin made. When the proper degree of acidity
has been imparted to the medium, the gelatin is
placed in a boiling water-bath for three-quarters of
an hour until all the proteins have coagulated, after
which it is filtered through peper, filled into sterile
tubes, and sterilized by steaming for fifteen minutes
on each of three consecutive days.
Fish Gelatin. — Five hundred grams of chopped fish
are added to 1,000 c.c. of water, and the material is
digested the same as given above for ordinary gelatin.
To the strained liquid 100 grams of gelatin, forty grains
of salt, five grams of glycerin, and five grams of aspara-
gin are added, and the mixture when perfectly fluid is
rendered slightly alkaline. It is then heated, tubed,
and sterilized as above. This medium is particularly
useful for the growth of phosphorescing bacteria.
Nutrient Agar. — One drawback to the ordinary
gelatin is that it cannot be used as a solid medium
at temperatures above 23° C. This has led to the
introduction of agar-agar as a stiffening agent. This
substance is a seaweed gathered off the coast of Asia.
It has no nutritive qualities of its own nor is it lique-
fied by bacterial ferments. Therefore it becomes a
very useful addition to media for special purposes.
The preparation of nutrient agar is very simple.
Ordinary bouillon is first made according to the direc-
tions already given. The agar may be obtained as a
powder or in threads; in the latter case the agar is
cut up into very small pieces, and twenty grams itwo
per cent.) is then added to the liter of bouillon, which
should be in a large flask, or, bettor, in an enamelled
jar. The vessel and contents should then be weighed,
882
REFEREXCF. HANDBOOK OF Nil: Minn \I. 51 II
II ii ti ri..i.iuii il Technique
after which the liquid should be gently boiled until
the agar has completely dissolved. The vessel is
now again weighed, and the difference I i the
two weights is made up by the addition of the proper
amount of distilled water.
It is advisable to place the agar now in a water-
bath at about 50° C. for several hours in ordi
allow the sediment to settle as much as possible.
The filtration of a two per cent, agar is a very slow
and tedious process even when carried out in a steam
sterilizer. It is sufficient for practically all purposes
to tiller through a layer of cot-
ton. The filtrate thusobti
is almost, if not entirely, clear;
ordinarily whatever little sedi-
ment may be present .Iocs n ,,i
interfere with the usefulness of
the medium. If much sedi-
ment is present in the filtrate,
it may be clarified by the ad-
dition of egg-albumin as men-
tioned under the preparation
of gelatin.
The filter is prepared by plac-
ing a piece of ordinary cotton,
about two inches square, in the
angle of a large
funnel, and then
while it is held
down by means of
a glass rod, a liter
Fig. 543. — Filtration Through Cotton Or SO of Very hot
Over a Porcelain Plate. (Novy.) water is passed
through, once or
twice, so as thoroughly to warm the funnel. Event-
ually the sedimented agar is carefully and slowly
decanted on to the cotton filter. If desirable the
agar can be filtered a second time. A very con-
venient arrangement for the rapid filtration of
agar through cotton is shown in Fig. 543. This
consists essentially of a Witte's perforated porcelain
plate, which is steadied in place in the funnel by
means of a glass rod which passes through the center.
The plate is covered with a layer of cotton on which
a similar porcelain plate is placed to prevent the
cotton from floating. The funnel is inserted into a
strong vacuum flask, which is connected with a
Chapman air pump. Boiling water is first passed
through the filter to warm it thoroughly, after which
the agar is added and suction applied. As soon as the
pump begins to act the top plate can be removed.
When it is desired to make a perfectly clear medium
it should be made with only one or one and a half
per cent, of agar instead of two per cent., as given
above. Such agar is softer and can be passed through
a previously moistened filter paper, especially if the
funnel is placed in a steam sterilizer or in a funnel-
shaped copper water-bath, such as is shown in Figs.
544 and 545.
The filtered agar is then tubed and sterilized by
steaming one-half hour on each of three consecutive
days, after which it is kept in an upright position; or
sterilization may be rapidly accomplished by plai ing
the tubes in an autoclave (Fig. 559) and keeping at a
temperature of 120° C. for fifteen minutes. Agar
media modified by addition of sugars (or certain
chemicals) cannot be sterilized at this high tempera-
ture since those constituents are altered. When it is
desired to make inclined or slant agar tubes, as many
of these as are needed are melted in a water-bath
and then inclined so that the agar comes within an
inch of the cotton plug.
Thtdmann's Agar. — Five hundred grams of meat are
boiled for one-quarter of an hour with 1,000 c.c. of
distilled water, after which the mass is made up to the
original weight and strained through muslin. One
per cent, of peptone and 0.5 per cent, of salt are then
added and the liquid is boiled, after which it is
again made up to the original weight, cooled,
filtered. < ine and one-hall i then
added and the weighed liquid i In a concen-
trated salt-water bath for about three-quart
hour, after which it is again made up to the original
weight. Thirty cubic ei are then titl
with normal sodium hydrate, using phenolphtha
as an indicator. The amount of alkali necessary to
neutralize the entire a unl of agar is ascertained,
and two-thirds of this quantity fa then added, in
portions and while shaking, to the agar. After heat-
tug fifteen minutes the material i- filled into tu
According to Thalmann and others this medium is
adapted for the cultivation of the gono
eially for diagnostic purposes. A httli ms is
d with the water of condensation, and then by
s of a wire, rod, or cotton swab the suspension is
thoroughly spread over the surface of a series of
inclined tubes or over Petri di-hes. The-,, when
kept for twenty-four hours at 36 37 I mall,
glistening colonies, which are single or confluent and
: like highly refract i\ 6 dl
The medium is not suitable for subcultures, and
Thalmann recommends thai the colonies be trans-
planted to serum bouillon. This is prepared by
adding to some bouillon two-thirds to three-fourth's
of the amount of alkali needed to neutralize the liquid.
After heating and filtering, an equal volume ot
serum is added and the mixture tubed. The tubes
are inclined and heated for one to two hours at 70° C.
on the first and also on tin' second day. and for one
hour at 100° Con the third day. According to Wa
mann hog serum is just as good as human serum for
cultivating the gonococcus.
Glucose Agar. — This is made by adding to the
filtered agar, or to so much of it as may be wanted,
two per cent, of glucose. The medium is then tubed
and sterilized by -teaming for twenty or thirty min-
utes on three consecutive days. It is used especially
for the growth of yeasts and anaerobic bacteria.
If desired, it may be colored with litmus as in the
case of gelatin. Lactose, maltose, saccharose, or
other sugars may be used as a modification, instead
of glucose. The medium in either case is made in the
same manner, with similar percentages of sugar.
i'n. 544. — Double-Walled
Hot-Water Funnel.
1 io. 545.— Single-Wall Hot-Water
Funnel with Ring Burner.
Rnthhrrgcr's Xcutral-red Agar. — This can be made
by adding to a 0.3-per-cent. glucose agar one per
cent, of a saturated aqueous neutral-red solution.
The typhoid bacillus does not change the color or
produce gas, whereas the colon discharges the red
and leaves a fluorescing color. The inoculation can
be made either by planting a shake culture or by
making a stab culture, which can then be covered
with a layer of agar to exclude air changes. The
addition of neutral red to bouillon is of service in
water examinations (Irons. Jordan).
SS3
Bacteriolostical Technique
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Endo's Fuchsin Agar. — When properly prepared,
this medium ranks among the first as a reliable
means of differentiating the Bacillus typhosus. It
is prepared as follows: To 1,000 c.c. neutral three per
cent, agar (made in the regular way) add ten grams
chemically pure milk sugar (lactose); 5 c.c. alcoholic
solution of fuchsin (freshly filtered); 25 c.c. ten per
cent, solution sodium sulphite; 10 c.c. ten per cent,
solution of soda. The milk-sugar solution and
fuchsin solution are added first to the dissolved
agar and well mixed. The solution of sodium sul-
phite is added gradually until the color of the medium
disappears. On solidifying, the medium should re-
main colorless. Put in tubes (about 15 c.c. each)
and sterilize in steamer for thirty minutes on three
consecutive days. Keep tubes in the dark until
ready for use.
Endo ascribes the resulting color changes to the
fact that fuchsin is a hydrochloric-acid combination
of rosanilin. Rosanilin is a colorless leucobase, but,
in combination with acids, gives colored compounds.
The sodium sulphite used in the medium is just
sufficient to reduce to the colorless base, thus giving
a practically clear medium.
In the presence of sugar of milk such organisms as
B. coli liberate lactic acid, which in turn acts upon the
Leucobase, and gives a deep red combination. But
the colonies of B. typhosus developing in this medium
do not produce an acid, therefore they have a clear
glassy appearance, or slightly bluish in transmitted
light. Plates are made and inoculated in the ordi-
nary manner from infective material. Incubation is
canied out at 37° C. and, when suspected colonies
develop, they may be fished out, transplanted, and
given the agglutination test with specific serum to
identify positively.
The Malachite-green Enriching Method of Lent:. —
This method has also been used extensively in the
separation of the typhoid bacillus, especially in the
cultivation from feces. The use of malachite green
for this purpose was first introduced by Loelfier.
Lentz and Tietz have modified and improved the
method. They direct that three pounds of chopped
lean beef be macerated in two liters of water for six-
teen hours. Express the extract, cook for one-half
hour and filter, add three per cent, agar to the filtrate
and cook slowly for three hours to dissolve. Then
add one per cent, peptone, 0.5 per cent, sodium chlo-
ride, and one per cent, nutrose (may be omitted).
Make neutral to litmus with soda solution, boil, and
filter into small flasks of 100 c.c. to 200 c.c. capacity.
Before adding the malachite-green solution, test
with neutral litmus paper, and slowly alkalinize with
sterile soda solution until the litmus strips give a
distinct red violet. The crystals of malachite green
(Hoechst) should be used to make this solution.
Lentz used different concentrations of the dye in
preparation of the medium, but Simon recommends
a concentration of 1:22,000 as being the most favor-
able. In such case make a fresh solution of 1:22(1,
and of this add 1 c.c. to each 100 c.c. of the hot agar,
thus obtaining the required concentration. The me-
dium is poured in Petri dishes, and allowed to cool for
use. Inoculations may be made upon its surface.
The dye inhibits the growth of B. coli and many other
organisms but in the above concentration the B.
typhosus develops slowly, usually from two to four
days. When kept in the incubator at 37° C. typhoid
colonies give the agar a yellow color. Test by specific
agglutinating serum to identify. Results obtained
by different observers have varied. It seems to be
difficult to secure a uniform preparation of malachite
green.
Lactose Litmus Agar. — This medium was intro-
duced by Wurtz, and is very useful in differentiating
between typhoid and colon bacilli. Acid formation
in the case of the latter is indicated by a change
in the reaction of the litmus. If this medium
is made by the addition of two per cent, of lactose
and litmus to the ordinary agar it will be found that
even typhoid bacilli will give a slight acid reaction.
This, however, is not due to the fermentation of the
lactose, but to the small amounts of muscle sugar
derived from the meat. It is therefore desirable
that the agar for this purpose should be made out
of sugar-free bouillon, which can be prepared accord-
ing to the directions already given. Prolonged boil-
ing of the agar must be avoided, inasmuch as the agar
itself, since it is a complex carbohydrate, may split
off some sugar.
It is often preferable to make the plain lactose
agar and to add to the tubed and sterilized medium,
whenever needed, by means of a sterile pipette, a
sterile litmus solution. Obviously other indicators,
such as rosolic acid, neutral red, etc., may be added
in the same way.
Glycerin Agar. — To the ordinary nutrient agar pre-
pared as above, five per cent, of glycerin is added.
The addition of glycerin serves to keep the surface
of the medium moist, and at the same time imparts
nutritive qualities to the agar. This medium is very
valuable for the growth of diphtheria, glanders,
pneumonia, and tubercle bacilli.
Glycerin Potato Agar. — In the culturing of the
glanders bacillus this medium has been found to be
especially valuable. It may be prepared as follows:
well-selected potatoes are peeled, washed in clean
water, then finely grated on a bread-grater; 500 grains
of the potato gratings are added to 1.000 c.c. tap water,
and allowed to macerate about eighteen hours in the
ice box; then heat to the boiling-point for fifteen
minutes; strain through several layers of cheese
cloth, or better a layer of absorbent cotton; to the
measured fluid add two per cent, of Witte's peptone,
and one-half per cent, of sodium chloride, dissolve
by heating; one and one-half per cent of agar is now
added and dissolved by heating in the autoclave for
one hour; the mixture is made neutral, using phenol-
phthalein as an indicator; when cool, add the whites of
two eggs, mix thoroughly, heat in Arnold sterilizer for
forty-five minutes; five per cent, of glycerin is added
to the filtered solution, then the medium is tubed and
sterilized in the autoclave for thirty minutes.
Mannite Agar. — Mannite, which like glycerin is a
polyatomic alcohol, was first used by Norris and Hiss
as a means of differentiating the typhoid from the
dysentery bacillus. The latter organism (Shiga type)
does not give rise to acid production when grown on
mannite media, whereas the typhoid bacillus does.
The agar should be prepared from sugar-free bouillon,
and to it one or two per cent, of mannite is then
added. Litmus may be added to the bulk medium
before it is tubed, or the sterile litmus solution may be
added to the sterile tubed agar by means of a pipette
whenever needed.
Pfeiffer's Blood Agar. — This is made by spreading
over the surface of ordinary inclined agar a few drops
of human blood. On. the surface thus prepared one is
able to cultivate the influenza bacillus. The blood
from the lower animals can be used in like manner to
good advantage.
The human blood required for this and similar pur-
poses can be drawn without difficulty by means of a
sterile syringe from the large median vein just below
the flexure of the elbow. The superficial circulation
should first be impeded by means of a rubber tube
tied about the middle of the arm. The surface of the
skin over the vein to be punctured is thoroughly
cleaned by means of a disinfecting solution, such as
mercuric chloride or lysol. The needle of the sterile
syringe is then introduced into the vein, and as the
piston is slowly withdrawn the syringe fills with blood.
Five or ten cubic centimeters of blood can thus be
obtained in a few minutes. When the needle is
withdrawn a compress of cotton, soaked in mercuric
chloride, should be applied to the wound. The blood
884
REFERENCE HANDBOOK OF THE MEDICAL S( II \< 1 -
Hi. i .-i iiii.it: l<:i! Tecbnlqne
must be al unci' transferred either to the surface oi
inclined agar or to previously melted agar, cooled t"
,50° C. In the lal ter case it is mixed at once, and I lie
tube is then set aside in an inclined position to solidify.
Thalhimer's Blood Agar. — This medium is a simple
modification of former methods for the preparation
of blood near. It is prepared as follows: fre hly
drawn beef blood is collected in a suitable jar, contain-
ing a number of medium-sized marbles, and defibrin-
ated by thoroughly shaking. To the defibrinated
blood an equal volume of distilled water is added and
laking is brought about. The laked blood is passed
through a sterile Reichel filter to remove bacteria.
Of the clear, red filtrate 20 to 30 c.c. are added to a
liter of sterile, melted agar at 45° C. The resulting
medium is clear, and bright red in color. The in-
fluenza bacillus grows readily upon this medium.
Also, the pneumococcus, streptococcus, and the
gonococcus grow luxuriantly. This medium is not
applicable to the study of the hemolytic properties
of an organism.
Blood-agar Mixture. — As mentioned above, human
blood may be mixed with melted agar, cooled to 5(1°
C, after which the mixture may be allowed to solidify
in an inclined position. For diagnostic purposes this
procedure has been utilized to detect the presence in
the blood of typhoid bacilli, gonococci, and other
organisms. Instead, however, of allowing the blood
mixture to solidify in the tube it is poured out into a
sterile Petri dish, and in this way a blood-agar plate
is obtained, on which eventually colonies of the sus-
pected organism may develop. The presence of a
very few organisms can thus be detected in 1 or 2 c.c.
of blood, which would not be possible by direct
examination or by staining. The amount of blood
which is added to the agar may be varied according
to circumstances. Thus it may be one to four, one
to two, or even one to one.
Blood from the lower animals can be drawn under
strictly aseptic conditions into sterile Nuttall's blood
pipettes, or into the modified form of Novy,
shown in Fig. 546. This can be easily made
from test-tubes of various sizes, according to
the kind of animal to be bled. Thus a five-
eight lis by five-inch test-tube may be used for
bleeding a mouse or rat, while a one by eight-
inch tube would be used in the case of a rab-
bit. The bottom of the test-tube and the end
of a piece of glass tubing are softened in the
flame of a blast lamp and then brought to-
gether. A narrow blast flame is then directed
against the test tube about an inch from the
bottom. On slow rotation in a horizontal
position a thickened constriction results, and
as soon as this is sufficiently thick the two
ends are drawn apart slowly. A tapering
capillary results, which is then sealed in the
flame at a point about two inches from the
tube proper. The tube is then plugged with
cotton and sterilized by dry heat. When it is
desired to prepare sterile defibrinated blood a
drawn-out tube or a narrow glass rod is passed
through the center of the plug. By moving
this about, after the blood has been
received in the pipette, complete
defibrination can be obtained, and
that without any contamination
from the outside.
In the case of the larger animals the blood is best
drawn from the carotid artery. For this purpose the
animal is anesthetized and the artery exposed for
about an inch. After the first incision it is advisable
to avoid the use of cutting instruments, and instead
to separate the tissues with the fingers. Pressure
forceps is then applied at the distal end of the artery.
Another pair is then applied about an inch below this
point. A finger is then placed under the clamped
portion of the artery and a very slight opening is
Fio. 546. — Blood
Pipette, Novy Form
made into the bl l-ve • I. 'I be blades of a very
narrow-pointed pair of forceps are then Introduced
into the opening, and, when distended, the tip of the
sterile blood pipette can readily be ced. Be-
fore i his is done, hou-e\ i T , thi tip ehed
with a file, then broken off, and the ope,, end sh<
be il: id for a moment to u
round off I lie -harp edge. \ oon B I he pipi tte is
in position the lower clamp is removed, when the
blood rapidly rises in the tube. If defibrinated bl 1
i desired, the blood should be stirred by an a
\\ he,, serum is wanted, this si irring is' omitti d.
oi m as blood ceases to flow . i he pipe! te i- rem..
and the tip is sealed in the bias! lamp.
Obviously in the case of small animal the
mouse or rat, this procedure is nol applicable. The
blood may be drawn up into a syringe from the art
A much better way, however, i- to take the blood
directly from the heart into a small pipette oi the
same form as that used for the larger animals. For
this purpose the thorax is opened, the heart is f
from the pericardium and rai ed by mean of oval-
tipped forceps. The tip of the pipette i- thi
duced into the right ventricle. Suction may be
applied to the other end of t he pipette in order to
obtain the fullest possible yield.
I'l 1 can be drawn from very large animals,
such as the horse, by introducing a linear into the
jugular vein. This is the procedure which is followed
in the preparation of antitoxins. The trocar is
connected by means of a short rubber tube with a
glass tube, which is inserted into the receiving
cylinder. In this way several liters of blood can be
drawn from the horse at each bleeding.
In ordinary laboratory work the blood which lias
been collected in the glass pipettes is then transferred
to melted agar, which has been previously cooled in
the water-bath to 50° C. The amount of blood which
is added to each tube will vary with the purpose in
view. It may be one part of defibrinated blood to
ten of agar or one to five, one to two, or one to one,
as the case may be. Exceptionally mixtures of two
to one and three to one are used. The blood is then
mixed with the agar and the tubes are set aside to
solidify in an inclined position. The transfer of the
blood to the tubes is best accomplished by means of a
sterile drawn-out bulb pipette, such as is shown in
Fig. 578, e.
The blood agar thus prepared requires no further
sterilization, for if the operation has been properly
carried out no organisms will be present. The tubes
can be used for culture purposes at once, or the}' may
be kept for several days to allow any organisms which
might be present to develop. This blood medium is
invaluable for the cultivation of various pathogenic
organisms. On such media it has been possible,
for example, to grow for the first time pathogenic
protozoa — Trypanosoma lewisi of rats and Trypano-
soma brucei the cause of nagana or the tsetse-fly
disease (Novy and McNeal). In studying the hemo-
lyzing properties of bacteria, it is more satisfactory
to prepare blood-agar plates. Usually one part of
sterile, defibrinated or cit rated blood is added to
nine parts of sterile agar at 45°-50 o C, well mixed,
then poured into Petri dishes to harden. The cit rated
blood is prepared by bleeding directly into a sterile
solution of sodium citrate of such concentration that
the resulting blood mixture will contain one per cent.
of the salt — this prevents coagulal ion. The organisms
under investigation may either be mixed with the
blood agar while at a temperature of l~>° C. before
plates are poured, or may be streaked over the sur-
face of the medium after hardening has taken place
in the dish.
Nory and McNi al's Blood Agar for Trypanisomes. —
Novy and McNeal have succeeded in cultivating a
number of the Trypanosoma!:! [Tr. lewisi, Tr. brucei,
Tr. evansi, and others) upon a specially prepared
SS5
Bacteriological Technique
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
artificial medium. It is made as follows: 125 grams
of rabbit or beef meat are extracted in 1,000 c.c. of
distilled water; add two per cent, of Witte's peptone,
one-half per rent, of salt, and two per cent, of agar.
Then make alkaline by adding 10 c.c. of normal
sodium carbonate. The agar thus prepared is tubed
and sterilized in an autoclave at 110° C. for thirty
minutes.
When cooled to about 50° C, two volumes of defi-
brinated rabbit's blood are added and the mixture is
allowed to solidify in an inclined position. After the
agar has solidified, the water of condensation which
settles at the bottom of the tube is inoculated with a
drop of freshly drawn blood from the infected animal.
The above investigators found that even the first
generation thrives upon this medium, and transfers
grow luxuriantly.
Dieudohne's Blood-agar Medium. — This selective
medium has proved to be of high value in the isola-
tion of the cholera vibrio from intestinal discharges.
Owing to its alkalinity it exerts an inhibiting influence
on the growth of fecal bacteria other than the spirilla
group. It is usually prepared as follows: 30 c.c. of
defibrinated ox blood are added to 30 c.c. of "NaOH
solution, thoroughly mixed, then heated forty-five
minutes at 100° C. in the steam sterilizer. While
still hot mix with 140 c.c. hot nutrient agar, and
pour thick plates. The nutrient agar is prepared
in the ordinary way, excepting it contains three per
cent, of agar, and 'must be neutral to litmus. After
pouring the plates they are partially dried by first
leaving the dishes open at room temperature for
twenty minutes, then placing them in an oven for
twenty to thirty minutes at 50°-60° C; finally, the
partially covered plates are placed in an incubator
at 37° C. over night. This treatment is necessary
before the cholera vibrio will grow upon the medium.
Several modifications of the medium have been
reported. It has been found that the meat infusion
may be omitted from the nutrient agar with the
advantage that the reaction need not be corrected
(Pergola). Pilon found that by using a twelve per
cent, solution of sodium carbonate (crystals) instead
of the sodium hydrate the plates could be prepared
for immediate use without the heating of the blood
mixture.
Krumwiede found that whole egg might be sub-
stituted for the ox blood, and recommends the follow-
ing formula, which includes the modifications men-
tioned above, for a medium: equal parts of water
anil whole egg are thoroughly mixed, then add a like
volume of 12-13.5 per cent, sodium carbonate solu-
tion, shake mixture, then filter through a thin layer
of cotton: steam twenty minutes in the Arnold ster-
ilizer. Thirty parts or this product are added to
seventy parts of boiling hot agar, well mixed, then
medium thick plates are poured. The agar is meat
free, and is composed of peptone and salt as commonly
prepared, and three per cent, of the agar. The plates
are dried at room temperature for twenty to thirty
minutes, then surface inoculations may be made at
once.
This modification offers several advantages; it is
a translucent medium which may be quickly pre-
pared for use, and gives distinctive colonies of the
vibrios.
Serum Agar. — This is made by adding variable
amounts of sterile serum to the melted agar, which
has been cooled to 50° C. in the water-bath. The
serum can be obtained by collecting the blood, as
given above, in sterile pipettes. The blood is allowed
to clot, and eventually when the serum has separated
it can l>e drawn up into sterile bulb pipettes and
transferred to the melted agar. The largest yield of
serum is obtained by using t lie Latapie pipette shown
in Fig. 547. This consists of an inner tube, which
is freely perforated and the narrow outer end of
which is drawn out into a capillary for insertion into
the blood-vessel. This tube is held in position within
the outer one by means of a rubber stopper. The
outer receiving tube, which is about an inch in diam-
eter, is provided with two side tubes, one of which is
drawn out and sealed while the other is plugged
with cotton. The entire pipette is first sterilized
by steaming in an autoclave. The tip of the inner
tube is then broken, flamed, and inserted into the
carotid artery of a rabbit or other animal. The
blood should not fill the pipette beyond the inner
tube. The tip is then sealed and the pipet te is allowed
to remain in a vertical position until the blood has
firmly clotted. It is then inverted and the serum,
as it is squeezed out of the clot, falls to the bottom.
The purpose of the perforated
inner tube is to allow more com-
plete shrinking of the clot. The
serum drains away at once from
the clot, and is therefore perfectly
clear. When it is desired to re-
move the serum the tip of the side
tube is scratched with a file, then
broken off, and the end is flamed
to insure absence of bacteria. The
tube is then inserted into a sterile
test-tube or flask and by blowing
into the other side tube the serum
is forced out. It can then be dis-
tributed to the agar tubes by
means of a sterile bulb
pipette. These are ^_^^
then allowed to solidify " * '■
in an inclined position.
As in the case of blood
agar the medium prepared in this
way is perfectly sterile if the
manipulation is properly carried
out. Inasmuch as sterilization
by heat is avoided, the protein
constituents of the serum remain
in as near to the native condition
as possible. Such serum agar
makes an excellent medium f or Fio. 547 —Blood Pipetto
the pneumococcus and for other Latapie.
organisms. Obviously, serum-agar
plates can be prepared, if it is so desired, in which
case the melted and cooled agar is inoculated with the
organism to be cultivated, after which the serum is
added and mixed with the agar, which is then poured
out into sterile Petri dishes.
Serum agar, made by adding human blood serum
to melted agar, has been used for the cultivation of
the gonococcus (Wertheimer). Ascitic or pleuritic
fluid may also be added to agar in the proportion of
one part of the fluid to two parts of the agar. Such
agar is used especially for the cultivation of the
gonococcus. The ascitic, pleuritic, or hydrocele
fluids may be sterilized by fractional sterilization or
by filtration through a Berkefeld filter underpressure.
Wassermann's Serum-nutrose Agar. — This also has
been found useful for cultivating the gonococcus.
Five cubic centimeters of hog serum are added to 30 to
35 c.c. of water, 2-3 c.c. of glycerin, and 0.8-0.9
grams of nutrosc. Nutrose is a sodium-phosphate
casein compound, and when added to serum prevents
coagulation on boiling. The solution is boiled for
twenty minutes, after which it is added in equal
parts to two per cent, peptone agar in test-tubes.
This mixture is then poured into Petri dishes. Nu-
trose has been used also in the preparation of the
Drigalski-Conradi agar. Hog serum, which is said
to be as good as human serum for cultivating the
gonococcus, has been employed also by Thalmann.
Drigalski-Conradi Agar.— This is a meat-peptona
nutrose agar containing lactose, litmus, and crysta
violet. The preparation is as follows: 1. A mixturi
of three pounds of meat and two liters of water is
SS6
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Bacteriology :.i Ti-cimiquo
allowed h> stand for twenty-four hours; the expressed
meal juice is then boiled for one hour and altered,
To (lie filtrate arc added JO grams of \\ itte's pep-
tone, 20 grains of nutrose, lit grams of -odium
Chloride, and the whole is boiled for One hour and fil-
tered. To this filtrate sixty grams of agar are added
and the liquid is boiled for three hours, or < hour in an
autoclave. It is then rendered alkaline to litmus paper,
boiled half an hour, and filtered. L\ A sol ut ion of litmus
is prepared according to Kubel-Tiemann as follows:
The powdered commercial litmus is repeatedly ex-
tracted with hot distilled water. The liquid is acidu-
lated with dilute acetic acid and evaporated to
syrupy consistence on a water-bath. The thick fluid
is then diluted by the gradual addition of ninety-
per-eent . ali ill ml, transferred to a flask, and an excess
of ninety-per-eent. alcohol is added. Tins precipi-
tates I lie blue pigment, while the red dye and I lie
potassium acetate remain in solution. The precipi-
tate is filtered and washed with alcohol, then dis-
solved in distilled water, after which the solution is
wanned and filtered. The filtrate is then added
gradually to very dilute sulphuric acid (one or two
drops of acid to 200 c.c. of water) till the color changes
to a wine red. The concentrated blue is then added
till the blue color is restored; 200 c.c. of this litmus
.solution is boiled for ten minutes, then thirty grams of
pure lactose are added, and the boiling is continued
for fifteen minutes. 3. The hot litmus is added to
the hot agar, mixed, and the reaction is made slight ly
alkaline; 4 c.c. of a hot sterile solution of ten-per-cent.
anhydrous soda and 20 c.c. of a freshly prepared
solution of 0.1 gram of crystal violet in 100 c.c. of
warm sterile water are then added, after which the
material is filled into tubes or flasks. Excessive
heating should be avoided, inasmuch as it alters the
lactose. The crystal violet is intended to restrict the
development of the unimportant bacteria.
The Drigalski-C'onradi medium has been recom-
mended for the isolation of the typhoid bacillus.
For this purpose the feces should be diluted with
ten to twenty volumes of salt solution. The authors
employ large plates, fifteen to twenty centimeters
in diameter. The agar is poured into the dishes to a
depth of at least two millimeters and the cover is then
kept off till the moisture has dried from the surface
of the agar. By means of a five-millimeter glass
rod, bent at right angles and previously dipped in
the suspension, a series of streaks are made over a
number of the dishes. The inoculated plates are then
kept at 37° C. for twenty-four hours. The colon
colonies are large, opaque, and red, while the typhoid
are small, glassy, and resemble dewdrops. The further
identification of the suspected colony is made by
applying the agglutination test and by growing in
Rothberger's neutral red agar.
MucConkey's Bile-salt Agar. — This medium is pre-
pared by dissolving one and one-half or two per cent,
of agar in bile-salt bouillon stock solution (see bile-salt
medium). If necessary it is cleared with egg-albumin.
Neutral red and a given sugar are then added, as
in the case of the broth preparation. It is used in
the examination of feces, sewage, etc., for intestinal
bacteria. The method of procedure is practically
the same as that given under the Drigalski and
Conradi medium. The growth of most bacteria is
inhibited, while that of B. coli and B. typhosus is
not. Colonies of acid-producing bacteria appear
rose-red in color. Alkali gives a yellow-red with
this indicator on plates. Other modifications are
used by water analysts.
Esculin Bile-salt Agar. — This medium is recom-
mended by Harrison and van der Leek in water
analysis for the detection of B. coli and certain other
excretal organisms. For its preparation they give
the following method: 15 grams of agar, 2.5 grams
of commercial bile salt, and 10 grams peptone
(Witte) are dissolved by boiling in 1,000 c.c. distilled
water. The solution I neutralized with normal
solution of sodium In. Irate. After cooling dl
below tin 1 ( '. t lie v. hite ,,f i wo e L ' L -- ai
i -It i Mi ii i i heated |,i boiling to coagulate I he albumin;
i he coagulum i- removed by filtration. If i
it is neutralized again, and to the hoi filtrate are
added 1 gram esculin (Merck) and I gram iron
citrate scales (Merck). After solution of tl
substances the a< idity is taken with decinormal oda
solution, if the acidity proves high, alkali is added
to bring down to , 0.6, if too low. more iron citral
added until I he react ion is t 0.6. Sterilize by steaming
twenty to thirty minutes on three consecutive d
[f the direct it 1 1 efully followed in the prepara-
tion of this medium it is claimed that ati factory and
even results will be obtained. The reaction with a.
and some other organisms is due to the splitting of
the esculin into glucose and e culetin; the esculetin
unites with the iron in the medium to form a dark-
brown salt. The medium must be sugar-free in order
to give the reaction. Ik lactis aerogenes gives the
nin lion but if may be included in "pre uinptive
tests" as an excretal organism. Some moulds and
laet,.-e fermenting yeasts also gives the test, a fact
which must be considered in certain examinations.
/;. re// coii uiies in this medium appear black with a black
halo about them. While />'. typhosus grows well upon
this medium, it does not produce the color reaction.
Matzuschita's Liver-gall Agar. — This medium is
especially recommended for the cultivation of the
intestinal flora. It is prepared a follows: Take
500 grains of finely chopped ox-liver; 30 grams
peameal; add 1 liter of distilled water and cook
until the soluble constituents are extracted. The
residue is removed by straining through muslin, and
to the filtrate add 7 grams peptone, 5 grams sodium
chloride, and 0.2 gram hydrochloric acid. The whole
is carefully shaken and then allowed to stand at
37° C. for three hours. After this 600 grams of
ox-gall are added, and the whole is again allowed to
stand for three hours at incubator temperature. It
is then heated for some time, filtered, and sufficient
agar (two per cent.) is added to give solid medium.
Filter, place in tubes, and sterilize. This medium,
notwithstanding the addition of the hydrochloric
acid, remains slightly alkaline. Matzuschita recom-
mends, for the culture of intestinal bacteria, that the
medium be neutral or very slightly acid.
Placenta Glycerin Agar. — Duval and WeUman
found that a medium containing untreated placental
juice was valuable for the cultivation of B. I
from the tissues. Of the different media employed
for this purpose, this was the simplest, and one most
easily prepared. Its special value seems to be due
to the large amount of amino-acids present in pla-
cental tissue. According to these authors, the
medium is prepared by taking a fresh human placenta
and washing out the contained blood by running
sterile saline solution through the blood-vessels;
after this the placenta is ground up in a meat chopper,
To each pound of the chopped up tissue, 0.5 liter of
sterile salt solution is added; the mixture is placed in an
ice bos and allowed to stand for forty-eight hours; the
fluid portion is separated and passed through a pre-
viously tested No. N. Berkefeld filter for sterilization;
to the clear, amber-colored filtrate, a two-per-cent.
sterile agar is added at a lemperat i ire of about 11 ( '.;
the addition of t hree-per-cent. glycerin to the agar
before sterilization is recommended; the ingredients
are thoroughly mixed, placed in tubes and slanted
to cool. Placental fluid alone also serves as a good
medium for the leprosy organism. It is claimed that
transplants of macerated leprosy tissue containing
the ai id-last organism will show a visible growth in
five to seven days upon this medium. /»'. tubi -
culosis and other acid-fast organisms (rat leprosy)
grow readily on the placenta medium.
a, latin Agar. — Several formulas have been pro-
ssr
Bacteriological Technique
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
posed for the preparation of this medium. Each
rinds its special application. That of C'apaldi was
recommended for the isolation of the typhoid bacillus
from feces. It is made by dissolving twenty grams of
Witte's peptone, ten grams of gelatin, ten grams of
glucose or of mannite, five grams of sodium chloride,
and five grams of potassium chloride in 1,000 c.c. of
water. The solution is filtered and two per cent,
of agar is added and dissolved by boiling, after which
it is rendered alkaline by the addition of 10 c.c. of
normal alkali. The filtered solution is then tubed
and sterilized by steaming.
Bccr-wort Agar. — Wort is of particular value in the
cultivation of yeasts and it is also used in the study of
certain bacteria. It may be used in the fluid form,
or solidified by means of either gelatin or agar.
Eyre recommends its preparation by taking 250
grams of crushed malt and placing it in a two-liter
flask with 1,000 c.c. distilled water. The mixture is
first heated up to 70° C. in the stoppered flask, then
placed in a constant-temperature water-bath, and
allowed to macerate at 60° C. for one hour. The
fluid portion is separated by straining through muslin;
then it is heated for thirty minutes in a steam steril-
izer and followed by filtration. The natural reaction
of the resulting wort is left unchanged.
In case the solid preparation is desired, add two
per cent, agar and proceed the same as in the prepara-
tion of nutrient agar. Sterilization is carried out by
placing in a steam sterilizer at 100° C. for twenty
minutes on each of three consecutive days.
Stoddart's medium is a gelatin agar which con-
tains five per cent, of gelatin, one per cent, of peptone,
and a half per cent, each of agar and of salt. A liter
of meat extract is prepared in the usual way. In this
ten grams of peptone and five grams of salt are dis-
solved, and the solution is then divided into two parts.
To one portion ten per cent, of gelatin is added, and
when this has dissolved, the solution is neutralized and
an excess of 10 c.c. of normal alkali per liter is added.
The other half of the meat extract is likewise neu-
tralized, and then 10 c.c. of the normal alkali are added
per liter to impart the requisite reaction. The liquid
is then measured or weighed, boiled, and filtered.
Five grams of cut agar are added to the bouillon,
which is then boiled until the agar dissolves. Dis-
tilled water is added to make up to the original
volume or weight, after which the two liquids are
combined and allowed to sediment. The entire
product is finally filtered through cotton or, better,
through paper. The medium is filled into tubes
which are then steamed for fifteen minutes on each
of three consecutive days. To use this medium, it
is poured out into sterile Petri dishes, and when
solidified the center is touched with the organism
to be tested. The typhoid bacillus, on account of
its motility, spreads rapidly over the surface as an
almost transparent growth whereas that of the
colon bacillus spreads less and is easily visible.
Guarnieri's gelatin agar is made in a somewhat
similar manner. Three grams of powdered agar are
emulsified with 50 c.c. of distilled water, and this is
then added to a solution of fifty grams of gelatin in 750
c.c. of meat extract. The whole is boiled till the agar
has dissolved, when a solution of twenty-five grams of
Witte's peptone and five grams of salt is added. The
entire liquid, which now makes up to one liter, is then
carefully neutralized with normal alkali, using litmus
as an indicator. The medium is tubed and sterilized
as usual. It has been used to advantage in the culti-
vation of the pneumococcus.
Weil's Meat-potato Agar. — The potato juice is pre-
pared as in the method of Holz or Eisner; 300 c.c. of
this are added to 200 c.c. of slightly alkaline bouillon;
3.75 grams of agar is then dissolved in the liquid, thus
yielding a 0.75-per-eent. agar solution. The typhoid
"bacillus presents threaded colonies on this medium,
the same as in Eisner, Hiss, and Piorkowski media.
Noguchi's Ascitic-fluid Tissue Agar. — Noguchi has
succeeded in making direct cultures of Treponema
(Spirochete) pallidum, and other spirochetes from
fresh infectious material from man. For this pur-
pose a medium is prepared as follows: two parts of
two per cent, slightly alkaline agar (at 50° C), are
added to one part of ascitic (or hydrocele) fluid,
thoroughly mixed in a tube in the bottom of which is a
fragment of sterile tissue. Rabbit kidney or testicle
is preferable, although other tissues as human pla-
centa, sheep-testicle, etc., may be used. The culture
medium is allowed to solidify in the tubes, then a layer
(three centimeters) of sterile paraffin oil is added to
prevent evaporation, and exclude the. air. The material
(tissue) for inocidat ion containing the organ isms should
be immersed immediately after removal in sterile phy-
siological salt solution, containing one per cent, of so-
dium citrate, and cut into small bits, some of which
are rubbed up into an emulsion in the citrate solution.
Each tube is inoculated with some of the bits of tissue
by pushing them to the bottom of the culture tubes
with a heavy platinum loop, also some of the emul-
sified material is deeply inoculated into the same
tube by means of a capillary pipette. Care must be
taken not to break up the medium. The contami-
nating bacteria which are present in first inocula-
tions appear to grow along the line of the stab,
while the spirochetes grow out into the medium for a
distance. The culture may finally be purified by
taking transplants from the distant outgrowths and
carrying over to fresh medium several times.
Noguchi has found this method applicable to the
isolation and cultivation of other spirochetal. He
succeeded in separating Spirochicta refringens from
infected tissue, and growing it in pure culture by the
procedure just outlined. Likewise, he isolated in
pure culture certain mouth spirochetal (Treponema
microdentium, Tr. macrodentium). In these cases, it
was necessary to enrich the material by growing one
or more generations in a special fluid medium. This
medium was composed of a large quantity of sheep
serum water (1 part serum and 3 parts of distilled
water) in a tube containing sterile tissue (kidney or
testicle of rabbit or sheep), and covered with a layer
of sterile paraffin oil. The inoculated tubes were
incubated at 37° C. for about ten days, during which
time the medium became more or less coagulated by
the contained bacterial growth. A small amount of
the impure culture was removed from the bottom of
the tube by means of a capillary pipette, and inocu-
lated into a solid medium composed of sterile serum
agar (in ratio of 1 to 3) and containing sterile tissue
(sheep or rabbit). The procedure was quite the same
as mentioned for the inoculation of tubes for the
cultivation of Treponema pallidum. After inocula-
tion the medium was covered with a layer of sterile
paraffin oil to exclude the atmospheric oxygen.
Noguchi's Method for Cultivating Treponema Palli-
dum in Fluid Media. — Experience has demonstrated
that Treponema pallidum cannot be cultivated con-
stantly in fluid media (even when they contain fresh,
sterile tissue), by the ordinary anaerobic methods.
Noguchi has overcome this difficulty by a method in
which both solid and fluid media are used in combina-
tion for simultaneous cultivation of the organism.
The method is as follows: A culture tube is first pre-
pared by fusing a short piece of strong glass tubing
(0.7 cm. bore) to the perforated bottom of a test-tube
1.7 cm. wide and 20 em. long, thus giving an outlet;
after thoroughly cleaning, the larger end of the tube is
plugged with non-absorbent cotton, the smaller end
(fused in tube) is passed through a perforated rubber
Stopper (No. 5), which in turn is fitted into a test-tube
2.5 cm. wide and 15 cm. long. The double tube, as
now set up, is sterilized in the autoclave in the regular
manner. When cool, the rubber stopper together with
the smaller (upper) tube is removed, one or two pieces
of sterile, fresh rabbit kidney are placed in the larger
888
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Bacteriological Technique
(lower) till"', then the two pails arc tightly fitted
together and not again taken apart. A piece of the
tissue, of such size that it will not pass I he bottom
outlet, is placed in the upper tube. .Next the Lower
tube is tilled from above through the upper tube
with ascitic fluid or a mixture of ascitic fluid and
bouillon, by means of a sterile hull) pipette. ] hi
pipette must have a small outlet tuhe which will
easily pass through the connecting tube of the double
culture tube, for delivery of the fluid, and freely per-
mit the escape of air. The lower tube must be com-
pletely filled to exclude till air bubbles. The next step
IS the inoculation with 77. pallidum, which should be
taken from a well-growing, pure culture. A portion
may be aspirated into a long capillary glass pipette
(sterile) by means of a syringe connected with a
piece of rubber tubing — a part of the material is dis-
charged into the fluid in the lower tube, the rest sur-
rounding the tissue in the upper tube. After the
inoculation the upper tube is almost filled with a solid
medium compound of one part of ascitic fluid and
two parts of a sterile, slightly alkaline, two per cent,
agar, mixed at a temperature of about 42° C. and
poured on while still fluid. Finally the surface is
covered with sufficient sterile paraffin oil to give a
depth of about three centimeters over the solidified
agar. The culture is incubated at 37° C. Utmost
care must be taken to prevent bacterial contamination
during the above manipulations.
Noguchi's Method for Cultivating the Spirochetal of
Relapsing Fevers. — Noguchi succeeded in growing in
pure cultures, four different species of spirochaetffi
(.s'/>. duttoni, Sp. kochi, Sp. obermeieri, Sp. novyi)
which give rise to the diseases classed as relapsing
fever. For this purpose he employed a fluid medium
with sterile fresh tissue, and proceeded as follows: a
piece of sterile fresh tissue (usually rabbit kidney)
was placed in each of a number of sterile test tubes,
two by twenty centimeters, to which were added a
few drops of citrated blood, drawn aseptically from
the heart of an infected mouse or rat; at once about
15 c.c. of sterile ascitic or hydrocele fluid were added
to each tube; to some of the prepared tubes a layer of
sterile paraffin oil was added others were left without
the oil. The presence of some oxygen seems necessary
for the growth of the organisms. The blood for inocu-
lation of tubes is best when taken from the animal
between forty-eight and seventy-two hours after it
has been artificially infected. It is essential that
ascitic fluids, which are to be used in this medium,
must contain no bile, but have the power to form a
loose fibrin when added to the fresh tissue in the tube.
The maximum growth at 37° C. in the inoculated
tubes was reached after seven to nine days.
Substitutes for the Meat Infusion. — In the prepara-
tion of the foregoing media a meat infusion serves as
the basis in each case. In special instances, but not
as a routine procedure, these media may be modified
by using the commercial Liebig's beef extract in place
of the meat infusion. The chief advantage lies in the
fact that the beef extract can be kept always on hand.
At the same time it must be remembered that media
made up with such extract are by no means as nutri-
tious as those made up with the meat infusion. The
amount of Liebig's extract which is used varies with
different workers. In general, from one to three grams
are added to one liter of water; five and even ten grams
may be used. To this solution peptone and salt may
be added in the usual amounts. The liquid when ren-
dered alkaline and filtered constitutes a Liebig's-
extract bouillon. In the same way gelatin and agar
media are prepared.
Peptone Substitutes. — Several compounds have been
suggested as substitutes for Witte's peptone. In Mar-
tin's and Pcckham's bouillon and in Deyeke's agar
this peptone is replaced by that which is formed by the
digestion of the muscle tissue. In other media
derivatives of albumin or casein are employed.
Heyden's "Nahrstoff " i ed egg albuminate,
while nui rose i a casein compound I he addition
of lecil hin, |n gen, he globin, etc., i made with
the object ot improving the nutritive qualitii tofthe
media.
Hiss' Tube Medium. — This is u ed a a meai
g for the typhoid bacillus. It i made by add-
ing 5 grams of Liebig's extract 5 grams of salt and S
grams of agar to 1,000 c.c. ol water. I he mi
is then heated until the agar ha di olved, after
which the water which i, [ s( by evaporation is
replaced and then eight per cent. 'gelatin i added.
As soon as the gelatin has di olved, the liquid is
partially neutralized by the addition of normal alkali.
The reaction is left acid, and to such an e ti ni that
ii would require 15 c c. of normal alkali per liter to
make the solution neutral to phenolphthalein. The
licpiid is then cooled to 60° (', and cleared by the
addition of the white of an egg stirred up in about 25
c.c. of water. The liquid is then boiled for a few
minutes, after which ten grams of glucose are added.
After sedimentation at 50 C. the medium can be
filtered through paper or cotton and tubed. This
medium is used only for slab cultures. Diffusion of
the growth through the medium in the case of very
motile organisms, such as the typhoid bacillus, anil
the production or absence of gas, are the criteria
sought lor.
Hiss' Plate Medium. — Hiss utilized the tendency of
the typhoid bacillus to form threaded colonies when
grown on soft media, as a means of differentiation
from the colon bacillus. The medium, as first pro-
posed, contained 1.5 grams of agar, 15 grams of
gelatin, 5 grams each of Liebig's extract and of
sodium chloride, 10 grams of dextrose, and 1,000 c.c.
of distilled water. This was cleared by the addition
of the whites of two eggs and filtered through absor-
bent cotton. The reaction was left acid, and of such
extent that it would require the addition of 2 c.c. of
normal alkali to make it neutral to phenolphthalein.
Subsequently Hiss made various modifications of
this formula, eliminating the unnecessary constitu-
ents. The simplest combination, which was found to
give excellent results, was made by adding 15 grains
of agar and 5 grams of Liebig's extract to 1,000 c.c.
of distilled water. No acid or alkali was added.
The medium was cleared by the whites of two eggs
and filtered through cotton. Plate cultures, made
at 37° C, show excellent differentiation between
the colonies of typhoid and colou bacilli in twenty-
four hours. The former show threaded colonies,
the latter do not.
Hesse's Nahrstoff-Heyden Agar. — The "Nahrstoff-
Heyden" is an albumose made from egg-albumin. It
should first be stirred up in a beaker with a little
water, and then added to the liquid. For cultivating
the tubercle bacillus the medium consists of: 5 grams
nahrstoff-Heyden, 5 grams salt, 30 grams glycerin,
10 grains agar, and 1,000 c.c. of distilled water; 5 c.c.
of normal soda solution are added. The latter repre-
sents a 14.3 per cent, of the crystalline salt t Xa t'0 3 +
1011,0) and not 28. G per cent., as stated by Hesse.
The Hesse-Niedner agar, wdiich has been recom-
mended for the study of water bacteria, is made by
dissolving 7.5 grams of nahrstoff-Heyden and 12.5
grams of agar in 1,000 c.c. of distilled water. Gage
and Phelps dissolve one per cent, each of agar and of
the nahrstoff in 1,000 c.c. of distilled water, and make
the solution neutral to phenolphthalein.
Blood Serum. — The preparation of serum from small
animals has been described at length under serum agar.
When it is desirable to use large quantities of serum
it is advisable to collect ox blood at a slaughter-house.
The more care taken in collecting the blood under
aseptic conditions the less troublesome will be the
subsequent sterilization. A convenient receptacle is
a half-gallon battery jar covered with paper and pre-
viously sterilized. The spurting blood is received
ssi)
Bacteriological Technique REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
directly into the jar, after which the paper cap is
replaced and the blood set aside until it firmly clots.
It can then be transported to the laboratory and set
aside in a cool place for the serum to separate. The
serum can then be drawn up by means of an aspirator
into a sterile globe receiver, such as is shown as a
part of Fig. 551. It can then be conveniently filled
into test-tubes or into flasks.
The earliest method of sterilizing blood serum is
that of Koch by fractional heating. The tubes are
placed in an inclined position in a serum coagulator
shown in Fig. 548. The Roux water-bath, shown in
Fig. 554, is particularly useful for this purpose.
The serum tubes are immersed in the water at 58° C.
and are heated for an hour at 58° C. on each of seven
successive days. This low temperature is selected
in order to accomplish the sterilization and yet keep
the serum in a fluid condition. Unfortunately
bacteria may be present in the serum which will
actually grow at the temperature employed, and in
that case this method of sterilization is inapplicable.
Fig. 54S. — Koch's Blood-serum Coagulator.
Some have endeavored to obviate this difficulty by
filtering the serum through a Berkefeld bougie.
Martin suggested that one to two per cent, of chloro-
form be added to the serum, which is then set aside
for several months, after which the chloroform can
be driven off by heating at 05°. Fraenkel dispensed
with the sterilization, relying entirely upon the asep-
tic collection of the serum. When the serum is
collected with the care outlined above, it will be found
that very few bacteria are present. Consequently
after the tubes have been filled with the serum they
may be incubated for several days, and at the end
of that time the contaminated ones can be discarded.
This procedure is preferable to those just given.
The sterile serum is then coagulated in an inclined
position by raising the temperature of the sterilizer
to 65° C, and keeping it there until the serum has
become solid. The medium thus prepared is trans-
parent and solid. When a higher temperature is
used, the serum coagulates to an opaque white mass.
Inasmuch as the above methods require much time
and skill and are in themselves very tedious, they
have been largely supplanted by fractional steriliza-
tion in steam. For this purpose the tubes are first
placed in an inclined position, either in a dry-heat
oven, or, better, in the coagulator, and then heated
to 85° to 95° C. until firm coagulation results. If
this is not looked after, the medium will be torn up
by gas bubbles during the next step. The coagulated-
serum tubes are then placed in wire baskets and
steamed, as in the case of agar, for half an hour on
each of three consecutive days. The medium thus
prepared is fully as useful as that which is transparent.
LdJJlcr's Blood Serum. — This consists of one part
of a one-per-cent. glucose bouillon and three parts
890
of blood serum. The mixture is filled into tubes and
sterilized in the manner just given. It is used verv
extensively for the diagnosis of diphtheria.
Alkaline Blood Serum (Lorrain Smith). To each
100 c.c. of blood serum add 1.0-1.5 c.c. of a ten-per
cent, solution of sodium hydrate, and shake gently"
Place in tubes and sterilize as mentioned under blood
serum. A clear solid medium results, consistine
principally of an alkali-albumin. This medium i<
also used in the cultivation of B. diphtheria
Glycerin Serum.— Five per cent, or more of' glycerin
is added as in the case of glycerin agar. The sterilize
tion is the same as that just given. It is used fur
the cultivation of the tubercle bacillus.
Serum-water Media.— When serum is diluted with
five to ten parts of water it can be sterilized by steam-
ing without coagulation taking place. Hiss employed
such a medium in differentiating between the pneu-
mococcus and streptococcus; also in distinguishing
between the dysentery and allied organisms He
prepares the medium by adding one part of' clear
beef serum to two parts of distilled water The
mixture is first heated to 100° for a short time so as
to destroy the glycolytic enzyme which is present
after which one per cent, of the sugar desired is added'
Dextrose, galactose, mannite, maltose, lactose sac-
charose, inulin, and dextrin have been thus 'used
The medium is colored by the addition of one per
cent, of a five-per-cent. aqueous litmus solution
The medium is then tubed and steamed for ten mini
utes on three consecutive days.
Marmorck's Media. — In order to maintain strepto-
cocci at their maximum virulence Marmorek used
several media, preference being given to them in the
following order:
1. Human serum 2 parts, bouillon 1 part.
2. Pleuritic or ascitic fluid 1 part, bouillon 2 parts.
3. Serum of mule or ass 2 parts, bouillon 1 part.
4. Horse serum 2 parts, bouillon 1 part.
These media can be sterilized by fractional heating
at low temperature, or, better, by nitration through a
Berkefeld bougie.
Thalmann's serum bouillon for cultivating the gono-
coccus has been mentioned in connection with his
agar.
Milk. — This is an excellent medium for diagnostic
purposes. It is advisable to use centrifugated milk if
possible. Otherwise the whole milk is placed in a
beaker or flask and steamed for about half an hour.
When partially cooled it can be poured into a large
separatory funnel, or into a bulb receiver shown as
part of Fig. 5072, and allowed to stand thus overnight.
The underlying layer of fat-free milk can then be
filled directly into tubes. These are then sterilized
by steaming half an hour on each of three consecutive
days. When time is an object the whole milk may
be filled directly into tubes. If desired the milk
may be colored with litmus. Instead of milk, whey
may be used to good advantage. This can be pre-
pared by coagulating the milk with rennet. The
liquid is first separated by means of cheese-cloth
and finally put through paper. It is then colored
with litmus, filled into tubes, and sterilized. Care
must be taken not to overheat the milk lest the lactose
undergo more or less oxidation. Whey-gelatin and
whey-agar are used for special purposes.
Petrusehky's Litmus Whey. — Very dilute hydro-
chloric acid is added to slightly warmed, fresh milk.
The casein is precipitated and removed by filtration.
The acid is just neutralized by the addition of dilute
sodium hydrate solution, then the fluid is steamed
for two or three hours, thus throwing out any acid
albumin which might have been in the solution.
The fluid when filtered off through paper should be
just neutral and colorless. Litmus solution is added
in sufficient quantity to give a distinct tint. Sterilize
as in ordinary milk tubes.
Urine. — By discarding the first portion of urine
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Bacteriological Technique
which is passed, the remainder can l»> collected in
sterile flasks and will l>c free from bacteria. Such
urine may be used directly for studying the various
fermentations which it may undergo. To prepare a
urine gelatin the secretion should be diluted so as to
have a specific gravity not to exceed 1.010. Ten
per cent, of gelatin is then added, and when il
dissolved the reaction is made to correspond to that
of the original urine. Heller's urine gelatin is pre-
pared in the same way, but has one per cent, peptone
and a half per cent, of salt. After solution the Liquid
is rendered faintly alkaline, then filtered and tubed.
Piorkowski Urine Gelatin. — Normal urine of 1.020
specific gravity is collected for two days, and is
allowed to become slightly alkaline in reaction. Then
1.5 per cent, peptone and 3.3 per cent, gelatin are
added, and the mixture is heated for one hour on the
water-bath, after which it is filtered and tilled into
tubes. These are sterilized by heating at 100° ('. for
fifteen minutes on the first day, and for ten minutes
on the second day. The medium is used to differen-
tiate the typhoid from the colon bacillus. Petri
plates are made and developed at 22° C. for twenty-
four hours. While the colon colonies are roundish,
finely granular, sharp-bordered, and yellowish, the
typhoid colonies are small and show a more or less
marked threaded border. This method has given
good results in connection with the examination of
typhoid feces.
Urine Agar. — This can be prepared by adding to
the freshly passed urine two per cent, of finely cut
agar. The mixture is then boiled until solution
results, when it is filtered through cotton or paper as
in the case of ordinary agar. This agar is then filled
into tubes and sterilized by steaming.
Another way of preparing a urine agar is to collect
the urine, after discarding the first portion which is
passed in a sterile flask, and then to transfer it by
means of a pipette, as in the case of blood or serum,
to the melted and cooled agar. One part of urine
to two parts of agar is ordinarily used. Normal or
albuminous urine may be used for this purpose, and
with very little care the urine can be collected entirely
free from bacteria. Such urine agar has been used to
advantage for growing the gonococcus.
Ox-bile Medium. — Conradi, Coleman, and Buxton,
as well as others, have recommended ox-bile media
in making direct cultural examinations of blood from
typhoid-fever patients. Ox bile possesses certain
advantages for this particular work since it prevents
coagulation of blood, inhibits the bactericidal action
of freshly drawn blood, and at the same time serves
as an excellent culture medium for B. typhosus.
Coleman and Buxton prepare their medium by adding
two grams peptone and 10 c.c. glycerin to 90 c.c. ox
bile. The mixture is placed in flasks of '20 c.c. each
and sterilized. The blood (3 c.c.) from the patient is
placed in flask, then incubated. The organisms
develop rapidly, usually in from twelve to fourteen
hours. Transplants are made to other media for
further growth and diagnosis.
Jackson's Lactose-bile Medium. — This medium has
been found to be especially useful in the isolation
of B. coli. and B. typhosus from water, milk, etc.
It is prepared from undiluted ox-gall (or, an eleven
per cent, solution of dry fresh ox-gall), to which is
added one per cent, of peptone and one per cent, of
lactose. The medium (40 c.c.) is placed in fermen-
tation tubes and sterilized by the fractional method.
The suspected water or milk is added in varying
amounts up to 10 c.c. to the sterilized medium in
the tubes. In this medium B. coli and B. typhosus
rapidly overgrow other organisms; the B. typhosus
may finally overgrow the B. coli. It is valuable as an
enriching medium.
Internal Organs. — For special use the several media,
such as bouillon, agar, and gelatin, may be made up
with the finely divided organs in place of the minced
meat. At times the -olid organs •,,,• terilized and
u-ed as such. For this purpose the spleen, li
panel,., . brain, intestinal mucosa, etc., have I
used. Matzuschita recommends their use in agar
preparations (as a substitute for th, ■ beef) fop
the pecial study of the flora of thi ,-,al.
'I"he steamed brain, for example, v. he,, cu( Up
slices and sterilized, can I i for cultivating
rele bacillu I er) and also the goi
(Thalmann I.
Egg Media.- Hueppe fir-t suggested tic use f
fresh eggs as a culture medium. For this purpos,
shell is thoroughly cleaned and disinfected with mer-
curic chloride. A small opening j s then pun
through the shell, anil through this the organism I,,
lie tested is introduced into the inside. The opening
is then sealed will, a bit oi t' rile pap, ,- and collodion.
Another procedure is to insert through the opening
in the shell a rather wide, drawn-,,,,1 tube pipette.
On applying suction, especially with the aid of an
aspirator, the contents of the egg can be drawn up
into the bulb, and can then be distributed to t
(Novy).
The egg may be used as a solid opaque medium
according to Wesener. The egg is thoroughly agi-
tated so as to mix the yolk with the albumin. It is
then coagulated at 75° to 80° C, after which the
shell is removed and the egg is cut up into slices and
placed in suitable dishes and sterilized by steam. In
like manner the coagulated white of the egg may be
cut up into slices and tubed. A transparent, coagu-
lated egg albumin may bo prepared by converting
it into an alkali albuminate, as suggested by Tar-
chanow and by Karlinski. for this purpose the egg is
placed in ten-per-cent. potash for fourteen davs, after
which the shell is removed and the solidified egg is
cut up into slices, tubed, and sterilized.
Dorset's Egg Medium. — Dorset introduced this
medium for the direct cultivation of /(. tuberculosis
from tuberculous animal tissues; it is prepared from
the whole egg alone or in Some instances with the
addition of ten per cent, of water. It, was found
that the whole egg content gave a more 1 satisfactory
medium than either the white or the yolk, and that
its reaction proved very favorable for the growth of
the tubercle bacillus. The medium is prepared as
follows: perfectly fresh eggs are cleaned, the shells
sterilized, openings made at each end. then emptied
into a sterile wide-mouthed bottle by carefully blow-
ing out the contents. By gentle agitation a homogen-
ous mixture is produced without causing any foam to
arise. About 10 c.c. are placed in each "test-tube
under aseptic precautions, then inclined in a blood-
serum oven, where they are hardened at 70° C.
Dorset states that this usually requires four to five
hours each day for two days, and sterilization takes
place at the same time. Before inoculation thr >r
four drops of sterile water should be added to each
tube, if the medium is dry, to supply sufficient mois-
' ture for growth.
Lubenau's Glycerin-egg Medium. — This medium
is composed of a mixture of a five-per-cent. glycerin
bouillon (neutral or slightly alkaline to litmus) with
wdiole egg contents. It is prepared by adding the
contents of ten eggs to 200 c.c. of the glycerin bouillon.
The same technique, as to sterility, etc., is employed
in handling the eggs as mentioned above under "the
Dorset egg medium. To the egg contents in a sterile
flask, the sterile glycerin bouillon is added, and a
homogenous mixture made by gently agitating. The
medium is tubed, placed in slanted position in the
blood-serum oven, and hardened at 70° (', the same
as the plain egg medium (Dorset) already outlined.
This medium also is used for the cultivation of
tubercle bacilli.
Potatoes. — These may be prepared in several ways.
The old method, introduced by Koch, is still used
where mass cultures are desired. The potatoes are
891
Bacteriological Technique
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
scrubbed clean under the tap, and any bad spots
carefully removed by means of a knife. They are
then placed in boiling water or steamed for three-
quarters of an hour. By means of a knife, which
has been sterilized in a flame, they are then cut into
halves and placed in a large moist chamber or suitable
pan provided with a lid. The bottom of this vessel
should first be covered with a piece of filter paper
which has been moistened with water or with mer-
curic chloride solution. The cut and sterile surface
of the potatoes can then be inoculated with the or-
ganisms to be cultivated, either by spreading the
material over the potato with a sterile knife or by
making parallel streaks. Inasmuch as there are
several sources of contamination in this method, it
has been largely displaced by the modified procedures.
In Esmarch's modification the potato is pared and
cut into slices about a third of an inch thick, which
are placed into small glass dishes about seven centi-
meters in diameter and one centimeter high, known
as Esmarch dishes. These are then sterilized by
steaming in the usual way.
The best way of using potatoes for culture purposes
is that introduced independently by Bolton and
Globig. The cleaned potato is placed in boiling
water for about half an hour. By means of a cork-
borer or a test-tube the end of which has been cut
off, cylinders of potato may be punched out. The
skin is removed from the ends of
the cylinders, after which these
are halved by a diagonal cut. The
wedge-shaped semicylinders are
now placed in sterile test-tubes
and sterilized by steam.
Another method which possesses
certain advantages over the above
consists of taking a large uncooked
potato, punching out cylinders,
and cutting wedges as just men-
tioned. These wedges are placed
in a suitable vessel and tap water
is allowed to flow over them about
twenty-four hours. This removes
certain soluble constituents of the
potato, which if allowed to re-
main might discolor the finished
medium after it has stood for
some time. Also, the washing
removes much of the acid which
fresh potato contains. After re-
moving the washed potato wedges
from the running water, they are
placed in Roux tubes and auto-
claved at 120° C. for fifteen
minutes. This cooks the potato
and also
sterilizes
t h o r -
oughly.
Roux
intro-
duced a
Fig. 549. — Roux Tube for Potato Culture.
very use-
A con-
ful modification of the test-tube method,
striction is made in the lower part of the tube, about
an inch from the bottom. This compartment may be
filled with water or, when cultivating the tubercle
bacillus, with five-per-cent. glycerin. These tubes
can be readily prepared from the ordinary test-tubes.
A narrow blast flame is directed horizontally against
the tube, which is rotated in a vertical position.
The Roux tube is shown in Fig. 549. A good sub-
stitute for this tube may be made by placing on the
bottom of the test-tube a layer of absorbent cotton,
which may be soaked with the glycerin solution.
Glycerinated potato may be prepared by soaking
the thoroughly washed, prepared potato wedges (see
above) in a twenty-five-per-cent. solution of glycerin,
from one quarter to one-half hour. Then they are
placed in tubes and autoclaved at 120° C. for fifteen
minutes.
Mashed potatoes spread over the bottom of a flask
have been used, but this offers no special advantage
over the methods given. The preparation of potato
gelatin with or without potassium iodide has already
been described.
Bread Medium. — Ordinary bread is toasted to a
crisp, then powdered, in which condition it may be
kept in stock. For use the powder is placed on the
bottom of small flasks and thoroughly moistened
with water, then sterilized by steaming. This me-
dium is particularly useful for cultivating moulds.
Plant Infusions. — These are useful for growing
certain bacteria and also amebas. Infusions of hay
straw, fruits, grains, etc., take the place of meat
extract. By the addition of agar or gelatin, solid
media may be prepared. Beer wort, either as such
or as a gelatin, is valuable for the cultivation of yeasts.
Protein-free Media. — With the exception of urine
all the media described thus far contain some proteid
matter. The latter, however, is not essential, for
it is possible to grow bacteria on media which contain
sulphur, nitrogen, and phosphorus in inorganic com-
bination. Such a solution was used, for instance, at
a very early date by Pasteur. It consisted of one part
of ammonium tartrate, ten parts of candy sugar, the
ash of one part of yeast, and 100 parts of water.
The botanist Cohn employed a similar solution, con-
sisting of 0.1 gram each of potassium phosphate
and magnesium sulphate, 0.01 gram of tribasic
calcium phosphate, 0.2 gram of ammonium tartrate,
and 20 c.c. of distilled water. Naegeli's solution
was made by adding 1 gram dibasic phosphate, 0.2
gram magnesium sulphate, 0.1 gram calcium chloride,
and 10 grams of ammonium tartrate to 1,000 c.c.
of distilled water.
After the lapse of many years these non-albuminous
fluids were again brought into use in a modified form
by Uschinsky. His solution consisted of: Water,
1,000 parts; glycerin, 30-40 parts; sodium chloride,
5-7 parts; calcium chloride, 0.1 part; magnesium
sulphate, 0.2-0.4 part; potassium phosphate, 2-2.5
parts; ammonium lactate, 6-7 parts; sodium aspara-
ginate, 3-4 parts.
Fraenkel's modification of this solution contains
5 grams of sodium chloride, 2 grams of potassium
phosphate, 6 grams of ammonium lactate, and 4
grams of sodium asparaginate. These substances
are dissolved in 1,000 c.c. of water and the solution
is then rendered slightly alkaline.
Similar solutions have been used by Maassen and
by others. Thus Proskauer and Beck cultivated the
tubercle bacillus on the following solution: Com-
mercial ammonium carbonate, 0.35 per cent.;
potassium phosphate, 0.15 per cent.; magnesium
phosphate, 0.25 per cent.; glycerin, 1.5 per cent.
For cultivating the nitrous and nitric-acid organ-
isms Winogradsky employed wholly inorganic solu-
tions. The nitric-acid producers were grown in a
solution consisting of 1,000 c.c. of water, 1 gram
potassium phosphate, 0.5 gram magnesium sulphate,
0.01 gram calcium chloride, 2 grams sodium chloride.
This is filled into flasks in portions of 20 c.c. each,
together with a little freshly washed magnesium
carbonate. To these flasks, after sterilization by
steam, 2 c.c. of a two-per-cent. solution of ammonium
sulphate are added, after which they are incubated to
eliminate contaminations.
For the nitrous-acid organisms the solution consists
of 1 gram ammonium sulphate, 1 gram potassium
sulphate, and 1,000 c.c. of water. It is filled into
flasks, magnesium carbonate added, after which
they are sterilized by steam.
As a substitute for gelatin Winogradsky employed
silicic-acid jelly, which was added to solutions of
essentially the same composition as those just given.
892
REFERENCE HANDBOOK OF THE MEDICAL SCIENl ES
Bacteriological Technique
A number of simple, synthetic i lia I ia \ . • been
suggested for the isolation of B, coli in water analysis.
Dolt has recommended two such media for this
purpose, which he claims possess certain advantages
over the ordinary standard lactose-litmus agar.
They are prepared as follows: In one, a solution
composed of 5 grams glycerin and 1 gram ammonium
phosphate, dissolved in 500 c.c. distilled water, is
used; in the oilier medium, 5 grams ammonium
lactate and 1 gram disodium phosphate are substi-
tuted for the above ingredients — the salts are dis-
solved in the same volume of distilled water. In
either case the solution is then added to 5(10 c.c.
of three-per-cent. purified agar, and neutralized with
sodium hydroxide, using phenolphthalein as an
indicator; one per cent, of lactose i- added just
before sterilization. One-per-cent. azolitmin (Kahl-
baum) solution is to be added to the medium; this
is prepared by adding one gram azolitmin to 1U0 c.c.
distilled water, boiling for fifteen minutes, then
ready for use.
Standardization of Media. — The procedure as
introduced by Koch, and still followed in many
laboratories, is to add a saturated solution of sodium
carbonate, in portions of a cubic centimeter or more,
to the nutrient medium to be neutralized until a
drop of the mixture, transferred by means of a glass
rod, turns red litmus paper promptly blue. In some
laboratories a strong solution of sodium hydrate is
used in the same way. Obviously this method lacks
quantitative precision, and the duplication of the
same reaction in several batches of material is out of
question. Moreover, it is an established fact that
the reaction of a medium has a very important influ-
ence upon the development of bacteria. For these
reasons the bacteriological committee of the American
Public Health Association, adopting Fuller's work,
recommended the following method for the titration
of nutrient media. The reagents necessary are:
1. Five-tenths-per-cent. solution of phenolphtha-
lein in fifty-per-cent. alcohol.
2. Normal sodium hydrate (N. NaOH). A liter of
this solution contains forty grams of NaOH.
3. Twentieth normal sodium hydrate ("NaOH).
A liter of this solution contains two grams of NaOH.
4. Normal hydrochloric acid (N.HC1). A liter of
this contains 30.5 grams HC1.
5. Twentieth normal hydrochloric acid (." IIC'l) .
liter of this contains 1.825 grams of HC1.
The preparation of these solutions requires some
familiarity with the methods of quantitative analysis.
The solutions can be built up by starting from a
twentieth normal solution of oxalic acid or, better,
succinic acid.
The titration is carried out as follows: To 5 c.c.
of the filtered medium in a six-inch porcelain evapo-
rating-dish add 45 c.c. of distilled water and 1 c.c.
of the phenolphthalein solution; boil for three minutes
to expel carbonic acid, then run in the twentieth
normal alkali, drop by drop, with constant stirring,
until a bright pink color results. The number of
cubic centimeters of the twentieth normal alkali
required to neutralize 5 c.c. of the medium gives
directly the number of cubic centimeters of normal
alkali (i.e. percentage) required by 100 c.c. of the
medium. Thus if 5 c.c. of the medium requires 2.8 c.c
of " alkali, then 100 c.c. would need 56 c.c. ,": or
2.s"cc. of N. NaOH.
The quantity of the medium remaining is now meas-
ured and the amount of alkali needed for neutraliza-
tion is calculated and added. After the addition of
the alkali the liquid is boiled and a portion is then
titrated as before. It should be neutral, and if it is
not, as often is the case on account of unknown
changes, the requisite amount of alkali to make it so
is added to the bulk.
The medium which is neutral with to
phenolphthalein is very alkaline « ithn pect to litmus.
Thus a bouillon which is neutral to litmus will re-
quire about 25 C.C. of normal alkali per liter to inn I ■•
it neutral to phenolphthalein. In general the addi-
tion of in c.c. of normal alkali to a medium which is
neutral to litmus imparl the most favorable di
of alkalinity. Hence the optimum reaction with
reference to phenolphthalein is obtained by adding
15 c.c. of normal acid to the liter of neutralized
medium. It is customary to u e the ign I to indi-
catean acid reaction, and — for one thai i.^ alkaline.
Thus + 15 means (hat the rear-lion is acid with
respect to phenolphthalein, and that one liter of the
medium would require 15 C.c. of normal alkali for
neutralization.
The titration with litmus as an indicator is 1" i
carried out in the following way: Port ions of ."> r.c. of
the medium are measured out into each of four or
five large test-tubes. In the case of bouillon the
amount of ^alkali needed to neutralize this amount
may vary from 0.3 to 0.0 c.c. Hence to lube 1 add
0.3 c.c; to tube 2 add 0.4 c.c; to tube '■', add 0.5 c.c,
ele. The contents of each tube are 1 hen boiled for a
minute, after which a slip of red and one of blue lit-
mus paper an' dropped into the hot liquid and allowed
to remain there for about a minute. The papers are
then drawn out, side by side, on the walls of the tube
when the colors can lie compared. In this way the
amount of alkali necessary to neutralize 5 c.c. with
respect to litmus can be determined. Bouillon, as
well as agar, usually requires about .5 c.c per liter
for neutralization while gelatin needs from MO to 35
c.c. Having determined the amount needed for
neutralization, this amount, together with an excess
of 10 c.c. per liter to impart a suitable alkaline
reaction, is then added to the medium.
Neutral red is sometimes used as an indicator to
determine the reaction of media. It reacts sharply
with weak acids and weak bases near the absolute
neutral point.
For ordinary purposes it is hardly necessary to
resort to these rather complicated methods. It is
sufficient to add directly to bouillon and to agar
15 c.c. of normal alkali per liter. Gelatin will require
about 40 c.c. In general, sodium carbonate is pref-
erable to the hydrate.
Preparation and Filling of Tubes. — The cheaper
grades of test-tubes should be avoided. They are
very thin and therefore break easily, and, moreover,
on heating they will often frost because of the separa-
tion of silicic acid. The best test-tubes are the
"blue-lined" or "resistant glass" quality, or those of
genuine Bohemian glass. The size used varies with
the purpose and the individual taste: 12X125, 15 X
150, and 20X150 millimeters are convenient.
The new tubes of the better glass can be used after
being swabbed out with warm water.
The cheaper grades are very alkaline, and for that
reason should be first soaked in very dilute warm
hydrochloric acid, after which they should be rinsed
or swabbed thoroughly in clean warm water; or what
is still better, immerse the tubes for about one hour
in the following cleaning mixture: 300 parts of a
hve-per-cent. solution of potassium bichromate in
water, to which is slowdy added 400 parts of con-
centrated sulphuric acid while constantly stir-
ring. This mixture removes all organic matter,
and is especially useful as a cleaner for old glassware.
The glassware is washed in running water to remove
all traces of the acid. The cleaned tubes are allowed
to drain, and when dry are plugged. Used tubes
should be sterilized by steaming for a half-hour
after which they may be filled with water and again
heated, so as to bring the more or less dried contents
into solution.
The simplest way of plugging is to place over the
S93
Bacteriological Technique
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Fig. 550. — Wire Basket
for Sterilizing Tubes.
mouth of the tube a piece of cotton, about two inches
square, which is then pushed within by means of a
narrow glass rod or a pair of smooth forceps. Such
plugs answer all ordinary purposes. They are, how-
ever, rather loose, and permit evaporation of the
media, and cannot be used when the tubes are to be
sealed with wax. A firm solid plug is made by
taking a piece of cotton about three inches square.
This is folded into thirds and
_^ii^ : tSSSM then roll' 1 ' I up from the end into
^^^™^^^ra||j as firm a cylinder as possible.
By a twisting motion the plug is
inserted into the tube, and only
enough cotton is left on the out-
side to permit grasping of the
plug. The plugged tubes are
then placed in a wire basket,
such as is shown in Fig. 550.
These baskets are made of heavy
galvanized netting. The usual
size is twenty-four centimeters
high and eighteen centimeters
square. Smaller baskets, 10 X
12 and 18 centimeters high, are very useful. Cir-
cular baskets of a size to fit the sterilizer are also
used.
Flasks, bulbs, etc., should be prepared for steriliza-
tion in the same way.
After the tubes have been sterilized by heating in
the dry-heat oven at 150° C. for one hour, they are
ready to be filled with the nutrient media. This can
be done by the aid of a small funnel. When large
quantities of media are to be
tubed much time can be saved
by using a large funnel or globe
receiver, such as is shown in
Fig. 551. The lower end of
the bulb is connected with a
drawn-out glass tube and is
provided with a pinch-cock.
In this way the media can be
rapidly filled into the tubes.
Another simple method con-
sists in using the ordinary Flor-
ence flask, containing the me-
dium and securely fitting a
two-bore rubber stopper in its
mouth. Through one of the
openings pass a straight thistle
tube, of such length that it
almost touches the bottom of
the flask, and plug the external
bulbular portion with cotton to
act as an air filter. Through the
second opening pass a straight
glass tube about ten centimeters
long so that it projects from two
to three centimeters into the
neck of the flask. To this tube
attach a drawn-out glass tube,
by means of a piece of rubber
tubing, to permit the use of a
pinchcock. For filling test-
tubes the flask is inverted, and
supported neck downward in a
ring retort-stand of suitable
size. This simple apparatus
admits of complete sterilization
intact together with the me-
dium. But in such case the
pinch-cock must first be removed to allow air or vapor
a means of escape from the flask during the heating.
By this method a sterile medium is ready for use as
soon as prepared.
Ordinarily the tubes are filled to the depth of one
and one-half or two inches. In special cases in which
definite quantities are desired, the simple apparatus
shown in Fig. 551 can be used. The containers,
Fig. 551.— Globe Re-
ceiver for Filling Media
into Tubes, with Burette
Attachment. (Novy.)
Fig. 552. — Treskow's
Apparatus for Measuring
Media into Tubes.
with the media to be filled, can first be sterilized by
steaming, after which the media can be measured out
into sterile tubes, which will not require further
treatment. A less desirable apparatus is that of
Treskow, shown in Fig. 552.
Sterilization. — By sterilization is meant the total
destruction or removal of all organisms in or about
a given object. This can be
accomplished in a variety of
ways.
1. By Direct Flaming. — This
method is applicable for the
sterilization of glass rods, slides,
cover-glasses, platinum wiresj
searing irons, and rough instru-
ments. Valuable surgical in-
struments would of course be
damaged by this procedure.
2. By Means of the Dry-heat
Sterilizer. — The form mosl
often used is that of Koch,
shown in Fig. 553. This is
made of sheet iron, is double
walled, and the outer wall may
be lined to advantage with
thick asbestos board. The
form as shown is designed to
sterilize not only tubes and
flasks but also glass tubing,
pipettes, and the like. The
oven is used for sterilizing only
glass and metal ware. It
must not be used for sterilizing
media. A temperature of 150
C. should be maintained for
one hour. Usually it will be
sufficient to allow the temper-
ature to rise, and as soon as it
has reached 200° C. the gas is
turned off. The cotton should show a slight tinge of
yellow after this heating. If the plug browns consid-
erably and powders it is due more to the fact that the
cotton has been chemically treated than to the heat.
3. Fractional Sterilization at 56°-5S° C— This method
was introduced by Tyndall, and has been used for
the sterilization of
liquid serum, milk,
and other fluids
which are liable to
be altered more or
less by heat. It is
based upon the fact
that the actively
vegetating forms of
bacteria are readily
destroyed as a rule
by exposure for
some minutes to
this temperature.
The resting forms
or spores are not in
the least affected by
such exposure. It
is necessary to wait
until the spores
have germinated
into the vegetating
forms, which can
then be destroyed
by a second like
heating. As ordi-
narily practised, the tubes are placed in an apparatus,
such' as that shown in Fig. 554, and are heated for
one hour at the given temperature on each of seven or
eight consecutive days.
This method sometimes gives good results, at other
times it fails. The reason for this lies in the presence
Fie,. 553
h's Dry-heat Sterilizer.
Sill
REFERENCE HANDBOOK OF THE MEDICAL BCIEN( ES
11.11 terloloclcal Technique
It absence of the so-called thermophilic bacteria.
'licM- organisms actually grow best at the temperature
mployed, and hence, if they chance to be present,
he method is inapplicable. A temperature of 70° C.
r**3
Fig. 554.
-Rous Water-bath for Sterilizing Serum, with Metallic
Regulator.
may be used in like manner, but this causes coagula-
tion of the serum.
By pasteurization is meant the partial destruction
of the organisms which are present in milk. This is
accomplished by exposing the milk for half an hour,
or more, to a temperature of about 68° C. (155° F.).
While this temperature does not destroy the spores
which may be present, it does kill the lactic-acid and
other bacteria, which do
not produce spores. As
a result, milk treated in
this way will keep for
several days without
coagulating. If a higher
temperature is used, the
taste of the milk is likely
to be impaired.
3. Sterilization in Flow-
ing Steam.— Several forms
of apparatus have been
devised for this purpose.
Fig. 555. — Koch's Steam Sterilizer.
Among the earliest is the well-known form which
bears Koch's name. This apparatus is used almost
entirely in Germany, and to a considerable extent in
this country. It is shown in Figs. 555 and 556.
It con i t of a cylinder of galvanized iron, or better
of copper, which can be given such dimei
may be desired. Ordinarily ii is about half a meter
high ami about twenty-five centimeters in diameter.
It is surrounded by a thick covering of fell M, to
prevent loss of heat by radiation. In the interior of
the cylinder at R i placed a grate whicl a a
support for the pail and other ve els to be disinfected.
The water in the lower com-
part llli Ml i llealeil liy one
or more large gas-burners.
\l>n\e ii i closed with a
cover I), which isalso covered
with felt. A central opening
permits 1 he escape of steam,
and can be u ed for I he in
sertion of a thermometer.
The pail -hou □ to the right
of t he sterilizer has a gral ing
for a bottom, to allow free
ai ess of the steam, and in
it are placed the articles to
be sterilized.
The nutrient media are as
a rule sterilized by steam.
A single heating for one hour
in steam at 100° C.ls usually
sufficient to render the media
sterile. Prolonged heating,
however, tends to alter the
media, and for that reason
fractional or discontinuous
sterilization is resorted to.
The latter has the additional
advantage that it renders the
medium more surely sterile.
can withstand steaming for one and even five or six
hours, and if such forms chance to be present it is evi-
dent that the material cannot be sterilized by the
single heating for one hour. In the other procedure
the media are steamed for fifteen minutes or half an
hour, according to the nature of the medium, on each
of three consecutive days. The first heat serves to
destroy the vegetating germs that may be present. In
Fig. 556. — Section of Koch's
Steam Sterilizer.
There are spores which
Fig.
-Arnold's Steam Sterilizer, Sectional View.
the interval which elapses between the first and second
heating, the spores which are probably present will
germinate and are thus converted into t he much weaker
form, which is then destroyed by the second steaming.
The second interval allows any remaining spores,
which may have failed to germinate the first day, a
chance to do so, and the third heating is expected to
dispose of these last organisms. As a rule all media
S95
Bacteriological Technique
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
should be incubated for one or two days to make sure
that they are perfectly sterile. If any growth develops
in the tubes or flasks these should be discarded, and
only those which are free should be preserved for use.
Failure to secure sterilization by this procedure is
due to one of the following conditions: The tempera-
ture which prevails during the
twenty-four-hour period which
elapses between the consecutive
heats may be so high that the
spores which are present not
only germinate, but the vege-
tating forms in turn give rise to
spores, so that a larger number
of resistant forms are present on
the second or on the third day
than were present in the begin-
ning. Again, it may happen
Fig. 55S. — Novy Steam Sterilizer.
that the temperature is too low, in which case the
spores cannot germinate, and hence will be found to
resist sterilization. Another source of error, though
much less common, was pointed out by Smith. If the
spores of anaerobic bacteria are present in a bouillon,
they cannot from their very nature germinate under
the ordinary conditions, that is in the presence of the
air, and may therefore escape de-
struction.
In this country and even in Ger-
many, the Arnold steam sterilizer
has met with a very favorable re-
ception. The apparatus is shown
in Fig. 557. It consists of:
(a) a flat, shallow boiler,
holding but a small
amount of water, and
therefore requiring but a
minimum amount of heat
to produce steam; (6) a
reservoir placed upon the
boiler, which it constantly
feeds and insures the con-
stant formation of steam;
(d) a covered steam chest
or receiving vessel, placed
above the reservoir and
connected with the boiler
by a cylindrical
tube of large
diameter (c);
and (c) a hood,
covering the re-
ceiver and en-
closing an air
space, which is
constantly sup-
plied with es-
cape steam.
The hood and the steam jacket which it encloses
prevent variations in temperature in the receiving
vessel so long as the heat applied to the boiler remains
unchangi d.
A cheap and thoroughly efficient steam sterilizer
Fig. 5. r »n. — Ohamberland Autoclave for Ster-
ilizing by Steam under Pressure. (Novy-)
adapted for individual work is shown in Fig. 558.
This consists of an ordinary Hoffmann iron water-bath
ten to twenty centimeters in diameter. On this is
placed a copper pail (20 X20 cm.), which is provided
with a perforated bottom. Two perforated rings on
the inside allow the passage of steam, and prevent
the cotton of the tubes from coming into contact wit h
the side of the steamer. The tubes filled with media
are placed in the pail, and this is then set on the water-
bath, the water of which has been previously raised
to active ebullition. In a few minutes steam will
issue from the tube in the top of the cover. It is
always advisable to take the temperature of the vapor
as it issues from a sterilizer and to count the time of
exposure from the moment that the vapor actually
shows the temperature of steam, that is 100° C.
4. Sterilization by Steam Under Pressure. — This pro-
cedure is used almost entirely by the French workers.
Its usefulness is such as to merit
a wide introduction into this
country. The apparatus, which
is designated as an autoclave, is
shown in Fig. 559. It consists of
a strong boiler, in the bottom of
which a small quantity of water
is placed. The articles to be
steamed are placed in a wire
basket, which is set on the bottom
of the boiler. The lid is closed
with a rubber gasket and securely
held in place by thumb-screws.
Inasmuch as the amount of aque-
ous vapor in a given space, as
well as the temperature, in the
case of confined steam, is greater than with flowing
steam, it follows that the autoclave is considerably
more efficient. Thus steam at 130° C, under pressure,
will destroy instantaneously spores which would resist
flowing steam at 100° C. for five or six hours.
The culture media can be sterilized by a single
heating for fifteen to thirty minutes at 110° C. A
higher temperature should be avoided, as it tends to
alter the reaction of the-media. Glass apparatus,
filters, rubber, etc., can be sterilized by heating at
120° C. for half an hour. In-
fected animals can be subjected
to 120° C. for the same length
of time, or to 130° C. or more
for a less period.
It must be remembered that
the autoclave requires more
care than an ordinary sterilizer
owing to the danger of explosion. The
following points should be observed in
its use : Enough water should be present;
after the burners are lighted, the steam
valve should be left open until the air
has been expelled ; when the steam has
flowed rapidly for one or two minutes
the valve is closed; as soon as the de-
sired temperature is indicated on the
gauge, the burners are turned down,
so that this temperature is maintained
for the required time; the burners are
then turned off, but the steam valve
is not opened until the temperature
has fallen below 100° G, after which
the lid can be removed. The safety
valve should be tested to open at about
125° C. It is a good rule not to leave the
autoclave out of sight while the fi G . 560— Pnsteur-C'ham-
temperature is rising. berland Filler.
Obviously this piece of ap-
paratus can also be used as a steam sterilizer with
temperature at 100° C. In such case the steam
valves above are opened and the water is heated to
the boiling-point. If steam is generated more rapidly
than it can make its exit, the pressure rises, conse-
896
REFERENCE HANDROOK OF THE MEDICAL SCIENCES
ll.ii ii-rluliiuli ,.l Tpclinlciun
guently the temperature goes above loo" ('. There-
fore boil gently or raise cover enough to allow free
escape of I he steam.
.".. Sterilization by Filtration. — It is possible to
remove completely all the organisms which may be
present, in a liquid by filtration. Filler paper, of
course, on account of the small size of the bacteria,
cannot be used for this purpose.
There are only two reliable filters
for bacteriological work. That
known as the Pasteur-Chamber-
land filter is the best, and is made
of unglazed porcelain. The form
as used for filtering water for
domestic use is shown in Fig. 5G0.
The original French filters are to
be preferred to the German imi-
tations. They are made in two
grades; that marked F is more
porous than that marked B.
The Kitasato filter, a narrow
form of the above, is also made
of unglazed porcelain, and is in-
tended for the filtration of very
small amounts of liquid. This
can, however, be done also with
the larger filter. It is shown in
Fig. 561.
The Berkefeld filter (Fig. 565)
consists of closely packed in-
fusorial earth. It can be ob-
tained in several sizes, having
the general shape of the Pasteur-
Chamberland bougie. It is considerably more porous
than the porcelain filter, and is therefore adapted for
rapid filtration, but it should be borne in mind that
it is more likely to allow the passage of bacteria.
A useful form of apparatus for holding the Pasteur-
Chamberland bougie, that of Martin, is shown in
Fig. 56'J. It consists of a metal cylinder with a
funnel-shaped top, which permits the filtration of the
culture through filter paper previous to its passage
through the bougie, and thus obviates or lessens the
clogging of the latter. A rubber ring serves to make
Fig. 561. — Kitasato's
Filter.
Fig. 562.— Martin's Filter.
a tight joint when the bougie is held in place by the
lower screw cap. The lower end of the bougie is
connected with a piece of vacuum rubber tubing to a
globe receiver. The entire apparatus is sterilized by
heating in an autoclave. The filtration may be
carried on by gravity, or an aspirator may be connected
with the upper tube of the globe receiver. When
Vol. I. — 57
the filtrate is o> be transferred, the drawn-out aide tube
is scratched near the end with a file, and then broken
off, after which the tube is (lamed and the liquid is
drawn off into sterile tubes or flasks. This globe
receiver can be used until the drawn-out tube is too
short, when a new lube is fused on.
A better form of a globe receiver is shown in Fig.
565. This is provided with three side tubes, which
arc plugged with cotton, after
which the receiver is sterilized in
a dry-heat oven. When it is to
be used, the cotton is removed
from the tube D, which is then
connected with the sterile bougie
by means of a piece of sterile
vacuum tubing. The horizontal
tube F is similarly connected with
t he sterile drawn-out glass tube G.
The tube E, with its cotton plug
in place, is connected with a
Chapman pump. The filtrate
may be withdrawn by means of a
sterile bulb pipette, or in the same
way as from the receiver of Martin.
The advantage lies in the short
rubber tubing, compactness, and
the convenience in attaching the
Fig. 563. — Novy's Filtering Apparatus.
drawn-out tube. This vacuum receiver can be ob-
tained in several sizes, such as one-quarter, one-half,
one, and one and one-half liter capacity.
Instead of a metal cylinder to hold the bougie,
Novy has devised one of glass. This is shown in
Fig. 563. The necessary tight joint between the
bougie and the glass cylinder is made with a rubber
ring, and the bougie is brought up tight into place by
means of small vises, which act on the flange and on
an iron washer. The arrangement is shown in Fig.
564. If desired the liquid can be filtered under
pressure, in which case the rubber stopper at H is
connected with a tank of compressed air. The
Fig. 564-
Conneetions for the Novy Apparatus,
rings; 4, iron washer.
1, 2, 3, Rubber
cylinders are made to withstand a pressure of over
100 pounds.
The Berkefeld filter may be attached to the above
glass cylinder by means of a rubber and iron washer
and the clamps mentioned (Fig. 565). A more con-
venient arrangement is to use a cylinder of brass of
suitable length and width, threaded at each end.
The lower end is provided with a screw cap, through
897
Bacteriological Technique
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
which the metal end of the Berkefeld bougie is passed.
The upper end is also closed with a screw cap, provided
with a three-eighths of an inch nipple, which serves
to connect the cylinder with the compressed air.
The tip of the Berkefeld is connected with a globe re-
ceiver. The filtration can then be carried out by
gravity, by aspiration, or by pressure.
The filtration of liquids constitutes an exceedingly
important part of bacteriological technique. By its
means the soluble products of bacteria may be
separated from the solid cells. In this way the toxins
of many pathogenic bacteria are prepared. Again it
is by the nitration process that it has been possible to
demonstrate the existence of the so-called ultrami-
croscopic organisms. While the
common bacteria will not pass
through a filter, there are a number
of diseases in which the germ is so
minute that it will go through the
Berkefeld, and, at times, even
through the Pasteur-Chamberland
bougie. Yellow fever, sheep-pox,
foot-and-mouth disease, contagious
pleuropneumonia of cattle, chicken
pest, rinderpest, horse sickness,
molluscum contagiosum of birds,
and the "mosaic disease of to-
bacco" are of this class; so also is
rabies. The fact that a given
filtrate infects is not proof that the
cause is always in this extremely
minute form. It may be that the
real organism is relatively large, as
in the case of the rat trypanosome,
and yet Berkefeld filtered cultures
of this will often infect animals.
This is due to the existence of
a minute stage in the develop-
ment of the organism. It is
therefore to be expected that
the pathogenic pro-
tozoa, though they
themselves may be
large, may give rise
to filterable sporo-
zoites.
6. Sterilization by
Chemicals. — This principle is applicable only to a
limited extent to nutrient media. The addition
of such substances as carbolic acid or mercuric
chloride will serve to destroy the organisms which
may be present; but since these compounds can-
not be removed from the medium, it follows that
it cannot then be used for culture purposes. A
few substances have, however, been used with
this object in view. Thus if chloroform is added
to milk or blood serum, and is allowed to act
long enough, it will bring about sterilization.
The remaining chloroform can finally be driven
off by means of gentle heat and by aeration.
Ether has been used in the same way, and indeed
this is a useful procedure for sterilizing such
weak cultures as those of cholera. Glycerin, as
is well known, is added to vaccine with the ob-
ject of destroying the common pus-producing
organisms which are so often present. It cer-
tainly will in time destroy all of these accidental
bacteria, but, unfortunately, prolonged exposure of the
vaccine virus to the glycerin damages it as well.
Chemical disinfection of drinking-waters has also
been proposed, especially in connection with military
operations. For this purpose various substances,
such as bromine and the organic peroxides, have
been suggested.
In the laboratory this method is resorted to more
or less io sterilize old used cultures, test-tubes, and
animals. Five-per-cent. carbolic acid or 0.1-per-
cent, mercuric chloride is employed.
898
The Incubator. — It is customary to divide bacteria
into two large groups — the saprophytic and the
parasitic — according as to whether they grow in
nature on dead matter or in the living body. Among
the latter are classed the disease-producing bacteria.
In general the optimum temperature for the growth
of the saprophytic organisms is about 25° C. (77° F.).
whereas the pathogenic bacteria thrive best at the
temperature of the body. In order to supply this
requirement it is necessary to use an incubator or
Fig. 565. — Berkeield Filter showing
Manner of Attachment to Globe receiver.
(Novy.)
Fig. 566. — Koch's Incubator.
thermostat, the temperature of which can be main-
tained without variation at any desired level. Vari-
ous forms of apparatus have been devised for this
purpose; that of Koch is shown in Fig. 566. It
consists of a double-walled box of copper, the sides
and top being covered with felt. The space between
the walls is filled with water. In the top is an
opening communicating with the interior air space,
and in it a thermometer is placed to indicate the
temperature. The openings in the corners com-
municate with the water space. One of these is
intended to hold a thermoregulator, while the other
serves for the addition of water. Inner and outer
doors are provided, and in the better models provision
is made for ventilation and for keeping the air moist.
The apparatus may be heated with an Argand
burner. The ordinary Bunsen burner is not
used because of the danger of "shooting
back." The Koch safety burner is to be
preferred, for it automatically shuts off the
supply in case the gas should by any chance
Fig. 567. — Koch's Safety Burners.
happen to be turned off. It consists of two iron
spirals w-hich, as they are heated, expand, and in so
doing communicate this motion to an arm which then
swings under and supports the weighted lever of the
valve. If by any accident the flame should become
extinguished, the spirals cool and contract; this
causes the supporting arm to swing out from under
the lever, which then falls and thus shuts off the gas
(see Fig. 567).
In case gas is not available the incubator is heated
with an oil lamp. The Sartorius model is especially
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Bacteriological Technique
well constructed for this form of heating. A good
substitute can always be found in the ordinary egg
incubator. In a few places the heat is supplied by
means of electric hot plates.
By far the most important accessory to an incubator
is a thermoregulator, which will automatically
control the supply of gas and hence the temperature
of the oven. Several of the more common forms are
shown in Figs. 568-571. The Reichert form, though
very widely used, is far from being the most satis-
factory. The lower bulb is filled with mercury,
which as the temperature rises shuts off the opening
through which the gas enters. In order I.. prevent
the flame from being extinguished a minute opening
is made in the gas-delivery tube whereby a minimum
flame can be maintained.
Fig,
56S. — Novy's Thermo-
regulator.
Fig. 569.-
-Reichert's Thermo-
regulator.
In the Bunsen form the lower compartment is
nearly filled with a mixture of equal parts of ether
and absolute alcohol, after which a sufficient quantity
of mercury is added to act as a valve. The upper
part is closed with a stopper, through which passes
the gas tube. When the proper temperature is
reached, this tube is pushed down till the gas flame
drops. The minimum opening prevents total extin-
guishment. By careful manipulation the regulator
can be set at any temperature which may be desired.
In both the Novy and Dunham forms the lower
bulb is filled with absolute alcohol. As this expands
it acts against a column of mercury, which in turn
shuts off the supply of gas. The lateral screw per-
mits the adjustment of the regulator to the desired
temperature. In the former the minimum supply
can be regulated to a nicety. This enables it to be
used for a water-bath, or for a small or large incuba-
tor. It can be obtained with the alcohol cylinder of
different sizes, according to the use for which the
apparat us is intended.
The metallic regulator of Rous is intended for
controlling the temperature of large water-baths
and of incubator r , for which pure etter
de\ ice can be found. It i made in tl "' ,
Fig. 570. — Dunham's
Thernio-regulator.
Fio. 571. — Bunaen'a
Thermo-regulator.
the straight and the U-shape, shown in Fig. 572.
It consists of two metal bands having different
coefficients of expansion. These are soldered toget her
the full length. As the temperature rises, the free
upper arm moves from and thus releases a spring
valve, which shuts off the main supply of gas. A
minute opening serves to supply a minimum amount
of gas, and thus prevents extinguishment of the flame.
dlib.'i >Amt
. 1"'' ''■' -•-■ ■ ■■'■ ! '^ |
Fig. 572. — Rous Metallic Thermo-regulator.
The incubator described in its several modifications
answers all ordinary purposes. In large laboratories
it can, however, be dispensed with almost entirely,
and its place is taken by the incubator-room. By
this is meant a re. nn, usually about eight feet cube,
which is maintained at a constant temperature.
899
Bacteriological Technique
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
This arrangement was first employed at the Pasteur
Institute, where the heat is conveyed to the room
by means of large pipes along the wall, filled with
water, or better with glycerin. The circulating
liquid is heated by a small gas stove placed on the
outside of the room.
A more simple and thoroughly efficient procedure
is to place a small gas stove in the center of the room.
Fig. 573. — Moitessier's Gas-pressure Regulator.
This stove, which can be obtained of the French
dealers, is so constructed that the gases of combustion
are carried out of the room into a flue.
Another procedure of limited application is to heat
the room with steam coils. The regulation of the
heat in this case is accomplished by means of an
automatic steam valve operated by compressed air.
The construction of the room requires no special care.
The walls, whether of brick or of plaster, should be given
several coats of white zinc. Shelves, water, gas and
electric light, and a window should be provided.
The regulation of the temperature in the rooms
heated by gas is done by means of the Rous U-
shaped regulator. All the connections should be of
Fig. 574. — Murrill's
Gas-pressure
(Novy.)
Regulator. Cross-section.
metal to lessen the chances of fire. In order to have
a temperature record it is advisable to place in the
room a thermometrograph, the best form of which is
made by Richard Freres, of Paris.
Gas-pressure Regulator. — The best results with any
form of thermoregulator are obtained when the gas
pressure is constant or nearly so. When the varia-
tion is considerable it is advisable to pass the gas
through a pressure regulator before it reaches the
thermoregulator. There are several forms of ap-
paratus for this purpose. The Moitessier regulator is
shown in Fig. 573. It consists of a cylinder A
which is filled to the level of G with a mixture of
equal parts of glycerin and water. On this is floated
the metal shell B. The gas is admitted to the in-
terior of B, through the tube K, the pressure being
indicated by the manometer P. The gas flows into
B until it is filled, when it raises it up and shuts off
the supply of gas by closing the valve D. The pres-
sure on the burner is regulated by the weights placed
in the pan H, which is connected with B by the rod
G. The amount of pressure on the burner is indicated
by the manometer on the left of the apparatus. The
burner is connected with the apparatus by means of a
rubber tube attached to /, and the height of the
flame is regulated by the stopcock M.
A cheaper and more simple regulator is that
devised in Novy's laboratory by Murrill and shown
in Fig. 574. The gas passes into a cylinder which
floats in liquid petroleum and leaves by two tubes
at the bottom, one of which is connected with the
thermoregulator, the other with a manometer. The
cylinder is weighted so as to give the desired pressure
to the outflowing gas.
During the hot summer months it is desirable to
have an apparatus which will keep a fairly constant
low temperature, below that which would cause the
gelatin cultures to melt. There are incubators con-
structed for this purpose which furnish a supply of
ice-cold water when the temperature rises above a
given point. If the temperature drops too low, the
electric lamp is turned on.
When the temperature of the water as it leaves the
ground is about 15° C. (59° F.) it is possible to use the
simple apparatus shown in Fig. 575. This is made of
galvanized iron. The inner box is held in place by
means of a couple of stout rods. The water enters at
the bottom through the small tube, which stops
short on the inside of the outer box. The water then
Fig. 575. — Novy's Low-temperature Incubator.
flows under and around the inner box, and eventually
reaches at the farther end the wide outflow tube.
The end of t"his is turned up and is provided witha
short piece of rubber tubing. By moving this up or
down the level of the water in the box can be regu-
lated. By regulating the flow of the water it ispossible
to maintain a fairly constant temperature in the inner
compartment.
The Methods of Cultivation. — The fundamental
basis of bacteriology may be said to be the fact that
it is possible to cultivate artificially, and that in pure
condition, nearly all of the known forms of bacteria.
Until methods had been devised for this purpose it
was not possible to determine definitely the part
played by any organism either in the ordinary
900
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Bacteriological Technique
phenomena of fermentation or in the more mysteriou
processes of disease. To arrive at a demonstration
of the causal relation of a given organism to the
change which it is supposed to induce it is necessary
to do two things: First, I he organism must be isolated
in pure culture; and second the pure culture, once
obtained, must be maintained by transplantation.
The pure culture thus kept up through a series of
transplantations, or generations as they are called,
can then be tested upon animals to see if it will
produce the disease, or upon suitable media to ascer-
tain if it will cause the kind of fermentation, the
pigment, or the light which it is supposed to
produce.
By a pure culture is meant one which is derived
from a single cell. A given bacterium, small as it is,
multiplies by division, and thus gives rise to two new
individuals. These in turn grow and divide, yielding
four cells. This process is kept up till many millions
of organisms constitute the offspring of a single cell.
Inasmuch as the division of bacteria is very rapid
under favorable conditions, many dividing every
half-hour, it follows that in a
few hours a visible growth may
be seen where at the beginning
but a single cell was present.
If the medium in which they
are growing is liquid, it will
usually become cloudy because
of the disseminated bacteria.
The early methods of cultiva-
tion, as employed by Pasteur,
made use of liquid media.
Under these conditions it was
exceedingly difficult to obtain
pure cultures, and indeed it
was largely a matter of chance
and patience. Suppose that a
given liquid contains two kinds
of bacteria; in order to separate
ra W ™ iff™ tnese so as t° have a single cell
II as a starter for the pure culture
it would be necessary so to di-
lute the liquid that in all prob-
ability a drop, or a cubic centi-
meter would contain but one
cell. This small quantity would
then be taken and transferred
to a sterile medium, and in this
way it would be possible to
obtain presumably pure cul-
tures. Failure, however, was
necessarily frequent and the
element of doubt always re-
mained.
The introduction of the nutrient gelatin by Koch
made it possible to secure pure cultures with the
greatest of ease. All that was necessary was to inocu-
late the liquefied gelatin with the mixture of bacteria,
and after thorough agitation so as to separate each
cell from its neighbor, to pour the liquid on to the
surface of a sterile plate. The gelatin now solidifies,
and imprisons, as it were, the separated cells. Each
of these now multiplies and reproduces its kind;
eventually, in the course of a day or two, a small
growth, perhaps of the size of a small pinhead, appears.
This is called a colony, and since it is derived from a
single cell it constitutes a pure culture. Such is the
principle of the dilution method for obtaining pure
cultures. The isolation once accomplished, all that
is necessary is to transplant the colony to sterile
culture media so as to keep up the growth.
The transferring of bacteria is usually done by
means of a platinum wire. The wire, which should be
about two inches long and fairly stiff, about No. 21 in
size, is fused into the end of a glass rod. According
to the object in view it is either straight, bent, or is
provided with a loop as shown in Fig. 570.
576. — Platinum
Fused in Glass
At times a bunch of very fine platinum wires at-
tached to a holder, the so-called Kruse's brush, is u -l
to spread the material over tin- surface of the media.
A glass rod bent at right angles is also very useful
for i his purpose. The Roux spat ula of nickeled steel
was first employed for the purpo e of transplanting
bits of diphtheritic membrane to the culture lube.
A similar spat ula made of thick iron wire is extremely
useful for transferring moulds and coin pact growths,
such as that of act inomyces. The Nuttall platinum
spear is particularly useful for transferring bits of
tissue, blood, etc., to the nutrient media. These two
instruments are shown in fig. 577.
The transferring of liquids, in large or in small quan-
tities, can best be done by means of drawn-out glass
tube pipettes, as is practised by the Pasteur School.
This technique is at once simple and
invaluable. The preparation of
these pipettes will be understood
from Fig. 578.
The glass tubing, which has a
diameter of about eighl millimeters,
is cut up into lengths of about
twelve inches. By means of the
blast lamp a slight constriction is
made at about two inches from
each end. This serves to prevent
the cotton plug from falling down,
and also tends to keep the liquid
from reaching the cotton. The
ends of each tube are then care-
fully rounded out in the flame. A
piece of cotton is then pushed into
the end of each tube. The tubes
thus prepared (Fig. 578, a) are
then sterilized in the dry-heat oven,
after which they may be stowed
away for future use.
Whenever it is desired to make
a pipette, one of these tubes is
heated in the middle in a blast
flame, and when the glass has
thoroughly softened, the two halves
are slowly drawn apart. A rela-
tively wide, thick-walled capillary,
about sixteen inches long, is thus
obtained (Fig. 578, 6). This is
then sealed in the flame in the mid-
dle, and the result is two pipettes.
For transferring large quantities of
liquid a bulb is blown in the pipette
(Fig. 57S, e). This is made by
directing a narrow blast flame
against the tube, which is at the
same time rotated. As the glass
softens the ends are slightly pushed together, so as to
form a thick ring of glass. This is repeated once or
twice. Finally a large blast flame is turned on, and
when the thickened glass is perfectly soft, the end
is brought into the mouth and the bulb is blown.
The glass should be rotated during this operation,
and in fact in all work of this kind.
To use a pipette, the mouth end should first be
rolled for a few seconds in a flame so as to insure
sterility; the capillary end is then scratched with a
file and the tip is broken off, after which the capillary
is flamed. As soon as the tube has cooled, which fact
can be ascertained by blowing through the pipette
against the back of the hand, it is ready for use.
The closure of the pipette when it is filled with the
liquid is effected by means of the tongue pressed
against the upper end.
The great value of the pipette lies in the fact that
it can be made in a few minutes, and can be used to
transfer liquids from one tube to another, for drawing
blood from the heart, fluids from the cavities, etc.
It is indeed even more useful than a platinum wire.
Plate Cultures. — Solid media, such as gelatin or agar,
901
Fig. 577. — a, Itoux
spatula; b, Nuttall's
platinum spear.
Bacteriological Technique
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
cither plain or modified, are employed for this pur-
pose. The starting-point in this method were the
slide cultures used by Koch in his early investigations.
The liquefied gelatin was poured upon the surface
of sterile glass slides, which were levelled and kept
cool by means of the apparatus shown in Fig. 579.
The lower dish was filled with ice-water and the whole
@S=
Fig. 57S. — Pasteur Pipettes, showing Method of Preparation. (Novy-)
was set true by the aid of a small spirit-level. A
series of parallel streaks was then made on the solid
gelatin by means of a platinum wire, which was dipped
in the material to be planted. A number of slides
were thus made, after which they were stacked on
glass benches (Fig. 5S0), and placed in a moist
chamber to develop (Fig. 581). The first streak,
i
Fig. 579. — Koch's Levelling Apparatus.
on account of the large number of organisms planted,
would probably yield a continuous solid growth.
The next streak would have fewer germs, and the
succeeding ones si ill less until eventually only single
germs would be deposited, separated by an appre-
ciable distance from the following ones. Wherever a
single organism was deposited, as a result of multipli-
5N,u. — Glass Benches and Culture Slides.
cation, a colony would soon make its appearance.
(See Plate XII., 18)
The slide method was soon improved by substitut-
ing larger glass plates ( 10 x 13 cm.). Instead of mak-
ing streak dilutions as just given, the gelatin was lique-
fied, inoculated, and poured out upon the sterile
plates, which were cooled on the plating apparatus.
This method of plating may be used when the special
Petri dishes, ordinarily employed, are not obtainable.
The fact that the method required a lot of apparatus,
slides, slide-box, levelling apparatus, ice, moist
chamber, etc., as well as the fact that contamination
from the air and from the dripping of the superposed
plates was unavoidable, led Petri to introduce the
modification which has almost entirely supplanted
the older method.
Gelatin Petri Plates. — In this
* =s —^-^.-^m l nr > a method, as in the preceding,
the gelatin is first melted by
/ immersion in warm water for
a few minutes. By means of
a sterile, looped, platinum wire
a small quantity of the ma-
terial to be examined is trans-
ferred to a tube of liquefied
gelatin, marked 1. By means
d of the wire the material is thor-
oughly mixed with the gelatin.
Another tube, marked 2, is
then placed beside the first,
from which three loopfuls of
gelatin are carried over to tube
2, with the contents of which
they are well mixed (Fig. 582).
A third tube, marked 3, is then
placed beside number 2, and
three loopfuls of gelatin are transferred from tube 2
to tube 3. It is evident from this procedure that
even if the first tube received a million germs the
second tube would contain only a small fraction, and
Fig. 581. — Moist Chamber with Stacked Plates.
the third tube would contain still less. The platinum
wire must of course be sterilized whenever an inocu-
lation is made into a new tube.
A number of Petri dishes (Fig. 583), which are ten
centimeters in diameter and one centimeter high, are
Fig. 5S2. — Method of Holding the Tubes when Making Dilutions.
previously sterilized by heating in a dry-heat oven
for one hour at 150° C, or for a few minutes at 200° C,
and allowed to cool. To pour the plate, the cotton
is removed from one of the tubes, and the open end is
rolled for a few seconds in the flame so as to sterilize it.
902
HKKKlil'AVi; iiwdii s h\ Tin; \| i; [ >|< ' \ |, scillXCES
Bacteriological Technique
In a few seconds the end of the tube becomes cool,
after which the contents are poured oul into the
Petri dish. The lid of the latter is removed just
sufficiently l<> allow the gelatin in !»■ introduced
By tilting, the gelatin is thru spread all mw the
bottom of the dish. The latter is then sel aside in a
cool place for the gelatin to set. With a g I
gelatin this will take place even in the ordinary room
within a few minutes. The remaining gelatin tube
are poured in the same manner. Each plate should be
numbered to correspond to the tube from which it
was made. They should be marked also with the
date and the kind of material used. A Faber 1
colored wax pencil is used for this purpose.
Agar Petri Plates. — Inasmuch as gelatin melts at
about 25° C. it follows that the method just gi\en
cannot be used when the organism requires the
temperature of the incubator. In such cases it is
necessary to resort to the use of agar. The nutrient
agar is first melted by heating in a water-bath at
100° C. The flame is then turned out and the tubes
are allowed to cool in the water-bath until a tempera-
ture of about 45° C is reached. The agar solidifies at
about 40° C, and consequently the dilution must be
made rapidly and the plates poured before that point
is reached. Dilution cultures are made in the same
way as just given for gelatin. The three agar
tubes are then poured out into the corresponding
sterile Petri dishes. The agar promptly solidities,
and for that reason the spreading of the agar over the
bottom must be hastened. The agar plates are then
set aside to develop either at the temperature of the
room or at that of the incubator.
Esmarch Roll-tube Culture. — This modification of
the plate method does away with the use of any
special container other than, the test-tube. The
dilutions in gelatin are made in the usual way.
9 : . \
Fig. 583.— Petri Dish for Plating.
According to the original directions the cotton plug
was cut off short, and the end of the tube was covered
with a close-fitting rubber cap. The tube was then
immersed and rotated in an almost horizontal position
in ice-water. The gelatin solidified in an even film over
the inside of the test-tube (Fig. 584).
A more convenient way of rolling the tubes was
devised by Booker. With the aid of a large test-tube
filled with warm water a groove is melted into a
block of ice. The gelatin tubes are then rolled in this
groove until the gelatin solidifies in a smooth, even
film. Nuttall has modified this procedure by replac-
ing the ice block with a marble block provided with
grooves for the test-tubes. Running tap water
serves to cool the tubes.
If the tubes are not rolled smoothly they can be
softened by gentle warming and be rerolled. < toe
advantage of this method lies in the fact that desicca-
tion can be retarded more than with the other methods.
Air contamination is likewise diminished. On tin-
other hand, the presence of a few liquefying bacteria
may spoil the tube. The Esmarch roll tubes should
be kept in a cool place to prevent melting. When
the colonies develop they may be examined by
placing the tube on the stage of the microscope.
To transplant the colonies a platinum wire, pro-
vided with a hook, as shown in Fig. 576, should be
used.
Shake Cultures. — Dilutions are made in gelatin or
V*
agar as heretofore de cribed, I are 1 hen
solidified in an upright position and I to
develop. If it is desired to trait plant a given colony
I he te i tube I d bi cral ehed n it h a dia mom
about the level of the colony. On touching the
scratch with a hot rod the crack can be led around
the tube, after which the t wo part can bi eparated.
Bj means of a sterile knife the medium can be cut
ami i In- colony expo ed. In t he i i ol i •• t he
entire cylinder of agar can be forced out of the tube
into a sterile di h l>\ the cautious application of a
Same to I he loner end of the t ube.
The method offers a convenient means of determin-
ing whether or not the organism planted generates gas.
If such is the ease gas bubble- will make their appear-
ance in the medium. As will be
seen later this method is also use-
ful in connection with the cultiva-
l ion of anaerobic bacteria..
Streak CultiiriK. This proced-
ure, w hich is essentially the same
aS that Used by Koch in his slide
cultures, is very frequently made
use of at the present time. Thus,
sterile gelatin or agar may be
poured into sterile Petri dishes,
and after the material has solidi-
fied a series of parallel streaks
may be made with an infected
platinum wire or platinum spatula.
The Kruse platinum brush maybe
used to spread the organisms over
the surface. A narrow glass rod,
bent and flattened at the end, has
been used for spreading gonorrheal
pus over plates. Cotton swabs
are used for the same purpose in
the case of diphtheria.
As in the case of the Esmarch
roll tube, the Petri dish may be
omitted in this method. In that
event the gelatin or agar is melted
and allowed to solidify in an in-
clined position. The streaks are
then made on the surface of the
inclined medium. Potato tubes
are inoculated in the same way.
(See Plates XI. and XII.)
To obtain perfectly isolated
colonies by this method the same
wire should be used to make parallel
streaks on each of four or five tubes.
When the colonies develop, trans-
plantations can be made by means
of a bent. wire.
Hanging-drop Cultures. — A con-
cave or well slide, shown in Figs.
599 and 600, is used. The cover-
glass must first be sterilized by
passing it several times through a "*■-'.— -
flame. A large drop of sterile Fig. 584. — Esmarch 's
bouillon is then placed in the mi- Roll Culture,
ter, and this is inoculated with the
germ to be studied. The slide with a ring of vaseline
is then inverted and brought down upon the cover-
glass, after which the preparation is turned over.
Care must be taken to see that the vaseline closure
is perfect. This method of cultivation is used to
study the multiplication of the bacteria under the
microscope.
Hanging-block Cultures. — In order to be able to
study the morphology and the multiplication of the
diphtheria bacillus to better advantage than that
afforded by the hanging drop, Hill devised the
following procedure: Melted nutrient agar is poured
into a Petri dish to a depth of about one-eighth to
one-quarter inch. When cool, a block of agar is cut
out, about one-quarter to one-third inch square, and
IJ
'0.
KM
003
Bacteriological Technique
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
\
of the thickness of the agar layer in the dish. The
block is placed, under surface down, on a slide and
Eroteeted from dust. A suspension of the growth to
e examined is then made in sterile water or a
bouillon culture is used. The suspension is spread
over the upper surface of the block as if making
an ordinary cover-slip preparation. The slide and
block are then set aside in the incubator at 37° C.
for five or ten minutes, to dry slightly. A clean
sterile cover-slip is then placed on the inoculated
surface of the block in close contact, avoiding large
air bubbles. The slide is then removed from the
under surface of the block, and the cover-slip is
inverted so that the agar block is uppermost. With
the aid of a platinum wire a drop or two of melted
agar is run along each side of the agar block, to fill
the angles between the sides of the block and the
cover-slip. This seal hardens at once and prevents
slipping of the block. The preparation is again
placed in the incubator for five or ten minutes to dry
the agar seal. Finally the preparation is inverted
over a moist chamber or suitable well slide. The
cover-slip is sealed in place with white wax or paraffin.
Vaseline cannot be used because it softens at 37° C.
The "hanging block," thus prepared, is examined
on a warm stage or in the incubator-room.
Transplantation of Colonies. — The entire object of
making plate culture by any one of the several
methods given is to obtain single isolated colonies;
these can be transplanted to other media, and the
organism present can then be studied in perfectly
pure condition. The colony as indicated is pre-
sumably derived from a single cell, and consequently
is a pure culture. The transplantations or sub-
cultures can be made to gelatin, agar, serum, bouillon,
milk, etc. When the colonies are on a plate or in a
Petri dish a straight wire is used. The plate is first
carefully examined under the microscope, and a
colony is selected which is clearly single. If possible
it should be the only one in the field of the No. 3
or one-third inch objective. The farther apart the
colonies are the less likely are they to intermingle. As
originally directed, the colonies were touched under
the microscope by a sterile platinum wire, and in
this way a few of the bacteria were removed. Care
had to be taken that the wire did not touch the
objective or any other part of the gelatin. This
operation of "fishing," as it is called, obviously
requires considerable practice and care. An equally
good procedure is to pick out the desired colony
under the microscope. The tube of the microscope
is then raised, and the point of the sterile wire is
brought down so that it cuts the colony and nothing
else. The tube is then again lowered and the site
of the colony examined to make sure that nothing
but the colony was touched. If such is the case the
wire is then used for the subculture.
Stab Cultures,. — A tube of solid gelatin is taken, the
cotton plug is seized by the right little finger and
removed. The mouth of the tube is then flamed,
after which the wire, laden with the bacteria, is
inserted and carefully passed down the center of the
gelatin. The organisms are thus planted along the
line of inoculation. The cotton plug is replaced
and the tube is labelled and set aside. The form
of the growth is then noted from day to day, also the
presence of gas, liquefaction, pigment, etc. The
characteristics of the stab cultures are of the very
greatest importance in the identification of bacteria.
If the gelatin is old and partially dried, the passage
of the needle is likely to cause a split in the medium.
This can be avoided by melting and resolidifying
the gelatin. (See Plates' XI. and XII.)
Streak Cultures. — These are also known as "smear
cultures." The gelatin or agar tubes are melted and
solidified in an inclined position. Similarly solidified
blood serum is also used; so also are the potato tubes.
The infected platinum wire is drawn along the
904
middle of the surface of the medium by making one
single streak. The growth develops along the line
of inoculation, and spreads in a more or less character-
istic manner. (See Plates XI. and XII.)
Flask Cultures. — Flat flasks may be used for the
cultivation of bacteria en masse where the organisms
are desired in large quantities. The flask possesses an
advantage over the Petri dish in that it is much less
likely to become contaminated from without. For
this purpose the Kolle culture flask, or any similar
flat flask with a smaller mouth, may be employed.
To a properly plugged and sterilized'flask, sufficient
fluid gelatin or agar medium is added to form a
layer about a quarter of an inch in thickness over
one side. It is again sterilized by steaming and the
medium is allowed to solidify with the flask lying
on its side. When solid the free surface of the medium
may be inoculated with organisms in broth or salt
solution suspension by spraying or brushing over
with a Kruse's brush. After the growth has suffi-
ciently developed, it is removed by being scraped off.
A spatula, glass rod with angle at end, or similar
instrument may be used for this purpose. Sterile
broth or salt solution may be used to aid in washing
the culture free. For the cultivation
of bacteria on a large scale, Novy and
Vaughan introduced large metallic
tanks with tightly fitting covers.
Liquid Cultures. — The tubes of
sterile bouillon, milk, ™rum, etc., are
inoculated by simply introducing some
of the material from a colony by
means of the sterile wire.
The subcultures from tube to tube
are made in the same way as just
given. The drawn-out glass-tube
pipettes and spatulas can be used to
transfer the material from one tube to
another or to flasks.
Anaerobic Cvlti ration of Bacteria. —
The methods just given are essentially
aerobic, since there is free access of
air. As is well known there are two
classes of bacteria with reference to
their oxygen requirements. The aero-
bic bacteria live in the presence of
air, while the anaerobic thrive only in
the absence of oxygen. In order to
cultivate the latter, special methods
must, therefore, be employed which
will supply the needed conditions.
Numerous procedures have been de-
vised for this purpose, and to give
all of these would be beyond the scope
of this article. It will be sufficient
to indicate the principles which serve
as a basis for these methods, and to
describe those which are most widely
used.
1. Exclusion of Oxygen. — This was
accomplished by Pasteur in his early
work by pouring a layer of oil upon
the culture fluid. This served to ex-
clude the air and allowed the bacteria
to develop. Koch obtained anaerobic
conditions by covering the surface of
the gelatin plates witli a thin sheet of mica,
have done the same with glass plates.
The Liborius method of cultivation in deep layers
falls under this head. It is simple and is constantly
used. Ordinary stab cultures are made in the
suitable media, preferably glucose agar. Another
tube of agar is liquefied, cooled to about 50° C, and
the contents of this are then poured on top of the
stab culture. Care must be taken to flame the
mouths of both tubes so as to avoid contamination.
The upper layer of agar serves to keep out the air.
The cultures can be prepared equally well by employ-
Fig. 5S5.—
Liborius Deep
Stab Culture,
showing Growth
of the Tetauua
Bacillus.
Others
Reference Handbook
OF THE
Medical Sciences.
Plate XI.
14.
15.
16.
17.
18.
19.
20.
Micrococcus
Staphylococcus
of Osteo-
The same
Staphylococcus
Streptococcus
Streptococcus
Streptococcus
Tetragenus.
m gelatine.
pyogenes
pyogenes.
of erysipelas.
of Puerperal
myelitis.
albus.
Fever.
TEST-TUBE CULTURES.
Reproduced from Huber & Becker's "Untersuchungs-Methoden "
REFERENCE BANDBOOK OF Till-: MEDICAL SCIENCES
Bacteriological Ti< hnloni-
ing agar or gelatin tubes filled with the medium to
a depth ol about two inches. It is well to place the
tubes in boiling water for some time to drive off the
absorbed oxygen, then solidify rapidly by chilling.
Use a tightly fitting stopper in the tube to exclude
the air. After the stab is made, the line of puncture
etoscs up itself, and the growth then develops in the
Lower pari of the tube, as shown in Fig. 585.
Isolated colonies ean also be obtained by this
method. The liquefied medium is inoculated and
dilutions are made as for shake cultures. The tubes
are then solidified, and if necessary an additional
layer of medium is poured
on top. When the colonics
develop they can be reached
according to the directions
given under shake cultures. Another pro-
cedure is to make Esmarch roll tubes and
then fill the inside with gelatin or agar.
The drawn-out glass-tube pipettes (Fig. 578)
have been used by Koux for this same pur-
pose. The liquefied medium is inoculated and
drawn up into the pipette, which is then
sealed above and below the contents. The
colonies which develop can be reached by
cutting the glass. A somewhat similar pro-
cedure was devised by Wright. A short glass
tube with constricted ends is used. Each end
has a piece of rubber tubing attached. One
of these is connected with a glass tube which
projects through the cotton plug of the test-
tube. The test-tube contains bouillon, and
this contrivance is sterilized and inoculated.
The bouillon is then drawn up into the con-
stricted tube, which is sealed by simply push-
ing down on the tube, so that both rubber
ends are bent back on themselves.
2. Displacement of Air. — This is accom-
plished by passing through the tube or a suit-
able container an inert gas till all the air has
been displaced. Hydrogen is the least injur-
ious gas for this purpose. It can be generated
from zinc and sulphuric acid in a Kipp's gen-
erator. The gas should be washed by passing
successively through alkaline lead acetate, six
per cent, potassium permanganate, and finally
through a solution of silver nitrate. After
passing through the apparatus the gas is sent
through a small wash bottle which serves as a
valve to prevent air from entering when the
current slows up. Such a wash bottle is shown
in Fig. 5S7, //. After the gas has passed for
an hour or more it should be tested by ap-
plying a light as it leaves the wash bottle.
If the flame burns with explosions it is evident
that all the air has not been displaced. The
operation is continued until the gas burns
evenly at the mouth of the tube. Owing to
the danger of explosion the light should never
be applied to the outflowing gas without the
safeguard of the water valve
for the pui po e oi obtaining plat e cull ires. Kita
employed a flal bottle, Inning a tube fused al the
lower end. The dilutions were mad.- in the ordinary
tubes, after which the material was poured into
these Basks, which were connected in series and
hydrogen passed through. Finally the ends ■
-inled by fusing in the flame, while the neck of each
flask was closed with a clam lied rubber I ill, e. Several
modifications Of this bottle have been made, but
they are linle used, since methods were soon per-
fected whereby it was possible to make Petri plates
in hydrogen.
One 01 the earliest attempts in this direction was
thai of Blucher, who made use of a funnel which was
weighted with lead and inverted over the plates in a
larger dish. Air was excluded by means of glycerin
water. Hesse inverted a glass vessel in a circular
trough filled with
irv. Liborius
used a copper bell-
jar which was com-
pn I 1 against a rubber gasket by means of
set-screws; others made use of bell-jars in-
verted upon a ground-glass surface. In many
respects the Botkin apparatus is useful. It is
shown in 1 ig. 587. It consists of a metal rack
on which are placed the Petri dishes. This is
set in a large outer dish which contains about.
an inch of liquid petrolatum. A bell-jar is
inverted over the stand. The inflow and out-
flow tubes are of rubber stiffened by a copper
wire on the inside. After the hydrogen has
been passed for a sufficient length of time,
the tubes are withdrawn and the apparatus is
then set aside.
The Novy apparatus shown in Fig. 588
leaves little to be desired. The hollow stop-
per has two perforations, one of which is con-
nected with a glass tube which extends almost
to the bottom of the bottle. In the case of
the plate apparatus the tube may be continued
by means of a piece of rubber tubing. A
perfect seal is obtained by simply turning
the stopper through an angle of 90°.
The bottle (Fig. 588, A) is made in two
sizes, 8X16 and 10X20 centimeters, which
dimensions do not include the neck. A piece
of cotton should be placed on the bottom.
The ordinary test-tubes containing any
medium are inoculated in the usual way. The
cotton plug is then cut off square, and by
means of a pair of crucible tongs the tube is
lowered into the bottle. It is advisable, if
the cotton plug is very tight, to loosen it up
by partially pulling it out. A single jar ean
be filled in this way with a large number of
tubes containing either solid or liquid media.
The stopper is then put in place and the ap-
paratus connected with a hydrogen generator.
When the gas has passed for a sufficient length
of time the bottle is closed by giving the
stopper a turn. As will be seen, this jar can
Fig. 586. — Fraen-
One of the earliest attempts at making tube kel's Modification of
cultures by this method was that of Liborius. the Liborius Tube be used likewise for the pyrogallate method.
He made use of a special test-tube with a deli v- for Anaerobes. The plate apparatus shown in Fig. 5SS, B,
ery tube fused into the side. After inoculation consists of two parts. The inner dimensions
of the liquid medium, gas was passed through, and of the lower part are 12X12 centimeters. The Petri
finally the neck of the test-tube, as well as the end
of the delivery tube, was sealed in the flame. This
method is of only very limited application, and re-
quires much time and is expensive. Fraenkel's modi-
fication is a distinct improvement. Ordinary large
test-tubes are used. These are provided with rubber
stoppers and delivery tubes, as shown in Fig. 586.
After the inoculation of the medium and expulsion
of the air, the tubes are sealed in the flame. If it is
desired to obtain colonies, the tube can be converted
into an Esmarch roll tube.
This principle has been adapted in various ways
plates are stacked into this compartment. The
flanges are covered with a mixture of beeswax and
olive oil (1:4). The two parts are then brought
together and a rubber band is slipped over the outer
edge of the flanges. Two or three clamps or small
vises are now applied. The jaws of these should be
covered with a piece of rubber tubing. Gas is passed
as in case of the bottle, and at the conclusion of this
operation the stopcock is given a turn so as to seal
the apparatus.
The other modification (Fig. 5SS, C) has a special
stopper, which enables it to be used for vacuum
905
Bacteriological Technique
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
cultures. It can, however, be employed equally
well for hydrogen cultivation. Moreover, both
forms of the plate apparatus, as well as the bottle, can
be used for the pyrogallate method.
3. Absorption of Oxygi n. — The most convenient ab-
sorbent for this purpose is an alkaline solution of
pyrogallic arid. The principle was first utilized by
Buchner for tube cultures, as shown in Fig. 589.
The large outer tube is provided with a closely fitting
rubber stopper. On the bottom of the tube is placed
about a gram of pyro-
gallic acid and a suit-
able support. The
tube containing the
nutrient medium is in-
oculated in the usual
way and placed on this
support. Finally 10
c.c. of a ten-per-cent.
solution of potassium
or sodium hydrate are
added from a pipette,
as rapidly as possible,
and the tube is then
quickly closed with the
stopper.
As mentioned above,
the Novy apparatus
can be employed for
the pvrogallate method. In the case of the jar a
wide "tube is introduced which contains about two
grams of the acid. After the culture tubes have all
been inserted, about 20 c.c. of a twenty-five-per-cent.
solution of sodium hydrate are introduced into the
pyrogallate tube from a pipette, and the stopcock is
then inserted as quickly as possible and turned. In the
case of the plate apparatus a crystallizing-dish, about
ten centimeters in diameter and about two centimeters
high, is placed on the bottom, and about four grams of
Fig. 5S7. — Botkin's Apparatus for Plate Cultures of Anaerobes.
quired which fit one into the other like the halves
of a Petri dish. They should be about two and
one-half centimeters in height and with relative
diameters such that when put together a space of
one-half centimeter exists between the sides; the
maximum diameter should be about ten centimeters
for convenience in handling, although any other size
may be used. After sterilization of the dishes the
inoculated agar is poured into the smaller, the same
as in ordinary Petri-dish plating, and again covered
with the larger dish.
The apparatus is in-
verted when the agar is
hard, the smaller dish
is lifted out of the
larger, and placed on a
moist surface to pre-
vent contamination.
About three grams of
pyrogallic acid are
placed in the bottom of
the larger dish, which
stands open. The
smaller dish, still in-
verted, is placed into
this, and sufficient five-
per-cent. solution of
sodium hydrate is
added (between the
sides) to fill the dish about one-half full. At once,
liquid paraffin is run into the space between the si
can bo placed on (lie side of I he concnv e slide. After
the cover is in place the slide can be tilted so as to
bring the two liquids together. A special slide for
this purpose was devised by Braatz (Fig' 590).
The hanging drop is made and placed over Hi' 1
well. The Hat. flask contains the pyrogallio acid ami
communicates with the space below the drop. Strong
alkali is finally added and the flask is closed with a
stopper. 1'yrogallic acid can also be employed in con-
nection with Hill's "hanging-block"
culture. Another apparatus lor anaer-
obic hanging drops is that of kuhne.
It is very serviceable and can be used
for either the gas or pyrogallic process.
4. Exhaustion of .1"'. —Pasteur em-
ployed U-shaped tubes, from which
the air was removed by means of an
air pump. Gruber applied the princi-
ple to the tube culture. He uesd a
stout glass tube, which was provided
with a stopper, through which passed a
short glass tube by which connection
was made with the air pump. The
test-tube was constricted just below
the stopper so as to facilitate the sub-
sequent sealing process. The tube was
filled in the usual way with the nutrient
medium and inoculated. It was then
connected with the pump, and as soon
as the air was exhausted the tube was
sealed at the constriction. The plate
apparatus shown in Fig. 588, C, is in-
tended for vacuum as well as gas or
pyrogallate cultures. It can be used
for tube or plate cultures.
5. Mixed Cultures. — This method of
cultivating anaerobic bacteria corre-
sponds to the way in which these
organisms grow in nature. If the
anaerobic is planted together with an
aerobic, the latter will consume all the
oxygen in the immediate neighbor-
hood, and as a result the anaerobe
will grow. Thus, if tetanus and hay
bacilli are planted at the same time
into a tube of bouillon, they will both
develop. Other aerobic bacteria, such
as Bacillus prodigiosus and Proteus
vulgaris, can be used for the same
purpose. The mixed culture method
is also applicable to the cultivation of
certain protozoa (amebas). But per-
haps this is due to altered medium
rather than any oxygen requirement.
Musgrave and Clegg found that amebas
could be cultivated upon a special medium when
grown with pure cultures of certain intestinal organ-
isms, as B. coli.
6. Cultivation in Air. — This of course is apparent
rather than real. If a tube of glucose gelatin, prefer-
ably colored with litmus, be inoculated with an anae-
robe and then set aside in the incubator, an abundant
growth will develop (Novy's method). Similarly,
when deep stab cultures are made of the anaerobes,
it will be found quite frequently that the water of
condensation on the top of the medium is cloudy
from the growth of the germs. The explanation in
the one case is that air is excluded partly by the
viscosity of the liquid and partly by the evolved gases.
The gas formation accounts for the growth of the
germs in the water of condensation. The culture in
glucose litmus gelatin is by far the simplest way of
growing anaerobes. Moreover, the cultures thus
obtained retain their vitality for many years. In
some cases the author has recovered cultures from
tubes five and six years old.
Collodium Sacs. — This method of cultivating has
been used extensively by the Pasteur School for exalt-
A
Fig. 5 8 9.—
Buchner's Pyro-
gallate Method.
ing the virulence of bacteria. The underlying Idea
is to grow the organisms in the peritoneal cavity of an
animal, and under such condition-, that the v. a te
products of the germs will be removed, an abundant
upply of nutrient material furni hed, and the germs
themselves protected again t the action of phago-
cytes. This is accomplished b i g the bacteria
in an hermetically sealed sac, the walls of which are
permeable to the waste products of the germ and to
the soluble proteins of the peritoneal fluid. Several
Russian workers have employed for this purpose the
inner lining membrane of reeds, bul the best procedure
is to make the sacs of collodium. Various methods
have been devised for the rolling of the sac, but un-
doubtedly the best and simplest, is that preferred in
\.e j ' . laboratory by < iorsline,
The rolling tube employed for making sacs is about
twelve to fifteen inches long, and of any width that
may be desired. For ordinary purpo e awidthof half
an inch is sufficient. One end of this tube IS rounded
off like a test -I ube, and has a two-millimeter opining
at the tip. This opening is first closed with collodium
cither by touching it with the cork which has been
'"..red with the solution, or the collodium may be
applied with the finger. Care must be taken to see
to it that the collodium does not ^ei inside of the tube.
In a few se ids the layer is dry enough 1 < > go ahead.
The collodium used is the United Slate.-- Pharmaco-
poeia solution, which by exposure to the air has I
concentrated by one-third or one-half. It should be
perfectly clear, and if not it must be filtered through
cotton by the aid of a pump. The collodium can be
kept in a glass-stoppered cylindrical vessel, such as is
used for the collection of blood. The collodium is in-
clined till it comes within a few inches of the opening.
The rolling tube, with the opening freshly closed, is
dipped in the collodium and rolled several times in
the liquid. It may be rolled so that only the lower
side of the tube touches the collodium. If the sac
is to be very thin it is sufficient to roll the tube but
Fin. 500. — Braatz'.s Slide for Anaerobic Hanging-drop
Examinations.
two or three times, after which it is raised from the
liquid and rolled in the ether atmosphere in a hori-
zontal position till the collodium has set. If the layer
is not thick enough the tube can be returned to the
collodium, but care must be taken to avoid the forma-
tion of air bubbles. The coated tube is finally rolled
in the air until it has reached the proper consistence.
This can be ascertained by touching the thickest part
with the finger. The collodium layer should be rather
firm. The tube is then immersed in distilled water
for a minute or two. If the collodium is not suffi-
ciently hard, it wall cloud or become milky on contact
with the water. It should remain perfect ly clear, and
when finished a thin sac placed in water is almost
invisible.
To detach the sac the tube is filled with distilled
water, and by blowing into the open end the water can
be forced through the opening below and upward
between the sac and the tube. By slight manipula-
tion with the fingers the detachment can be effected
readily on all sides. The free end is then trimmed
square, after which the sac is placed in distilled water,
where it remains until it is ready to be attached to
the glass tube.
An ordinary test-tube having a diameter slightly
less than the sac is constricted in the blast flame at
about two inches from the end. A scratch is then
907
Bacterio.ogical Technique REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
made, about half an inch below the constriction, with
a diamond, and with the aid of a hot rod the end
is removed. The resulting tube has the form shown
in Fig. 591, a. The cut end should be rounded in
the flame so as to remove the sharp edge.
The inside of the neck of the sac is dried by means
of filter paper, after which the end of the tube is
inserted. This can be done more easily if the end of
the tube is previously dipped in alcohol. The next
step, that of shrinking the sac upon the tube, is very
important and requires care. Most of the shrinking
is done by rotating the tube, in a horizontal position,
some distance above a small spare-flame burner. In
this way the collodium can be made to contract down
Fig. 591. — Preparation of Collodion Sacs. (Xovy.)
upon the glass, but the operation must be done slowly
and at some distance above the flame, otherwise
there is danger of igniting the sac. The adhesion is
rendered more complete by the application of a hot
glass rod. Finally a silk thread is wound as closely
as possible over the glass neck, and this in turn is
covered with a layer of collodium. The sac now lias
the appearance shown in Fig. 591, b. The finished
sac is now filled with distilled water and placed in a
test-tube on foot, which also contains water (Fig.
591, e), and the whole is sterilized by steaming in an
autoclave for half an hour at 110° C.
When the sac is to be used, the water is removed
from the inside by means of a drawn-out pipette and
replaced in like manner with bouillon which has been
inoculated with the organism to be tested. The
threaded part is then wrapped in a piece of sterile
filter paper, for convenience in handling, and the con-
striction is sealed in a sharp-pointed flame. The
sealed sac is then placed in a sterile test glass.
The rabbit or guinea-pig which is to receive the
sac is now attached to a holder and the hair is removed
from the abdomen. The field of the operation is thor-
oughly washed with lysol or mercuric chloride. After
the animal is anesthetized an incision is made in
the abdominal wall, and through this the sac is in-
troduced into the peritoneal cavity. The incision is
then sewed up and covered with cotton and a little
collodium.
The sac is allowed to remain in the animal for a few
or even for several months. To remove it the
annual is killed with gas. The sac is freed from the
adhesions and transferred to a sterile test glass with
the glass end downward. By means of a hot rod an
opening is burned into the end of the sac, and through
(llis ll " - contents arc removed by means of a drawn-
out tube pipette. When large sacs are to be inserted
mi 'i an animal it is advisable to strengthen them by
908
placing within a perforated glass tube as shown in
Fig. 591, d, e.
The collodium sacs can be used not only as just de-
scribed, but also with marked advantage for dialyzing
experiments. For this purpose the sacs can be made
an inch or more in diameter and twelve or fifteen
inches long. The thin collodium membrane is con-
siderably more permeable than parchment paper
Separation of Spore-forming from N on-spore-forming
Organisms by Heal.— Heat is sometimes employed in
the separation of spore-forming from non-sporelform-
mg species of bacteria when both are present in mixed
'•iilture. For this purpose the mixed culture con-
taining spores, is heated for fifteen minutes at ,so°
C. The vegetative forms are destroyed while the
heat-resisting spores remain viable and will develop
under proper conditions. If more than one species
of spore-forming organisms are present, they may lie
separated further by the plating method, or by animal
inoculation.
Mechanical Separation of Bacteria from Fluids. —
For this purpose various types of the centrifuge are
used. It is essential that they run smoothy, and
revolve at a high speed. The type best adapted for
the separation of bacterial and other cells from fluids,
pathological exudates, etc., are those equipped with
slender glass tubes with conical ends to collect the
sedimenting material. They are usually driven by
means of water or electric motors. The electric-
motor type is more satisfactory and may be procured
to be driven by cells, storage battery, direct or
alternating current. The ordinary clinical centri-
fuge driven by hand may be used, but in most cases
this is exceedingly slow in sedimenting organisms.
Drying of Bacteria, Toxins, Antitoxins, etc. — In the
chemical or biological study of bacteria and their prod-
ucts, it frequently becomes necessary to remove the
water content. Since the labile constituents would
be destroyed if dried by heat, as in ordinary chemical
manipulations, other means must be used. This can
best be done by drying in vacuo in the presence of
certain substances, as phosphoric anhydride (P„0 5 ) or
concentrated sulphuric acid (H 2 S0 4 ) which readily
absorbs the water vapor. The temperature may be
kept at that of the working-room or even lower.
Most suitable for this purpose is the ordinary heavy
glass vacuum desiccator. This is partially divided,
with an upper and lower chamber, by means of a
movable perforated porcelain plate which forms a
shelf for receptacles. Either in the wall or cover of
the desiccator a heavy glass tube with cock is fused
or passed by means of a ground-glass stopper. This
forms a means of communication with the interior
of the vessel. The apparatus must be of heavy con-
struction to prevent breakage from the external air
pressure when air content is exhausted. For use,
first place in the bottom chamber a layer of con-
centrated sulphuric acid, or, better, phosphoric an-
hydride, filling the chamber about one-quarter to one-
half full. The material for drying should be previously
spread or poured in a flat dish, such as the halves of
a Petri dish. Now place the dish on the porcelain
shelf over the water-absorbing substance. Adjust
the cover and firmly seal in position with an adhe-
sive paste. It is well also to use the same paste on
the glass stopcock to prevent leakage at that point.
Such a paste may be prepared by taking one part of
pure rubber (black elastic rubber tubing cut in small
pieces), one part of paraffin, and three parts of vase-
line. Mix together and heat until dissolved. Take
extra thick-walled rubber tubing and connect an air
pump (of the large type) to the exhaustion tube of
the desiccator. Open the glass stopcock and pump
out the air to produce vacuum. At once close the
glass stopcock of desiccator tube, and observe if any
air leaks are evident. If not, detach pump. It is
necessary to pump out the desiccator at least once a
day until the substance is entirely dry. The ordinary
i;i;ii:i:i:nci: handbook ok tiik mkdkal scikxces
Bacteriological Technique
water pump cannot be used owing to the water vapor
which is always present and travels back during
exhaustion.
The alici\ e ni. 'I hod fur I he de iccal ion of main ia]
is open to certain objections. Among these may be
mentioned: the time period required in reducing any
considerable volume of immune serum, toxic broth,
etc., to the dry state; the changes resulting in blood
serum during the process which makes re-solution
difficult in most instances; and, in the case of labile
Fig. 592. — Syringe Holder and Sterilizing Pan. (Novy.)
components, as toxins, complement, etc., a great
depreciation, or even a total loss of value may result.
A method of drying, proposed by Shackell, offers, at
least, a partial solution of the above difficulties. By
his method, which has been further improved by
Harris, the material to be dried is thoroughly frozen
as rapidly as possible by means of a salt-ice mixture,
or by means of carbon dioxide snow. The frozen sub-
stance, in an open dish, is at once placed in the bottom
of a Scheibler's vacuum jar (which has also been
thoroughly chilled, by being partially immersed in a
salt-ice mixture), then an open dish containing con-
centrated sulphuric acid (cold) is placed upon a wire
gauze support in the upper portion of the jar. The
jar is sealed at once with the exception of a connec-
tion which is made with a Geryk vacuum pump. The
pump is put in operation immediately to exhaust the
air from the vacuum jar. When this is accomplished
in so far as possible, the connection is cut off by means
of the stop-cock. Care must be taken to exclude all
air leaks, which is not difficult if a proper lubricant
is used. Occasionally the vacuum jar is rotated
gently in order that the sulphuric acid may be kept
well mixed, and its absorption ability kept at its
highest degree of efficiency. By this method, Harris
found that even a rabbit brain (rabic) would become
thoroughly dry in from thirty-six to forty-eight
hours. Desiccated serum readily passed into solu-
tion after this means of treatment. Care should be
taken to seal the materials, when finished, to exclude
the air since the dried material is quite hygroscopic.
Inoculation of Animals. — According to the
nature of the experiment these are made with pure or
impure cultures of bacteria, or with the chemical
products elaborated by them. The use of impure
material is met with in diagnostic work. Thus in
suspected glanders the discharge is introduced into
animals in order to ascertain if the bacillus of glanders
is present. The same is often done in tuberculosis,
pneumonia, bubonic plague, anthrax, tetanus, rabies,
etc. In all these experiments the animal serves as a
plate, since it eliminates all the saprophytic bacteria
which may be present in the original material and
allows the disease-producing ones to develop in pure
or almost pure cultures. The inoculation with pure
cultures is made to test their identity, to study their
effect upon animals, to ascertain the diverse means
of infection, and for purposes of immunization. The
inoculation with the chemical products enables one to
ascertain t be pre cue, oi poi onous substam
produce vaccines or antito
The inoculations may be made with a fine need!
lance, I ii 1 1 i e ott en with the aid ol a syringe. The
drawn-out glass-tube pipette is also used a ..
introducing infectious material.
The syringe used varies with different workers. The
Germans are especially favorable to the Koch svringe,
which consists of a glass cylinder, graduated, tin
row end of which connects with the i die whili
upper end tits into the metal collar of a rubber bulb.
The advantage claimed is thai the cylinder and Deedle
can be effectively sterilized by dry heat. As a mat ter
of fact the Koch syringe is extremely inconveni
and unsatisfactory, and equally good results with
less time and annoyance are obtainable with the
ordinary hypodermic. The
all-glass type of hypodermic
syringe is perhaps the i
satisfactory for inoculation
purposes. The latter models,
of course, must be sterilized by
boiling in water for ten or
fifteen minutes. A convenient
holder for the syringe is shown
in Fig. 592.
When large quantities of
liquids are to be introduced,
as when injecting horses with diphtheria toxin in
the preparation of antitoxin, an apparatus similar to
that shown in Fig. 593 can be used.
The necessary instruments, such as knives, scissors,
needles, etc., are sterilized by boiling in water, or
better in a saturated solution of borax. A very con-
venient sterilizer for this purpose is that shown in
Fig. 598.
In all operations the animal must be secured in
some way or another. Various kinds of holders have
been constructed for this purpose. That of Latapie,
shown in Fig. 594, is very convenient, and is to be
preferred to the ordinary models. It can be used for
guinea-pigs, rabbits, birds, etc.
The Voges holder, shown in Fig. 595, is useful for
taking temperatures and for injecting small animals.
A good substitute can
be made by using a
glass cylinder.
Special holders have
been devised for rats
and mice. These,
however, can be
handled best by
means of a pair of
compression or artery
forceps. The animal
is seized by the nape
of the neck with the
forceps, which is then
transferred to the left
hand. The tail and
the hind legs are also
held by this hand.
Fig. 593. — Graduated Cylinder for Injecting Liquids. (Novy.)
The animal in this way is put upon the stretch, and
the inoculation can then be made with the right
hand. Even full-grown wild rats can be handled in
this way without the help of an assistant.
After inoculation the animals are placed in special
jars or cages. The ordinary glass battery jars, pro-
vided with a galvanized-wire top; weighted with lead,
serve to confine rats and mice, and can even be used
for guinea-pigs (Fig. 59G). If the animals are
900
Bacteriological Technique
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
inoculated with a very dangerous organism, such as
the pest bacillus, it is advisable to place the jar
inside of a ten-gallon crock. In special cases, as in
animals infected with trypanosomes, bubonic plague,
etc., it is well to cover the cage with a piece of mos-
quito nrtting or cheese-cloth as a safeguard against
insects spreading the infection.
Guinea-pigs, rabbits, and the like can be kept in the
Vaughan cage shown in Fig. 597. The cage proper is
thirty centimeters high, thirty-eight centimeters deep,
and fifty-four centimeters wide. The feet are twelve
centimeters high.
Fig. 594. — Latapie's Animal Holder. (Novy.)
1. Cutaneous Application. — Ordinarily bacteria do
not penetrate the unbroken skin or mucous mem-
brane, but the direct application of some organisms,
even in the absence of any known lesion, leads to
infection. This is the case when the virus of the
foot-and-mouth disease or the bacillus of plague is
brought into contact with the mucous membrane.
The pus germs, when rubbed into the skin by the aid
of vaseline, may cause infection.
2. Subcutaneous Application. — For this purpose the
hair is removed from the region where the inocula-
tion is to be made. The place is then rubbed with a
disinfectant. In the rat this is usually on the back,
at the root of the tail; in the guinea-pig it is on the
side. A nick is made with sterile scissors, and then
with a narrow scalpel or spatula a pocket is made
Fig. 595.-
Hulder for Small A n i m als. (Novy.)
under the skin. A piece of tissue, a bit of earth,
blood-laden wire, etc., is then introduced into the
opening, which if made small requires no special
closure.
3. Subcutaneous Injection. — The suspended material
is introduced under the skin by means of a syringe.
The hair should first be clipped close and the place
of inoculation touched up with a disinfectant.
4. Intravenous Injection. — In the case of the rabbit
this is easily done. The marginal branch of the
posterior auricular vein is selected, although it may
appear to be narrower than the needle. The hair
may be removed and the surface of the ear rubbed
freely to stimulate circulation. A clamp is then
applied at the base of the ear so as to distend the
vein. The needle is then inserted at a very slight
angle to the vein. In other animals the jugular
can be exposed and the injection made without any
difficulty.
5. Intraperitoneal Injection. — This procedure is very
commonly resorted to. The skin over the abdomen
should be raised and the needle of the syringe is
then introduced into the
cavity. Care should be
exercised in order not to
penetrate the hollow viscera
in small animals. In such
case the fluid may enter
the intestine, for example,
and be discharged without
producing any effect. In
the case of the horse, while
the animal is standing a
trocar is introduced through
the skin at a point a few
inches anterior to the crest
of the ilium.
6. Intrapleural Injection.
— The needle is introduced
into the right pleural cav-
ity, care being taken to
prevent any injury to the
lung or to the heart. Large amounts of liquid can-
not be tolerated by the animal.
7. Intracranial Injection. — This method was intro-
duced by Pasteur as a means of surely infecting
animals with rabies. The procedure is followed out
when inoculating animals either for diagnosis or for
the purpose of preparing the vaccine for hydropho-
bia. It is usually practised on rabbits and guinea-
pigs. The skin from between the ears forward is
shaven clean and disinfected. An incision about an
inch long is then made. Those of the Pasteur school
apply a hand trephine, and make an opening into the
skull. A small trephine, operated by a dental engine,
Tig. 596.— Rat Cage and
Forceps.
Fig. 597. — Vaughan Cage. (Novy.)
is much more convenient. In the absence of either
an opening may be made into the skull with a stout
scalpel. By means of a hypodermic syringe a few
drops of the brain or cord suspension are then intro-
duced under the dura. At times the injection is
made into the brain proper, in which case it is spoken
of as intracerebral. After the injection a suture or
l wo are applied, and the wound is covered with collo-
dium and cotton.
910
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
narlrrliiloKlcal lYrlinlquo
8. Intraocular Injection. — Cocaine is first applied
to the eye, after which this is fixed with forceps and
tilt' material is injected into the anterior chamber.
]f desired, an opening can be made with a cataract
knife or narrow scalpel and the solid material can be
introduced in this way.
9. Injection into the Lymphatics. — This is usually
made by introducing the material into the testicles.
10. Respiratory Infection. — While the preceding
methods may be looked upon as wound inoculations,
this concerns itself as nearly as possible with duplicat-
ing the natural infections along the respiratory tract'
The direct method consists in causing the animal to
inhale the finely divided material, w hich can be readily
done by means of an atomizer. In some cases I he
animal is caused to inhale irritating fumes, such a
bromine vapor. This excites a slight inflammatory
reaction of the respiratory mucosa, and causes the
animal to become more liable to infection.
When the atomizer is used to produce a spray, the
operator must take special precaution to protect him-
self against infection. The animal should be placed
in a specially constructed tight box. All openings
for air should be loosely packed with absorbent cotton
which acts as an air filter. The spray can be throw n
in through an opening admitting the tube of the
atomizer with sufficient cotton wool about it to pre-
vent escape of spray from the aperture. Another
procedure may be called the intratracheal injection.
This is carried out by making an opening into the
trachea, and through this introducing the infectious
agent.
11. Alimentary Infection. — Since water and food
serve to introduce the pathogenic agent of many
diseases into man and animals, it is necessary at
times to resort to a similar method of infection. The
animal may receive the infectious agent in water.
milk, or in solid food. Thus bread may be soaked
in a bouillon culture of the organism. At other
times it may be necessary to introduce the material
into the stomach by means of a rubber tube. In
order to prevent the animal from biting the tube.
it is well to pass it through a perforated cork or plug
of soft wood. Under exceptional conditions a lapa-
rotomy may be made and the material injected into
the intestines. This is spoken of as the intraduodenal
injection.
Observation and Autopsy of Injected Animals. —
The matter of suitable caging of animals has already
been touched upon. Attention may be called to
the need of daily observations of the infected animals,
so as to note the symptoms manifested. The animals
must have plenty of food and drink, and must be
kept in as clean a condition as possible. Their
weight and temperature should be taken daily, for in
this way the best information can be gained as to
the physical condition of the animals.
When the animal dies it should be autopsied at
once, or else it must be put aside in an ice-box. The
need of immediate examination is shown in some of
the trypanosomatic infections, as nagana and caderas,
where the organisms may disappear from the blood
within an hour or so after death. Moreover, delayed
examination may lead to the invasion of the organs
of the cadaver by the intestinal bacteria, in which
case the search for the specific germ is rendered
more difficult, if not impossible.
The animal is prepared for autopsy by being placed
on its back and tacked down on a board. A conven-
ient board of this kind is one which is about thirty-
four by fifty-four centimeters and has a raised border.
The cracks, if any, should be filled with paraffin.
After the animal is laid out , the hair should be thor-
oughly moistened with mercuric-chloride solution.
The necessary instruments can be sterilized in a
copper sterilizer, such as is shown in Fig. 598. In
the absence of such an arrangement the instruments
may be sterilized by heating directly in the flame,
but this, of course, injures them. A searing iron,
several drawn-out pipettes, and sterile dishes, as well
as the necessary media, should be conveniently at
hand.
Willi a sterile scalpel an incision is made along the
entire length of the body from the neck to the pubis.
Lateral incisions are then made in the direction of
each of the extremities, and the two large flaps thus
resulting are t urned back. The condition of the sub-
cutaneous tissue, the presence Of edema, bloody
■ ■I! ii ions, enlarged lymphatic glands, etc., are noted.
The glands or portions of the ti ue maj be trans-
ferred by means of sterile instru nts to a sterile
dish. Cover-glass smears or streaks can be made
and examined eil her at once or later.
The abdominal and thoracic cavities are usually
opened at the same time. 'I lie abdominal wall in
the lower part of the body is slightly rai ed and
nicked with Sterile scissors; then the lower blade is
inserted and the incision prolonged upward to the
pit:. 598. — Iustruiueut Sterilizer.
diaphragm. The ribs are then cut as low down as
possible, and the wedge-shaped piece of the wall of
the thorax is removed. The condition of both cavi-
ties and of the organs is carefully noted. Cover-
glass streaks are made from the peritoneal surfaces
and from the cut surfaces of the organs, and examined
either at once or later. Any fluid which is present
in the cavities may be transferred to sterile tubes by
means of the pipette.
Cultures should always be made from an intact
organ. For this purpose it is cut open with sterile
scissors, and a piece of the pulp removed on a sterile
wire or by the aid of a Nuttall spear or spatula (Fig.
577). The heart blood is usually given preference
for culture purposes. The pericardium should be
opened, after which the surface of the heart is seared
with a hot iron. An incision is then made into the
ventricle, from which the blood can be removed by
the aid of a looped wire. The best way of removing
the heart blood is by means of a sterile Pasteur bulb
pipette. The end of this is broken, flamed, and when
cool it is inserted into the heart, and by suction the
blood is drawn up into the pipette. The contents of
the tube can then be used to inoculate culture media
or for making blood streaks.
After the autopsy the animal should be placed in a
vessel and steamed or autoclaved, and eventually
burned. The board should be washed with mercuric
chloride, and all instruments and utensils should be
sterilized by steaming. Throughout the autopsy
care must be taken to prevent infection either by the
scattering of material on the floor or by its being
carried away by insects.
Examination of Bacteria. — In order to gain
some definite information regarding the bacteria
which develop on the nutrient media or in the ani-
mal body, recourse must be had to the microscope.
911
Bacteriological Technique
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
The organisms may be examined in the living con-
dition or in stained preparations. The former pro-
cedure is resorted to so as to learn all that is possible
regarding the living cell: its form, size, color, granula-
tions if any, motion, grouping of the cells, presence of
spores, etc. Such facts are ascertained by making
a preparation in which the bacteria will continue to
live for some time.
Living Bacteria. — 1. The simplest procedure is to
place a drop of the bacterial liquid on a slide, after
which the cover-glass can be applied and the prepara-
FlG. 5U9.
tion examined under the microscope. This method
is usefiii for rapid orientation, but it has certain draw-
backs, chief among which is the fact that evaporation
takes place along the edge of the glass, and as a
result currents are established in the liquid. Such
currents tend to interfere with the observation of
any one organism or group of cells. Again, a prepa-
ration of this kind cannot be kept under observation
for any length of time on account of the desiccation
which soon takes place.
2. The examination in a hanging drop, as it is
called, obviates the difficulties mentioned. A rather
thick slide with a concave well is used (Fig. 599).
A ring of vaseline is spread around the edge of this
well. A clean cover-glass, about three-fourths of an
inch in diameter, is placed on the table, and a drop
of water is applied to the middle by means of a looped
platinum wire. It is desirable that the drop should
spread out flat, and if it does not it is because the
cover-glass is not clean. The drop of water is then
inocuiated with a little of the culture. Just enough
material is added so that, the liquid is slightly cloudy.
The vaseline-ringed slide is then inverted and
brought down upon the cover-glass. The preparation
is turned over, and, if need be, pressure is applied to
the border of the glass so as to have an air-tight hang
ing drop. Under these conditions evaporation does
not take place, and consequently the specimen may be
examined for hours, if necessary, without any inter-
ference by currents due to evaporation. As men-
tioned above, this method can be used for the cultiva-
tion of bacteria, and thus their growth and multi-
plication can be followed out. In that case it is
necessary to use a flamed cover-glass and a sterile
liquid.
Instead of the concave slide a so-called well-slide
can be used (Fig. 000). This is essentially a square
bit of glass with a circular opening, which is cemented
to an ordinary glass slide, and the hanging drop is
then made in the manner described.
One disadvantage in either method lies in the fact
that the drop is more or less convex, and consequently
when using higher powers it is difficult to examine the
deeper portions. This difficulty can be overcome
by employing the Ranvier slide, which has a circular
trough, Mud the portion within the circle is ground
down so thai its level is about 0.1 mm. below that of
I lie slide, When a drop of liquid is placed within
the circle and covered with a cover-glass, the liquid
912
o. c
-Concave Slide showing Hanging Drop. A, Surface
view; B, side view.
spreads out into a thin layer, every part of which
can be examined under the microscope. A ring of
vaseline is placed along the edge so as to prevent
evaporation. By flaming the slide and cover-slip,
and using sterile liquid the preparation can be ob-
served for several days if need be. This method is
especially to be recommended for studying trypano-
somes, malaria parasites, etc.
Staining of Bacteria. — In order to obtain good
stains it is necessary to have good clean cover-glasses.
The cover-slips, as purchased in the market, are
unfit, for use until they have been cleaned. One
method of doing this is to heat the slips in a beaker
with concentrated sulphuric acid and potassium
bichromate. The cover-glasses are then washed in
running water, after which they are kept in alcohol.
Another procedure which gives very satisfactory
results is to soak the cover-glasses first in alcohol,
after which they are wiped with soft, washed linen,
placed in an Esmarch dish and heated in a dry-heat
sterilizer at about 200° C. for an hour or two. This
high heat completely destroys ■ the organic matter
that may be on the glasses. A" cover-glass is not clean
if a small drop of water, when spread over the surface,
does not remain even, but gathers into droplets.
Several kinds of forceps have been devised for
holding cover-glasses while staining. The Cornet
forceps (Fig. 601, a) is well known, and is useful
though rather awkward. Stewart's modification is
widely used (Fig. 601, b). A much more convenient
type of forceps is shown in Fig. 601, c. The lower
blade has a thin edge which permits one to pick up
the cover-glass without contact with the fingers. The
upper blade is bent in order to avoid capillarity, and
is narrowed to a point so that the specimen is held by
point contact. A catch serves to hold the cover-slip
in place.
Aniline Dyes. — The aniline dyes which are em-
ployed for staining purposes are either basic or acid
in character. The former contain amido groups
and are spoken of as nuclear stains, since they color
the nuclei of cells as well as bacteria. The latter
contain hydroxyl groups and do not stain bacteria
but are used chiefly for contrast coloring, and to
some extent for decolorizing. The basic dyes are
usually employed as salts of hydrochloric acid, while
the acid dyes occur as sodium or potassium salts.
A', .•
3
Fig. 600. — Cell Slide showing Hanging Drop. A, Surface view;
B t side view; b, edge of cell; c, hollow of cell; d, cover glass; e f
hanging drop.
Among the basic aniline dyes which are commonly
employed may be mentioned fuchsin, gentian violet,
methyl violet, crystal violet, methylene blue, thionin,
safranin, methyl green, neutral red, and vesuvin or
Bismarck brown. These are all more or less crystal-
line powders, and while some are definite chemical
compounds, others are mixtures. For this reason
various brands are met with on the market, and it
will be readily understood why the exact duplica-
tion of stains is not always possible.
Reference Handbook
OF THE
Medical Sciences.
Plate XII.
1.
2.
3.
4.
5
6
7
Bacillus of
Bacillus ot
The same
Finkler-Prior's
Deneciie's
Miller's
Bacillus iA'
Tuberculosis.
Cholera Asiat-
ics.
in gelatine.
Comma Ba-
cillus.
Bacillus
Bacillus
Typhoid Fever
8.
9.
10.
11
12.
13.
14
Pneumococcus.
Bacillus or
Bacillus of
The same
Bacillus of
Bacillus of
Bacillus of
Glanders.
Anthrax.
in gelatine
Malignant
Oedema
Septicaemia
of Mice
Septicaemia
of Rabbits
15.
16.
Bacillus of
Bacillus of
Chicken
Pigeon
Cholera.
Diphtheria
n.
Slide Culture
(reduced?
Plate Culture
treducedJ
TEST-TUBE CULTURES.
Reproduced from Huber & Becker's "Untersuchungs-Methoden.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Bacteriological Technique
It is advisable to keep on hand not only ihe solid
dyes, but also stock solutions which are saturated
alcoholic solutions. The amount iv<|iiircd to .satu-
rate will vary from two to live per cent.
The concentrated alcoholic solutions are never used
as such, luii serve for the preparation of the dilute
dyes which are the stains proper. Tin; latter are
made by placing a few cubic centimeters of the con-
centrated dye in a small tincture bottle, and adding
ten to twenty parts of water. This bottle is then
provided with a cork and a piece of glass lulling which
Fig.
601. — Cover-glass Forceps, a, Cornet's; 6, Stewart's;
Novy's.
serves as a pipette. The different dilute dyes can
be kept in a stand, such as is shown in Fig. 602.
The dilute dyes after a while undergo alteration and
yield deposits. In that event they should be filtered
before use, or else new dilutions should be made.
The acid aniline dyes are represented by eosin, acid
fuchsin, and fluorescein. The concentrated and the
dilute dyes are prepared as above.
The staining solutions may be used as such, or
their properties may be accentuated by the addition
of substances which act more or less directly as
mordants. A number of these solutions are in daily
use, and for that reason their preparation is here given.
Loffler's methylene blue is made by adding 30 c.c. of
concentrated methylene blue to 100 c.c. of a 0.01-
per-cent. solution of potassium hydrate. A similar
solution with less alkali was first used by Koch.
The alkali not only serves to make the cell more
permeable, but also increases the staining power by
liberating the free base from the dye.
Carbolic fuchsin, or Ziehl solution, is made by add-
ing 1 gram of fuchsin and 10 c.c. of alcohol to 100 c.c.
of a five-per-cent. carbolic-acid solution. The stain
is very widely used for simple as well as double stain-
ing. Czaplewski modified it by substituting glycerin
for the alcohol. His solution is prepared by rubbing
up in a mortar 1 gram of fuchsin with 5 grams of car-
bolic acid, and to this 150 grams of glycerin and 100
c.c. of water are added.
Carbolic methylene blue, first employed by Kiihne,
consists of 1.5 grams of methylene blue, 10 grams of
absolute alcohol, and 100 c.c. of a five-per-cent.
solution of carbolic acid.
Carbolic thionin consists of 10 parts of a saturated
solution of thionin and 100 parts of a one-per-cent.
solution of carbolic acid (Nicolle).
Carbolic gentian violet is"made the same as the pre-
ceding (Nicolle).
Vol. I.— 58
Aniline Water, Gentian Violet, etc. The carbolic
acid, like the alkali, favors the penetration ol the
tain. Aniline water acts in like manner and was
in i used by Ehrlich. To prepare the aniline water
a few cubic centimeters of aniline are placed in a test-
tube, and this ia then filled with distilled water and
thoroughly shaken. The milky liquid i filtered
through a moist lilt or. To the water-clear filtrate
enough concentrated fuchsin or gentian violet D
then added to make the Liquid opaque, and bo that
it just begins to form on the surface a slight metallic
film of precipitated dye. The solution is then used
as such, but if the deposit is very marked it may be
necessary first to filter it. The aniline-water dye do
not keep very well, and for that reason it is well to
make a fresh solution every time thai it is to be used.
Oil of cloves has been suggested by London as a
substit ule for aniline.
The aniline-water stains were first, employed by
Ehrlich for coloring the tubercle bacillus, and are
still used for that, purpose, They are, however,
employed especially for staining whips and in con-
nection with drain's stain. In the latter case, after
I lit; preparation litis been stained with the solution,
a mordant is applied, known as Lugol's solution,
which serves to form a difficultly soluble compound
between the dye and the cell contents.
Lugol's solution consists of 1 part of iodine, 2 parts
of potassium iodide, and MOO parts of distilled water.
The Staining of Cover-glass Preparations. — Thee
may be considered under the head of (1) simple, -')
double, and (3) special stains. For the simple stains,
when it is desired to have a heavily colored prepara-
tion, either fuchsin or gentian violet is used. When
it is desired to bring out structural characteristics, it
is advisable to employ solutions which stain more
feebly, such as methylene blue or thionin. In either
case the simple or reinforced stains, given above,
may bo employed.
To make a stained preparation of a pure culture the
procedure is as follows: A drop of water, preferably
distilled, is placed upon a clean cover-glass, which
either lies on a board or is held in a pair of forceps.
By means of a sterile platinum wire a minute amount
of the bacterial growth is picked up and transferred
to the water. Only enough should be added so as to
impart to the water a slight cloudiness. The remain-
der on the wire is then burned off. The drop is then
spread over the whole surface of the glass and allowed
Fig. 602. — .Stand for .Staining Solutions.
to dry in the air, or the process may be hastened by
passing it above a flame. Care must be taken not to
dry too rapidly as, in such case, vacuolation of the
protoplasmic contents of the cell results. The air-
dried preparation must now be fixed in order that
the bacteria may not be washed off in the subsequent
treatment. The fixing is done by passing the cover-
glass three times through a llame. Care must be
taken not to scorch the specimen, for in that case
the dye will not act. It is well to turn down the
913
Bacteriological Technique
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
flame so that it is at most but two inches high. The
properly fixed cover-glass is now covered with the
Main, which is allowed to act for ten to twenty seconds.
The dye is then washed off under the tap and the
cover-glass inverted upon a glass slide. Any water
which ma3' be on the surface of the slip should be
removed bj r means of a piece of filter paper. The
preparation can now be examined under a No. 7
objective, or with the one-twelfth-inch oil immersion
lens. If the specimen is such as to merit preserva-
tion a drop or two of water may be applied to the
edge, and in this way the slip can be floated off with-
out damaging the film. The excess of water can
then be touched off with a piece of filter paper, after
which the specimen is dried in the air or by passing
it over the flame. The thoroughly dried film is then
inverted upon a drop of Canada balsam placed on the
center of a clean slide. By gentle warming or by
pressure the balsam can be made to spread out evenly.
Smear or streak preparations made from the fluids
or organs of the body are stained in the same way.
In selecting a stain for such preparations perhaps
Loffler's methylene blue solution is the most satis-
factory. It does not stain the tissue material so deeply
a- some of the other commonly used bacterial stains.
Also Pappenheim's pyronin and methyl-green mix-
ture may be used for the same purpose. It is com-
posed of 3 to 4 parts of saturated aqueous solution of
methyl-green to 1 to 1J parts of saturated solution
of pyronin, and applied the same as the above stain.
With this stain bacteria take a bright red coloration;
the nuclei of the body cells take a bluish stain. The
fixation of the cover-glass when it contains much pro-
tein matter, as in the case of blood streaks, requires
special care. The best results are obtained by im-
mersing the slip for a few minutes in a mixture of
equal parts of absolute alcohol and ether. Fixation
is thus accomplished without any injury to the blood
cells. It is sometimes advisable, instead of adding
the dye to the cover-glass, to float the latter upon
the dye in a watch-glass.
To make good blood preparations requires consider-
able care and experience. A small drop of blood is
placed on a perfectly clean cover-glass, which is held
in a pair of forceps. A second cover-slip is then
applied evenly and without pressure, and as soon as
the blood has spread out the two glasses are drawn
apart. The blood cells must not be crushed and
should lie in a single layer.
The smears from the cut surface of an organ are
made by gently applying the cover-glass, without
pressure, and then drawing it away; or a piece of the
organ may be taken up in the forceps and streaked
over the cover-glass, care being taken to leave only the
thinnest film possible.
The ordinary dass slide is often used in place of the
cover-glass. The streaks or blood smears are made
as in the case of the latter. When the growth is
hard, as in the case of actinomyces, it is well to crush
it between two glass slides.
Double Staining. — This procedure is resorted to
when staining the tubercle bacillus and the allied
acid-resisting bacilli. It is also used for staining
spores, and in differentiating bacteria by means of
Gram's stain. Other special methods are given
under gonorrhea and meningitis.
The group of acid-resisting bacilli, the type of which
is the tubercle bacillus, is stained with more or less
difficulty by the simple stains. The dye, however,
can be forced into the cell by the aid of heat, and
especially if the reinforced stains, such as carbolic
fuchsin or aniline-water gentian violet, are used.
On subsequent treatment with acid and alcohol the
ordinary bacteria which chance to be present are
readily decolorized, whereas the acid-resisting retain
th -lain. A contrast color, such as methylene blue,
will then stain the background and the ordinary
bacteria a light blue.
Staining of the Tubercle Bacillus. — The cover-glass
is air-dried and fixed in the usual manner, after which
any one of several methods may be used. The
Ziekl-Neelsen method is usually employed. It is
carried out as follows: The cover-glass, held in the
forceps, is covered with carbolic fuchsin and heated
over the flame so that vapors are given off for one or
two minutes. It is then rinsed in water and dipped
for a few seconds in a twenty-per-cent. solution of
nitric acid, after which it is washed in dilute alcohol
i sixty per cent.) till it is almost colorless. Methyl-
ene blue is then applied for a few seconds and washed
off. The specimen is transferred to a slide, the
surface dried, and examined under the microscope.
The tubercle bacilli will appear red on a blue back-
ground. The ordinary bacteria will appear blue.
The Koch-Ehrlich method consists in staining with
aniline-water fuchsin or gentian violet with the aid of
heat for a few minutes. The specimen is then decolored
in thirty-five-per-cent. nitric acid for about a quarter
of a minute, washed in dilute alcohol till nearly color-
less, after which methylene blue or Bismarck brown
is applied for a contrast color.
In the Fraenkel-Gabbet method the preliminary
staining is effected with carbolic fuchsin as above.
The decoloration and contrasting is done at once by
immersing the cover-glass in a saturated solution of
methylene blue in the following: Sulphuric acid 25
parts, alcohol 50 parts, distilled water 1,000 parts.
It is then rinsed with water and examined.
Czaplewsky's method differs from the preceding in
the way the decoloration is effected. He employed
for this a solution of one gram of fluorescein and five
grams of methylene blue in 100 c.c. of alcohol. The
specimen is first stained with carbolic fuchsin; then,
without rinsing in water, it is placed for a few seconds
in the fluorescein methylene blue solution. Finally it
is dipped ten or twelve times in a solution of 5 parts
of methylene blue in 100 parts of alcohol. It is then
washed witli water and examined.
Numerous modifications of the above methods have
been proposed, but they possess no special advantage
over those given.
Herman's method for the staining of the tubercle
bacillus is said to possess advantages over the carbol-
fiuhsin method. For this stain a three per cent,
solution of crystal violet (6B) in ninety-five per cent,
of alcohol is combined with a mordant consisting of a
one per cent, solution of ammonium carbonate in
distilled water; the proportions are one part of the
former to three parts of the latter solution. The fixed
smear of the material is warmed, then the stain is
poured on and held over flame until vapors rise for
one-half to one minute. The deeolorization is carried
out in ten-per-cent. nitric acid, until the color is prac-
tically gone followed by ninety-five-per-cent. alcohol.
The smear is then washed, and counterstained with
Bismarck brown, methylene blue, or other suitable dye.
Staining of Spores. — The cover-glass preparation is
treated for some minutes with hot carbolic fuchsin,
either on the forceps or by floating on the dye. It
should then be rinsed and examined in water. If the
spores are colored, the next step is taken; if not, then
the heating with the dye is continued until they are
stained. The specimen is then decolorized in dilute
acid and alcohol until the spores stand out red on a
colorless background. • Methylene blue is then applied
for a contrast, washed off, and the preparation is
ready for examination. The bright red spores are
seen within the light blue cells. This method
requires considerable care, and every step must be
controlled by frequent examinations under the
microscope.
In order to enable the dye more readily to enter
the spore, Moller treated the cover-glass, first, for a
minute or two with a five-per-cent. solution of chro-
mic acid, after which essentially the above procedure
was followed. By repeated passage through the
914
REFERENCE HANDBOOK OF THE Mr.HH \I. SCI1
Bacteriological i •• bnlqac
flame <>r by heating with strong sulphuric acid for a
few seconds the substance of the spore can be disinte-
grated so that on subsequent staining with carl
fuchsin the spores will readily lake the dye. Thi
treatment, however, destroys tl riginal cell, and
hence contrast coloration is not possible.
Klein varies the procedure of spore staining given
above by adding an equal volume of carbol-fm l
solution to a suspension of the spore-bearing organism
in physiological salt solution. The mixture is gently
warmed for six minutes. Cover-glass preparations
are then made, dried, and fixed. They are then de-
colorized in one-per-cent. sulphuric acid solution, and
counter-stained in the regular manner. This method
may be useful in staining those varieties which are
especially resistant.
By the Abbott method the above order of staining
is reversed in that the spores are stained blue, while
the bodies of the cells are red. The cover-glass
E reparation is deeply stained with methylene blue
y heating about one minute at a point where the
staining fluid is kept almost constantly boiling. The
stain is washed oft in water, then in ninety-tive-per
cent, alcohol containing between two- and three-
tenths per cent, of hydrochloric acid to decolorize;
again wash in water, then stain in aniline fuchsin
solution for about ten seconds. Wash, dry, mount
for observation.
The Gram Stain. — This is one of the most vale
methods in bacteriology, since it often serves to dis-
tinguish between organisms which otherwise resemble
each other very closely. The cover-glass prepara tion
is floated for a few minutes on aniline-water gentian
violet or on carbolic gentian violet. Heat may be
applied, but in that case the excessive staining will
interfere with the subsequent decoloration. 'I lie
specimen is then rinsed in water and immersed in
Lugol's iodine solution for two or three minutes.
After rinsing in water it is then placed for a few min-
utes in strong alcohol until most of the dye has been
washed out. Very dilute eosin solution is now applied
for about five seconds. After thorough washing with
water it is ready for examination. The organism
will appear a deep violet on a pink background.
Gram's method is applicable to the bacilli of ant hrax.
symptomatic anthrax, diphtheria, leprosy, malig-
nant edema, mouse septicemia, rouget, tetanus,
tuberculosis, the Fraenkel diplococcus, Micrococcus
telragenus, the various staphylococci and streptococci,
actinomyces, moulds, and yeasts. It is not given by
the bacillus of glanders, typhoid fever, hog cholera.
Asiatic cholera, chicken cholera, influenza, plague,
Friedlander's bacillus, colon bacillus, gonococcus,
rhinoscleroma, and recurrent fever spirillum.
The Staining of Flagella. — Special care must be
given to the preparation of the cover-glass. The
cultures should be made on freshly inclined, moist
agar, and should, as a rule, be less than twenty-four
hours old. A very dilute suspension of the growth
is made, and when spread over the cover-glass is
allowed to dry in the air. The fixation must be done
with the least amount of heat possible. This can best
be done by passing the cover-glass, held between the
thumb and forefinger, through the flame.
In Loffler's method the specimen is covered with a
mordant solution which consists of 100 parts of a
twenty-per-cent. tannic-acid solution, 50 parts of a
cold saturated ferrous-sulphate solution, and 10 parts
of alcoholic fuchsin. The cover-glass is heated over
the flame so that vapors are given off for a minute or
two. Every trace of the mordant must then be
removed by washing with water, and if it has dried
down around the edge it should be removed with a
knife. The last traces of the mordant can be removed
by momentary immersion in absolute alcohol. The
specimen is then heated with aniline-water fuchsin
for a couple of minutes, washed with water, and
examined. The chief difficulty in this method lies
in the formation "i a heavy deposit of foreign matl
which masks the bad
I i i I" i i light modification of thai .,f
Loffler. It consists of •_' grams of di \ tannin, 20
of water, I I I and 1 C.C of
concentrated alcoholic fuchsin. The aniline water
fuchsin is made by adding about .", grams of fuchsin,
and 1 c.c. of a one-per-cent. solution of sodium 1
to Kill c.c. of aniline water.
Bunge employed a mordant consisting of 7.". parts
of concentrated tannin solution. _'."> parts of a tivc-
per-cent. olution of ferric chloride, and Mi part- of
a com entratedaque * uchsin solution. After stai
ing some days hydrogen peroxide I until a
reddish dp i is obtained.
Pitfield makes use of a Million of mordl
and dye. Two solui first prepared: (1) con-
sisting of 1 ce. of saturated alcoholic gentian violet
and 10 c.c. of saturated aqueous alum; ting
of 1 gram of tannic acid and II) <-.i-. of distilled water.
two solutions are filtered and then combined.
'I he mixture is heated on I he covei -gla - over a tin
for about a minute, and then washed off.
Van Ermengem's method i- essentially differ.
The cover-glass is wan 1 for about five minutes with
a fixing solution consisting of till c.<-. of a twenty-per-
cent, tannin solution, 'M) c.c. of two-per-cent. osmic-
acid solution, and four to five drops of glacial acetic
acid. It is then washed with water, rinsed in alcohol,
and dipped for one or two seconds in a sensitizing
solution of silver nitrate (one-half to one per cei
After this it is placed for a few seconds in the reducing
solution which consists of 5 parts of gallic acid, 3
parts of tannic acid, 10 parts of sodium acetate, and '
350 parts of distilled water. It is again placed in the
silver-nitrate solution, in which it is moved about
until the liquid darkens, after which the preparation
is washed with water, dried, and examined.
Of the numerous other modifications which have
been proposed that of Gemelli only need be given.
Gemeili cleans the cover-glasses in a boiling mixture
of potassium bichromate (three per cent.), and sul-
phuric acid (five per cent.). After washing in water
they are kept in alcohol. Before use each cover-glass
is flamed several times. Gelatin cultures developed
at 37° C. are said to give the best results. A loopful
is transferred to 5 c.c. of water in a watch-glass, and
from this suspension a drop is taken and spread over
a cover-glass, which is then set aside over calcium
chloride to dry. The specimen is then placed for ten
to twenty minutes in a one-fourth-per-cent. solution
of potassium permanganate. The preparation is now
washed well in distilled water, after which it is placed
in a three-fourths-per-cent. solution of calcium chlo-
ride, to which has been added a one-per-cent. solution
of Griibler's neutral red in the proportion of twenty
to one. After remaining in this for fifteen to thirty
minutes the specimen is washed, dried, and mounted.
The method is said to give excellent and sure results
without the annoying precipitates which form in the
other procedures.
Staining of Capsules. — Welch's method consists in
treating the cover-glass with glacial acetic acid for a
few seconds. The excess of acid is drained off with
filter paper, after which the specimen is washed in
aniline water gentian violet, and finally in a sodium-
chloride solution (0.S5 to 2 per cent.). The heavily
stained bacillus will be found to be surrounded by a
pale violet halo.
Nicolle treats the cover-glass with a mixture of one-
per-cent. carbolic acid (10(1 parts) and saturated alco-
holic (95 per cent.) gentian violet solution , III parts).
It is then washed in absolute alcohol containing one-
third its volume of acetone, rinsed in water, dried, and
mounted.
Hiss' copper-sulphate method consists of preparing
films by mixing the organism with a drop of diluted
serum on a cover-glass. If the organism has been
915
Bacteriological Technique
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
grown upon ascitic or serum medium, the addition of
serum is not neeessar_v. the film being made direct from
culture. The film is dried in air and fixed with heat.
An aqueous solution of gentian violet (5 c.c. saturated
alcoholic solution gentian violet to 95 c.c. distilled
water) or fuchsin may be used, as stain. The stain
is placed on the fixed cover-glass preparation, and
carefully heated over a flame for a few seconds until
steam rises. The stain is then washed off with a
twenty-per-cent. solution of copper sulphate (crystals).
The stained preparation is dried between filter papers
and mounted for examination.
Rosenow's method for the staining of capsules is
especially applicable to the pneumococcus and the
Streptococcus mucosus. -Make a thin smear of the
material upon a perfectly clean slide or cover-glass.
In the case of sputum, "if too thick, add sufficient
distilled water so that an even spread may be made,
or if growth from solid medium (blood agar, Loffler's
blood serum) is used, remove a small amount and
mix with a drop of serum upon a slide. Spread the
material by means of fine tissue paper. When the
smear is nearly dry, cover with a five to ten per cent,
aqueous solution "of tannic acid for ten to twenty
seconds; wash in water and blot; stain with carbol (1
part sat. alcoholic sol. gentian violet, 4 parts five per
cent, aqueous sol. phenol) or aniline-gentian-violet,
gently heat over flame without boiling for one-half to
one minute; wash in water, place in Gram's iodine
solution for one-half to one minute, decolorize in
ninety-five per cent, alcohol; stain with saturated
alcoholic (sixty per cent.) solution of Griibler's eosin
from two to ten seconds depending upon the thick-
ness of the smear; wash in water and blot. Examine
directly, or clear in xylol and mount in balsam.
Pneumococci stained by this method appear sharply
differentiated from the capsule; the cell-body takes a
deep brownish-black, the capsule a pink stain. If
the organism is Gram-negative, Loffler's or aqueous
methylene blue may be used as a contrast stain.
Staining of the Babes-Ernst Granules. — Neisser rec-
ommends the following method as a means of differen-
tiating the diphtheria bacillus from like organisms.
A culture grown on Loffler's serum should be used.
Tne specimen is treated for one to three seconds, or a
little longer, with the following solution: one gram of
methylene blue, 20 c.c. of absolute alcohol, 50 c.c. of
glacial acetic acid made up to one liter with distilled
water. It is then washed with water and stained
with Bismarck brown (two-per-eent. aqueous solu-
tion) for three to five seconds. Finally it is washed
with water and examined. The blue granules will
stand out in the light brown bacilli.
Piorkowski heats the preparation for one-half to
one minute with an alkaline solution of methylene
blue, then decolors for five seconds in alcohol con-
taining three per cent, of hydrochloric acid. A one-
per-cent. aqueous eosin is applied for contrast, after
which the preparation is washed and examined.
Impression Preparations of Colonies. — It is very
often desirable to reproduce or preserve the charac-
teristic surface colonies. The selection of the surface
colony is made under the microscope, after which the
tube of the instrument is raised and a cover-glass is
dropped down upon the colony. Gentle pressure is
applied, the cover-glass lifted off, air-dried, fixed, and
stained with methylene blue in the usual way.
Staining of Protozoa. — The study of the protozoa and
kindred microorganisms is so closely associated with
bacteriological methods that it will not be amiss to
discus^ briefly the more useful stains employed in con-
nection with this important class. Many advances
have recently been made along this particular line of
work which has thrown much light upon diagnosis and
i be el iology of disease.
Romanowsky' s Chromatin Stain. — This method is
extremely valuable for staining protozoal parasites,
such as those of malaria and the trj-panosomes. It
may also be used for staining Treponema (Spiro-
chieta pallidum. When properly carried out it gives
an admirable differentiation of the chromatin, which
appears red on a blue background. Nocht's modi-
fication gives very good results, and is briefly as
follows: A solution of one-per-cent. methylene blue
and one-half per cent, sodium carbonate is kept at
about 60° C. for several days to "ripen." The
change which takes place is one of slow oxidation, and
as a result a number of products form, among which
is the one which is essential to this method. This
active red constituent has been designated as methyl-
ene azur. To about 2 c.c. of water in a watch-glass
two to three drops of a one-per-cent. solution of eosin
are added, and then the altered blue, drop by drop,
till the eosin tint just disappears. The specimen is
floated on this dye for five to ten minutes, after which
it is washed and examined.
Independently Wright, Leishman, and Reuter
arrived at a simple modification. The ripened or
polychrome methylene blue is treated with an eosin
solution to slight excess. The precipitate, which
Reuter has called a methylene-blue eosin, is then
filtered, washed, and dissolved in methyl alcohol.
This solution can now be obtained from Grubler.
Thirty drops of this are added to 20 c.c. of distilled
water in a large watch-glass or Petri dish. The spec-
imen, which can be fixed with ether alcohol or with
formaldehyde alcohol (10 :90), isimmersed in the dye
for fifteen to thirty minutes. It is well gently to
agitate the liquid from time to time. It is then
washed, dried, and mounted.
Wright's modification has been recommended by
Musgrave and Clegg as giving the best results in
staining the ameba of dysentery. The Leishman
stain has been prominently brought forward by
Wright and Douglass in their staining of white blood
cells (phagocytes) while studying the opsonic action
of blood serum. As a phagocytic cell stain, this
apparently possesses no advantage over Wright's
or certain other modifications of the Romanowsky
stain. These stains, ready for use, can be procured
from dealers.
Laveran employs 1 c.c. of a one-per-cent. solution
of azur, 2 c.c. of a 0.1-per-cent. solution of eosin, and 8
c.c. of water. The specimen is stained for ten minutes
then washed and immersed for two or three minutes
in a five-per-cent. tannic acid solution, after which
it is washed, dried, and mounted.
Giemsa has made several modifications of the stain.
The following is one, which, in the hands of Williams
and Lowden, has given excellent results in the study
of the finer morphological characteristics of "Negri
bodies." It is composed of azur II-eosin, 3.0 grams;
azur II., 0.8 gram; glycerin (Merck's chemically pure),
2.50.0 c.c; methyl alcohol (chemically pure), 250.0 c.c.
The glycerin and alcohol are heated separately to 60°
C. The dyes are put into the alcohol, and the glyc-
erin is slowly added while stirring. The mixture
is allowed to stand at room temperature for about
twenty-four hours, when, after filtration, it is ready
for vise.
The technique followed by Williams in the study of
"Negri bodies" was to prepare smears of brain tissue
(cortex from near the fissure of liolando. Amnion's
horn, and cerebellum), and air-dry. The smear is
fixed in methyl alcohol for five minutes. The stain is
added to distilled water, which has previously been
made alkaline by the addition of one drop of a one-per-
cent, solution of potassium carbonate to each 10 c.c. of
the water. The stain is used in the proportion of one
part of stain to one part of the slightly alkaline water.
This solution is poured over the fixed smear at once,
and allowed to stand from one-half to three hours,
but a longer time brings out the structure better.
The stain is washed off in running tap water from one
to three minutes, and dried between fine filter papers.
In this method of staining, the cytoplasm of the
916
REFERENCE HANDBOOK < )!•' THE MEDICAL BCIENI
Bacteriological Technique
"bodies" stains blue and their central bodies and
chromatoid granules stain a blue-red <>
far as this method is concerned, but they can .-till be
found by means of Gram's method. Duval has
cultivated an organism directly from human leprous
tissue which he considers to be B. lepra. Fortius
purpose special artificial media are used. He has in-
fected such animals as the Japanase dancing mouse,
guinea-pig. and the monkey (Macacus rltcsus) with
the cultures grown on artificial media.
9. Cerebrospinal Meningitis. — The Diplococcus in-
919
Bacteriological Technique
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
tracellularis meningitidis is found in the cerebro-
spinal fluid. Hence during life it is necessary to re-
move some of the fluid by lumbar puncture. This
fluid should be planted abundantly on glycerin, or
better on serum agar. Cover-glass preparations
made direct will show the typical organism resembling
the gonococcus in form and in its presence within the
leucocytes. It is not stained by Gram's method, but
can be given a double stain by that of Pick and Jacob-
sohn, or by the modification suggested by Fraenkel.
The dye is made by adding to 20 c.c. of water eight
drops of a saturated solution of methylene blue, and
then forty to fifty drops of carbolic fuchsin. The
dye is allowed to act for five minutes. The cocci
are blue on a red background.
10. Pneumonia. — In all pneumonic conditions the
blood-streaked sputum should be examined by making
simple and Gram stains. In this way it becomes
possible to recognize the pneumonic form of plague.
Ordinarily, however, pneumonia is due to the Fraen-
kel diplococcus and at times to the Friedliinder
pneumobacillus. The form, staining, and cultural
properties of these organisms permit ready differentia-
tion and identification. The lance-shaped diplo-
coccus of Fraenkel, as found in the body, is surrounded
by a capsule, and is stained by Gram's method. The
colonies and cultures on glycerin agar are very faint
and dewdrop like, and tend to die out in a few days.
Their vitality and virulence are best preserved by
cultivating them on rabbit blood or serum agar.
Calcium broth may be used for the same purpose. In
doubtful cases the material should be injected under
the skin of the ear of a rabbit or subcutaneously in
white mice. If death results the diplococcus will be
found in large numbers in the heart blood and organs
of the animal.
11. Rabies. — The cause of this disease is as yet
unknown, but it is to be found, in pure condition so
to speak, in the brain and spinal cord of the affected
person or animal. The diagnosis rests upon animal
inoculation with such material. A few drops of a
suspension of the brain or cord are injected subdurally
into a rabbit or guinea-pig. The method has been
already described.
The histological changes in the nervous system are
very slight, and it has been suggested that the diag-
nosis of rabies may be hastened by making an examina-
tion of sections of the cord and ganglia. The lesions
are not sufficiently marked in all cases to permit
diagnosis, and for that reason this method should not
be relied upon to the exclusion of the only positive
test, that of animal inoculation.
The work of Williams upon "Negri bodies" has
called attention to the fact that a rapid diagnosis
may be made from smear preparations of the brains
oi animals which have suffered from rabies. After a
long series of observations, both clinical and experi-
mental, the Department of Health of New York City
has adopted this method of diagnosis. Their present
method of procedure is as follows: Make smear
preparations from the cortex taken from the region
corresponding to the fissure of Rolando, Amnion's
horn, and the cerebellum. Fix the smears while
moist in a solution composed of methyl alcohol (pre-
viously neutralized with sodium carbonate) containing
one-tenth of one per cent, of picric acid. After allow-
ing to act about one minute, pour off the fixing fluid,
and blot with fine filter paper.
The stain is prepared by adding five drops saturated
alcoholic solution of methylene blue, and one drop
saturated alcoholic solution of basic fuchsin, to 10 c.c.
distilled water. This should be freshly prepared just
before using. Pour stain on slide; warm until it
steams; pour off; rinse smear in water; blot and allow
to dry. Upon examination under the oil-immersion
lens, the "Negri bodies" will be found in the nerve
cells; some also are free. The cytoplasm of the
"bodies" takes a distinctive red color; their inner
structures a dark blue. The nerves are light blue,
and the blood cells a pale salmon-red. At room tem-
perature this stain is not permanent, but it has the
advantage of being a very rapid method for the diagno-
sis of rabies. If "Negri-bodies" are not found by this
method of examination, some of the brain tissue of
the suspect animal is then inoculated into guinea-pigs
by the regular procedure, as a further aid in diagnosis.
12. Tetanus. — The point of inoculation must be
found first. This may not always be easy, for the
original wound may have healed over. The portal
of entry may be a bad tooth, or the wound produced
by an old rusty nail, a splinter of wood, or the powder
grains of a pistol. Cover-glass preparations should
be made from the pus, if there is any; and, if not,
from such serum, blood, or tissue as can be obtained
from the wound. They should be stained with
carbolic fuchsin. The specimen should be examined
for "drum sticks" or rods with terminal spores, and
particularly for the presence of rather narrow, long
bacilli. These are present even when no spores can
be found.
Cultures should be made on glucose litmus gelatin,
and at the same time a series of glucose agar plates
should be made and developed at 37 C°., either in hy-
drogen or in the pyrogallate apparatus. The original
tissue should be planted under the skin of a white
mouse and of a guinea-pig. The cultures when
developed are carefully searched for the 'drum-stick
forms.
13. Tuberculosis. — The pulmonary form is usually
recognized by an examination of the sputum, prefer-
ably that which has been collected in the morning on
rising. The cheesy particles, if such can be recog-
nized, should be picked out by means of the wire and
spread over the cover-glass. The specimen is then
stained either by the Ziehl-Neelsen or the Herman
method. The organisms if present are readily recog-
nized by their contrast color against the counter-
stained background.
The same method is employed in the examination
of pleuritic fluid, pus, urine, milk, etc. In all these
examinations, however, two facts should be borne in
mind. In the first place the tubercle bacilli may be
present, but in such small numbers that they escape
detection. Again, acid-resisting organisms, such as
the leprosy, smegma, timothy-grass bacillus, etc.,
may be present, and may be easily mistaken for the
tubercle bacillus.
In either case it is the animal experiment which will
serve to remove the doubt. When the tubercle
bacilli are few or doubtful, it is well to submit
the material to preliminary centrifugation; or first
subject the material to antiformin digestion. This
preparation consists of a strongly alkaline solution
of chlorinated soda, which has the power to dis-
solve such substances as mucus, animal cells fibers,
etc., also most bacteria other than those which are
acid-fast. In the case of sputum, good results may
be had by mixing equal parts of sputum with thirty
per cent, of the antiformin, and digesting at room
temperature for one hour. Centrifuge, and decant the
supernatant fluid from the sediment. The sediment
is washed with sterile distilled water, and again cen-
trifuged; the sediment may be stained for the tubercle
bacillus or injected into a guinea-pig. If the anti-
formin digestion is permitted to continue too long,
the tubercle bacillus loses some of its staining ability,
also its viability. The injections should be made
subcutaneously into the guinea-pig. If tubercle bacilli
are present in the material used, even if so scarce as
to be unrecognized by the microscope, the animal
will develop the disease and will die in the course of a
month or two. The tuberculous organs and glands can
be examined then for tubercle bacilli, and cultures
can be made on glycerin agar, potatoes, and on either
Dorset or Lubenau egg medium. Hesse's Heyden
agar also proves quite satisfactory for isolating the
920
REFERENCE HANDBOOK OF THE MEDICAL SCI]
Bacteriological TeduUqae
tubercle bacillus from sputum.. The acid-resisting
bacilli, other than the tubercle bacillus, are not fatal
to animals, and, moreover, the histological changes
which they induce are quite different from those cau ed
by the tubercle bacillus.
14. Typhoid F< ver. — The verification of the diagno-
sis is usually ma. \ number of infections due to moulds and allied
forms and also to yeast-like bodies have been de-
scribe,!. The former are represented by the strepto-
thrices, or. more correctly, by the actinomyces of
Madura foot and of cattle farcy. The yeast or blast o-
mycotic affections have been noted in certain forms
of dermatitis, and may even be systemic in charai
In all these diseases the examination of the pus and
of sections of t issue, as well as the culture of the organ-
ism, must be carried out.
16. Protozoal Diseases. — Several very important
diseases are due to organisms of this class. The ex-
amination for amebas in tropical dysentery has al-
ready been touched upon. The sporozoa include
among others the Plasmodium of malaria, the piro-
plasma of Texas fever, and of horses, sheep, and dogs.
The flagellata cause the various trypanosomatic
diseases, such as the surra of Asia anil of the Philip-
pine Islands, nagana or the tsetse-fly disease of South
Africa, dourine or "maladie du coit" of the Mediter-
ranean littoral, caderas of South America, the (1am-
bian fever and the sleeping-sickness, the last two
being diseases of man. Moreover, many animals
harbor in the blood parasites of this group, as in the
case of the wild rat.
In all suspicious cases the blood should be examined
for these two groups of organisms. Tin- plasmodium
of malaria is found especially within the blood cells.
The trypanosomes are free in the plasma. Tho
blood may be examined direct under the cover-glass,
or in hanging drop, or in a Rainier slide. Stained
preparations can be made with methylene blue,
thionin, or best with some modification of the Roman-
owsky method. The preparation of the specimens
and the staining methods have already been described.
The trypanosomes of the rat and of nagana. have been
cultivated artificially by Nbvy and McNeal. Their
presence is best detected by direct examination of the
blood, though at times they may be very difficult to
find, and may require daily examinations for several
weeks.
DETERMINATION of TnE Thermal Death Point of
Bacteria. — In this work and also in testing disin-
fectants it is necessary to have almost homogeneous
suspensions of the organism to be tested. Water
suspensions should be used first, and later those of
bouillon, serum, etc. The liquid is introduced by
means of a bulb pipette into the tube of an agar
culture. The growth is rubbed up as much as possible
and the suspension is then transferred to a sterile
glass-wool filter. In this way the masses of bacteria
are removed. The cloudy filtrate may be used as such,
or it may be diluted so as to have fewer organisms in
the test. It may be used as such for determining the
action of moist heat and for testing disinfectants.
921
Bacteriological Technique
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Again, for dry-heat work and for many disinfecting
tests the suspension is allowed to dry upon the surface
of sterile glass slips, glass or garnet beads, silk threads,
muslin squares, etc.
To test the action of dry heat a number of cover-
glasses on which the test organism has been dried are
placed in a sterile Petri dish and exposed to a given
temperature. At given intervals a specimen is re-
moved and planted in bouillon.
To test the action of moist heat the best procedure
is to draw up the liquid into sterile capillaries, as
shown in Fig. 603. The tube is sealed below and
above the liquid. The advantage of this method lies
in the fact that the heat promptly penetrates every
part of the suspension. A number of tubes thus
equipped are placed in a water-bath, the temperature
m:) t>
Fig. 603. — Filling of Capillary Tubes for Thermal Death-point Determinations.
c. Tube filled ready to be sealed at x; 6, emptying of tube. (Novy.)
of which is kept at a constant point by means of a
regulator. At intervals a capillary is removed,
cooled, opened at one end, and the contents are ex-
pelled into a tube of bouillon by gently toucliing the
closed end to a flame.
Testing of Chemicals. — In this work it is necessary
to distinguish between the antiseptic and the disin-
fecting action of a substance. The former refers to
the amount of the substance which wid inhibit the
growth, but not necessarily kill the organisms. The
latter implies the actual destruction of the test object.
Obviously a substance which will kill bacteria, when
diluted sufficiently will merely restrict their growth,
and when the dilution is excessive will have no action
whatever.
The antiseptic action is determined by adding to
the suspension in bouillon varying amounts of the
chemical so as to make different dilutions, for ex-
ample: 1 in 500, 1 in 1,000, 1 in 5,000, 1 in 10,000,
etc., solutions. The tubes thus equipped are then
placed in the incubator for several days. The very
weak solutions will show growths, while the very
concentrated ones will show none. The amount
which just inhibits the growth represents the an-
tiseptic power of the substance.
The germicidal action of a gas, such as formalde-
hyde, is determined by exposing cover-glass prepara-
tions, silk threads, bit of muslin, etc., impregnated
witli the suspension, dry and moist, to the action of
the gas in a tight room. At the end of the exposure
the preparations are transferred to sterile tubes of
bouillon and incubated.
The germicidal action of liquids is ascertained,
either by adding the solution to the bacterial suspen-
sion or by immersing in the solution the dried cover-
slip preparations mentioned. In the former case, at
stated intervals, a small loop of the liquid is trans-
ferred to bouillon, while in the latter case the slip or
thread is first rinsed in sterile water and then placed in
the bouillon.
The Serum Agglutination Test. — The serum of an
animal which has been immunized to a germ when
brought into contact with a suspension of that germ
will cause the organisms to gather in masses. The
fact is utilized in the Widal test for typhoid fever.
A drop of the scrum from a typhoid patient is diluted
with tin, twenty, thirty, fifty, one hundred drops
respectively of water in a watch-glass. A drop of
each mixture is then transferred to a cover-glass and
inoculated with a very small amount of a fresh agar
culture of the typhoid bacillus, care being taken to
avoid an excess of the organisms. Hanging drops
are then made and the preparations examined under
the microscope. The limit of the reaction is in-
dicated by the dilution which is just able to cause
paralysis of motion and clumping in one hour. In-
stead of diluting with water some prefer to use a
very young bouillon culture. The agglutination test
is most delicate when carried out under the micro-
scope. Very good results, visible to the unaided eye,
may be obtained by adding the serum to bouillon
culture of the organism. The tubes thus treated
should be set aside for some hours at 37° C. when the
agglutinated masses will settle to the
bottom and leave the liquid clear.
When applying the test to a suspected
case of typhoid fever it is not always
possible to obtain large amounts of
the serum. In such instances the
blood may be placed in single drops
on a sheet of filter paper, or, better,
tinfoil. The dilutions can then be
made with these drops of dried blood
as with the serum itself. The appli-
cation of this test to the recognition
of the typhoid bacillus in drinking-
water, feces, etc., has been given.
The Complement Fixation Text. —
This test is one of importance not only in clinical
diagnosis, but also in general bacteriology. It affords
a most delicate means, under proper conditions, for
the differentiation of varieties of a bacterial species.
However, its accuracy depends much upon the proper
preparation of the materials to be used in the test and
the methods used in carrying it out.
The test is based upon the so-called Bordet-
Gengou phenomenon. Those investigators observed
that when an antigen, its specific antiserum, and com-
plement were brought together and incubated, the
latter component was fixed or bound — it could not
functionate again in similar reactions. As an indica-
tor of this complement binding with bacterial anti-
gens and their antisera, sensitized red blood cells are
added later to the above combination. If the comple-
ment is bound no hemolysis occurs on the second
incubation, but if not bound it combines with the
sensitized blood cells and causes a definite hemolysis.
As evident this test can be used for the recognition
of specific antibodies, or, conversely, the specific anti-
gens giving rise to antibodies.
In order to carry out the test, say for example, with
the serum of an animal immunized against a given
organism, the following materials are necessary: (1)
normal red blood cells; (2) a specific hemolytic serum
against the blood cells; (3) complement; (4) an antigen
prepared from the specific organism. Usually the
normal blood cells are those drawn from the jugular
vein of the sheep. After defibrination of the blood
the cells are washed several times in physiological
salt solution by the centrifuge method to remove all
traces of serum. The specific hemolytic serum may
be derived from a rabbit by giving repeated injections
of thoroughly washed sheep erythrocytes. Generally
an active hemolytic serum is obtained if three or
four injections are given intraperitoneally, spaced
about three days apart; the initial injection may be
5 c.c. packed corpuscles; the doses are gradually
increased until the final injection amounts to 15 or
20 c.c. The animal should not be bled until about
ten days after the last injection. The blood is allowed
to clot, then the clear serum is separated and placed
in sealed bottles for use. The serum is inactivated by
heating for thirty minutes at 56° C. before standard-
izing. It is standardized by taking decreasing
amounts (i.e. 0.01 to 0.001 c.c.) and placing in a series
922
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Bacteriological Technique
of test tubes; to each tube n ]o c.c. complementing
serum is added, then all brought to a constant volume
with 0.9 per cent, sodium chloride solution, aftei
which one centimeter of 5 per cent, blood suspension
is added; the system is incubated in water bath for
one hour at .17° ('. After removal from the water
bath, the tubes are placed in an ice chest until the
intact cells settle to the bottom of the tube. That
amount of the hemolytic serum which just completely
dissolves all of tin- corpuscles in the test tube is called
the hemolyt ic it amboceptor unit. For complen
freshly clotted out guinea-pig serum best serves the
purpose. In the complement fixation test proper,
the normal guinea-pig scrum should also hi' standard-
ized since the complement content is variable. This
is done by finding that amount (one unit) which just
produces complete hemolysis when added to a mix-
ture of one unit of hemolytic serum, and 1 c.c. of
5 per cent, suspension of sheep erythrocytes, after
incubating one hour at 37° C.
In preparing the bacterial antigen for the test, the
best results are had by using a filtrate (Berkefi I I
derived from slant agar growths which have been
partially autolyze.d in distilled water. The antigen
must be standardized against a definite amount
(0.1 to 0.2 c.c.) of a specific antiserum in order to
determine the amount which will fix perfectly wit hout
showing anticomplementary action in the regular
test. The quantity thus found is used as the antigen
unit in the test proper, but should be sufficiently low
that double the amount will not be anticomplement-
ary. Having provided and standardized the neces-
sary components for the complement fixation test, it
is carried out as follows: to a series of test tubes are
added decreasing amounts (0.10, 0.09, 0.08 ....
0.01 c.c.) of the inactivated serum for examination;
to each tube one unit of the bacterial antigen is added;
then two units of the complement; finally, sufficient
physiological salt solution is added to bring to a con-
stant volume throughout. The following controls
are also run in the complement fixation test: one tube
containing double amount of the bacterial antigen
used in the series, plus the hemolytic system; one
tube with double the highest quantity of antiserum
used in the series, plus the hemolytic system; one
tube with a known positive serum, and one with a
negative serum, both of which are carried through in
parallel with the test serum; finally, one tube with
only the regular hemolytic system. The test series
(with the positive and negative control sera) of tubes
are incubated for thirty- minutes in water bath at
37° C. After incubation to each (including control
are added two or three units of the hemolytic immune
serum (amboceptor), and then 1 c.c. of a 5 per cent,
suspension of sheep erythrocytes. The tubes are
shaken, and again returned to the water bath at 37° C.
for one hour. At the end of this period they are re-
moved and placed in an ice chest until the blood cells
settle to the bottom of the tube, then the readings
are made. If the controls are satisfactory, the results
of the test are recorded. .Since in the ease just con-
sidered, the serum being tested was derived from an
immunized animal, some if not all of the tubes would
show no hemolysis. In those showing no hemolysis,
the complement was bound by the antigen-antibody
complex, and none remained free to act upon the sen-
sitized corpuscles added later. If the serum under
examination were not of especially high value, those
tubes of the series which received the smaller quanti-
ties of the serum would show hemolysis — that is, free
complement which acted with the hemolytic system
present.
Preparation of the Soluble Bacterial Toxins. — Solu-
ble or extracellular toxins are produced by a number
of pathogenic bacteria (B. diphtheria-, B. tetani, B.
botttlini, etc.) when grown upon proper culture
media, under favorable conditions. For the purpose
of practical immunization of animals, it is necessary
io have highly eon. entrated to i fore, pre-
cautions mu i he taken in cultivating, to brink; about
the proper conditions. Vltl .■. ,,f
toxin production is as v.i QO | fully understood,
has shown that certain media are more
" able than ot he, ,,i tai trains of I be
organism vary in their ability to elaborate t<
In the preparatii f diphtheria toxin lark recom-
mends as a suitable culture medium a nutrient broth
prepared in the regular manner from young veal, i ■•
each liter add two per cent peptone | \\
sufficient alkali to give an alkalinity equivalent to
the addition of 8 c.c. of normal solution of potassium
hydrate above the m lU8 , Sufficient
nutrient broth is placed in thin layers 'a*
mehes deep) in large-necked Erlenmeyer Basks, to
access of air. After inoculation with H.
the flasks are incubated between :;.V and
: '0° C. PI on of toxin is p
cut between the tilth and eighth days of bacterial
growth. After the tenth day, at incubator tempera-
ture, tin' toxicitj decreases mop. or less rapidly, o
to its labile character. After one week's growth, a
test for purity of culture is made by microscopical and
culture methods. If found pun", the bacteria are
killed by the addition of ten per cent, of a five-per-
cent, solution of carbolic acid. After standing for
forty-eight hours, the dead bacilli settle to the bottom,
and -t of them may be removed by filtering the
broth through ordinary Sterile filter paper. Bottles
are filled with the so-called toxin, sealed, and stored
in the ice chest until n led. A hypodermic in-
jection of 0.01 c.c. or even less should kill a 250-gram
guinea-pig.
The bacillus of tetanus also produces a very power-
ful poison under artificial means of cultivation.
Since the bacillus of tetanus is anaerobic in character,
its cultivation for toxin production must he varied
from that of the diphtheria bacillus. Park's met ho. I
consists in using a nutrient beef broth of slight
alkalinity, containing one per cent, peptone t Witt. ,
0.5 per cent, common salt, and one per cent, glucose.
The broth thus prepared is placed in flasks until they
are about two-thirds filled, then sufficient molten
paraffin (melting-point about 45° C.) is added to
form a semi-solid covering one-half to one inch in
thickness. The whole is sterilized and when ready
for use the flask is sufficiently heated to liquefy the
paraffin layer. A shake culture of B. tetani in agar
is dropped in the warm medium. The heated broth
will cause the agar to dissolve and liberate the
organisms and spores. When cool the paraffin
hardens over the broth and seals it off from the air,
thus producing anaerobic conditions. The agar
shake culture is best removed from the test-tube by
quickly heating until the agar about the wall dis-
solves: then it may he poured into a flask. Precau-
tion should be exercised to prevent outside con-
taminations. The culture is incubated at a tem-
perature of 37° C. for five to six days. After the
necessary tests for bacterial purity are made, the liv-
ing organisms and spores are removed by first lil-
tering through paper pulp (funnel and suction),
then through a Berkcfeld filter. To the filtered
toxin 0.5 per cent, carbolic acid is added; flasks are
then completely filled, sealed, and kept in a cool
tlark place. The strength of this toxin is quite
variable, much depending upon the conditions of prep-
aration. According to Park, under best conditions
the amount of toxin produced in cultures on the fifth
day may be such that 0.000005 C.C is a fatal dose for
a "fifteen-gram mouse. Tetanus toxins as prepared
by the above method may show such a degree of
toxicity that 0.001 to 0.0001 c.c. will cause death
within four days to a guinea-pig weighing from 300
to 350 grams.
The other soluble bacterial toxins may be prepared
in a similar manner, but the composition of media and
923
Bacteriological Technique
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
conditions must be altered to meet the special re-
quirements of the organism under cultivation.
Methods of Immunization. — Only the general princi-
ples of active immunization can be considered. The
injections are made subcutaneously, intraperitoneal]}',
or intravenously. When immunizing a horse for the
production of antitoxin serum, the injection of toxin
should always be made subcutaneously. Experience
has proved that the antitoxin is formed much more
rapidly and reaches a higher concentration in the blood
under such procedure. The primary dose of toxin for
a normal animal must be very small. An initial dose
of 0.01 c.c. of diphtheria toxin has proved fatal to a
horse. Therefore, in immunizing a previously un-
treated horse, it is necessary to begin the injections of
diphtheria toxin (also tetanus toxin) with a dose under
one one-hundredth of a cubic centimeter, to keep
within bounds of safety. A repeated injection of
toxin should not be given until the animal has practi-
cally recovered from the reactionary symptoms of the
previous dose. In the routine immunization of horses
against diphtheria Park recommends that the initial
dose be about 20 c.c. of fairly strong toxin; the second
and third doses are slightly increased. But with each
of the first two injections about 10,000 units of the
antitoxin is given. In this way the animal is protected
until it has an opportunity to elaborate its own anti-
bodies, then the injections of antitoxin should be dis-
continued. This procedure aids in bringing an animal
without danger up to a high degree of immunity in a
relatively short time, as compared with the older
method. In either case, after a few months' treat-
ment, a horse may withstand several hundred cubic
centimeters of highly potent toxin, at a single in-
jection, without serious results. When a soluble
poison is injected, a true antitoxin develops in the
animal and is present in the blood and hence in the
serum. This is the case in diphtheria, tetanus, and
venom immunity. On the other hand, when the
solid cell is injected, the serum may acquire anti-
infectious properties, the best instance of which is
seen in the antipest serum. The organisms may be
killed by exposing them to the action of ether, of
chloroform, or of moist heat at 60° C. In special
cases the attenuated living germ is used, and at times
even the most virulent form is employed. By the
injection of cells other than bacteria, diverse cytolytic
sera are obtained. Thus the injection of the red blood
cells gives rise to a hemolytic serum. The tempera-
ture and the weight of the animal must be taken
daily, since they afford the best indication of the condi-
tion of the animal.
Testing the Strength of Antitoxin. — The strength of
an antitoxin is expressed in immunity units. A
unit, according to the old definition of Behring and
Ehrlich, represents that amount of serum which will be
just sufficient to protect a 250-gram guinea-pig against
100 minimum fatal doses of a given diphtheria toxin.
Thus if 0.1 c.c. of serum protects against this dose of
poison, then it will contain one immunity unit, and 1
c.c. of such serum will contain ten immunity units.
To determine the antitoxic value of a serum accord-
ing to the earlier method, the first essential is to
ascertain the minimum lethal dose (M. L. D.) of the
toxin, by which is meant the amount of toxin which
will kill a 250-gram guinea-pig on the fourth or at
most on the fifth day. Varying amounts of the serum
are then added to portions of the toxin representing
100 minimum fatal doses. These mixtures are then
injected into guinea-pigs of the weight given. That
fraction of a cubic centimeter of the serum which
just suffices to save a guinea-pig under these condi-
tions represents, as stated above, one immunity
unit.
This method is subject to some error, inasmuch as it
has been found thai a serum which has been tested
against one toxin will show a different value when
tested against another. This is due to the fact that
the toxin undergoes changes on keeping, and is con-
verted into a non-poisonous body or toxoid, which,
however, retains the power of combining with the
antitoxin. For this reason Ehrlich proposed a new
method of testing the antitoxic value of a serum. A
standard dried antitoxin is made the basis of the
measurement. This is diluted so that a gn r en amount
just represents one immunity unit. The test dose
(L +) of toxin is then ascertained and represents the
amount of toxin which, mixed with one immunity
unit of serum, will cause death on about the fourth
day. The serum to be tested is then diluted, mixed
with the test dose of the toxin, and injected into a
guinea-pig. If the animal dies in a day or two it is
evident that the serum contains less than one immu-
nity unit. If, on the other hand, it lives for seven or
eight days, or even recovers, it shows that the amount
of serum taken contains more than one unit. By
using suitable dilutions of the serum, eventually tin;
point will be reached where the amount taken will
represent exactly one unit.
It is possible to secure an antitoxic serum from horses
immunized against diphtheria toxin which contains
over 1,000 immunity units in 1 c.c. But this is quite
exceptional. Usually the serum of horses, as com-
monly immunized, averages between 300 to 500 units
per cubic centimeter. Gibson succeeded in preparing
a concentrated preparation of diphtheria antitoxin by
precipitating the proteins, and separating the globu-
lins from antitoxic serum by the addition of certain
salts. The globulin fraction which contains the anti-
bodies, is finally freed from the salts, etc., by dialysis.
By the Gibson method a preparation (fluid) may be
obtained which contains 1,500 to 1,800 units per cubic
centimeter. Recently Banzhaf has improved the
method to the extent that the protein concentration
is materially reduced, while at the same time the anti-
toxic content is increased. By this improved method
a preparation may be obtained which contains
3,000 units per cubic centimeter, with a protein con-
centration of only twenty per cent. These so-called
antidiphtheritic globulins or concentrated antitoxins
are prepared by different serum laboratories.
Opsonic Technique. — The fact that certain cells
of the body will take up and destroy microorganisms
has been known for years. The phagocytic theory of
immunity is based upon this phenomenon. Dcnys and
Leclcf were the first to demonstrate the presence of a
substance in immune serum which made the corre-
sponding organism more susceptible to phagocytosis
by leucocytes. They showed that this substance
acted upon the organism and not on the leucocytes.
Later Wright and Douglas called attention to the
fact that such sensitizing substances are present in
fairly constant amounts in the normal blood. This
substance, which they call opsonin, exists in smaller
amounts or widely fluctuating amounts in the blood
of a patient suffering from specific bacterial infec-
tion. The opsonic content may be increased by prop-
erly vaccinating with killed cultures of the specific
organism. Bacterial vaccines are beginning to play
an important role in the newer therapeutics. It
is obvious that such means of treatment must be
carefully controlled, or, instead of being of material
aid to the body, they become a damaging factor.
Therefore, in order to follow the vaccination treat-
ment, a means must be found by which a fairly ac-
curate measurement can be made of the opsonins in
normal blood and in the blood of a patient suffering
from any bacterial infection. Wright and Douglas
have practically overcome this difficulty by a tech-
nical method by which they derive the so-called "op-
sonic index." This "index" simply shows the relation
existing between the opsonic content of a patient's
blood as compared with the opsonic content of the
blood of a normal person.
The general method used in deriving the opsonic
index calls for the following materials: Blood serum
924
REFERENCE HANDBOOK OF THE MEDICAL SCI] \' I -
Bacteriological Technique
from patient, control scrum from normal person,
normal trashed corpuscles, and the bacteria] emulsion.
The same technique is used in preparing serum
from both the patient's and normal blood. A
puncture is made in the lobe of the ear or one of the
tinners with a needle, ami pressure is used to cause
the blood to How. When the blood begins to exude,
eight or ten drops are drawn up into a pipette, and at
once transferred to a small test-lulie, about one-
quarter inch in diameter and two inches in length.
The blood is allowed to clot, thus permitting the
scrum to separate.
To secure t he leucocytes, the blood is draw n directly
into a small test-tube containing about H» c.c of a
one-and-one-half per cent, solution of sodium citrate
in physiological salt solution. This solution prevents
the blood from clotting. One cubic centimeter of
blood will furnish a sufficient number of leucocytes
for the test. The corpuscles are centrifuged until the
solution above the packed cells appears transparent .
The solution is carefully removed with a capillary
pipette, then about 10 c.c. of physiological salt solu-
tion are added and well shaken to wash the cells. It
is centrifuged again to throw down the corpuscles, and
the salt solution is removed with capillary pipette.
Care should be taken not. to disturb the superficial
creamy layer of blood cells, as this layer contains the
greater share of the leucocytes. When the fluid has
been removed, the leucocyte layer of cells should be
taken up carefully with a capillary pipette, and the
thick emulsion reserved for the test. Blood which
shows any clotting must be rejected.
The bacterial emulsion should be a uniform suspen-
sion, but it is very difficult to avoid some clumping of
organisms. Different organisms vary in this respect.
Tubercle bacilli are extremely hard to get into a uni-
form suspension. To prepare an emulsion of such
organisms as staphylococci, streptococci, pneumo-
cocci, and such bacilli as typhoid and colon, cultures
are grown on the most favorable agar medium, and
used fresh, i.e. not older than twenty-four hours.
A portion of the culture is removed with a medium-
sized platinum wire, and transferred to a small test-
tube containing 3 or 4 c.c. of physiological salt solu-
tion. The mass of organisms is carelully rubbed with
the wire against the wall of the tube at the surface of
the salt solution until a turbid suspension results. Cen-
trifuge until the larger particles of bacteria are thrown
down, but discontinue before the finer suspension is
sedimented. Experience will indicate the proper de-
gree of turbidity which is desirable. Wright recom-
mends that the bacterial suspension be such that four to
live cocci are found for each cell in the final mixture.
For emulsion of tubercle bacilli some workers culti-
vate the organism on glycerin agar and kill the organ-
isms by exposure to direct sunlight for twenty-four
hours, or by other means. Some of the growth is re-
moved from the culture tube, and placed in a small
agate mortar, where it is thoroughly rubbed up with
1..") per cent, salt solution. The resulting suspension
is centrifuged to remove clumps. Other workers
prepare their emulsion of tubercle bacilli from dried
and ground-up bacilli. In preparing the emulsion, the
procedure is the same as the above. In each case
when the emulsion is finished, the upper portion is
remove from the centrifuge tube, with a pipette, and
reserved for use. Wright states that the tubercle
emulsion should be of such thickness that one or two
organisms are found to each cell in the final smear.
Now, having prepared the necessary materials for
the work, the next step is to measure out the blood
cells, serum, and bacterial emulsion for mixtures.
Best for this purpose is a pipette made by taking glass
tubing with about five millimeters internal diameter
and about fifteen centimeters in length. It is drawn
out in the flame in the same manner as described under
Pasteur pipettes (Fig. 5096, 6), with the exception that
no end constriction is made. The capillary portion of
each should i»- about twelve to fifteen centirm
long and about one millimeter in diameter. A rubber
nipple, such as is used on an ordinary medicine
dropper, is slipped ovei the large end. The capillar;
cud IS cut off squarely and a mark IS made with a
glass marking pencil about three to four centimeters
from the end. By mean, c ■ f the nipple, Quid can
easily be drawn up into the capillary tube. The mix-
ture is made by drawing up the heavy suspension
of blood corpuscles (containing leUCOCytl I <" the
pencil mark; a little air is drawn in by raising the
blood column, then an equal volui f serum is drawn
in by tilling up to t he pencil mark; again an air bubble
is allowed to enter; then finally an equal volume of
tin' bacterial suspension is drawn in. In this way the
different suspensions can be equally and accura
measured. The whole content is blown out of the
pipette on a clean, hollow-ground slide, where it is
thoroughly mixed by drawing up and ejecting from
the pipet 1 1> several times. Finally, the whole mixture
kept free from air bubbles is drawn up into the pipe! te
and the capillary end is scaled olf in a flame. The
pipette containing the mixture is placed in an incu-
bator at ::7 ('.for fifteen minutes to permit phagO-
< \ tic action to take place. After removing from the
incubator the sealed tip of the pipit tc is broken off,
and the suspension is well mixed on a clean hollow-
ground slide. Drops of moderate size are placed upon
each of a number of clean slides. Each drop is spread
by means of the end of a second slide, as is done in
ordinary blood work. The smear is allowed to air-
dry completely, then stained with aqueous methylcne-
blue solution, or with a polychrome dye such as the
Wright or Leishman stain. In the case of tubercle
bacilli the films are fixed in saturated aqueous solution
of mercuric chloride ten minutes. The films are
washed in water, stained with Czaplew T sky's carbol-
fuchsin solution, and again washed in water. They
are decolorized in two-per-eent. sulphuric acid, washed
well, and counterstained one minute with one-per-
cent, aqueous solution methylene blue. The stained
preparations are dried and examined under high-power
objective. The bacillary index is found by taking the
total number of phagocyted bacteria counted in a
series, and dividing it by the number of leucocytes
making up the series. Fifty or more leucocytes should
make a series. The opsonic index is derived by divid-
ing the value (bacillary index) of the patient's serum
by the value found for the normal serum used as con-
trol. It is an advantage to collect the normal serum
from three or four healthy persons and mix all
together. This gives more reliable results in finding
the opsonic value for the normal condition.
In making counts for the opsonic index, the per-
sonal equation is frequently pronounced, but by con-
tinued experience this factor ma}' become lessened
and fairly constant. It also must be noted that
marked discrepancies exist between results of ex-
perienced workers when estimating the opsonic index
of the same sample of serum. Simon recommends
that the percentage of phagocyting leucocytes be
estimated in connection with the bacillary index.
He states that this will act as a check upon the
bacillary index, and will reveal errors in counting.
A close correspondence exists between the bacillary
index (Wright) and the percentage index of Simon.
Examination of air. — The bacteria which chance
to be present in the air are in a dried condition, and tend
to settle when the motion of the air is lessened. The
simplest method consists in exposing a plate of gelatin
or agar to the air for a given length of time. Si ime of
the organisms settle on the gelatin and eventually
give rise to colonies. Koch improved slightly upon
this by placing the gelatin plate in the bottom of a
sterile cylinder of known volume. After opening the
cylinder in a given locality it is closed with a cotton
plug and set aside, when the organisms contained in
925
Bacteriological Technique
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
that volume of confined air settle to the bottom on
the surface of the plate. The results, it will be seen,
are crudely quantitative (Fig. 604).
Hesse's method consists in drawing the air through
a large Esmarch roll tube (Fig. (305). The volume
of the air drawn through can be de-
termined from that of the aspirating
bottles. The bacteria in the air im-
pinge upon the gelatin surface, where
they develop into colonies which can
be counted and studied.
The apparatus of Petri, although
very expensive, may be said to give
the best results. It consists in the
first place of an air pump, which
automatically registers the movements
of the piston, and thus gives the
volume of the air which has been
drawn through. The air is aspirated
through a tube (Fig. 606) containing
several layers of sterile sand. The
suspended bacteria are thus held back.
At the close of the operation the sand
is transferred to a Petri plate, where the bacteria will
form colonies and thus become accessible for study.
Instead of sand, Sedgwick and Tucker employed a
filter of sugar. The special tube employed by them is
shown in Fig. 607. After the air has been drawn
through, the sugar is tapped down into the wide
portion of the tube, then gelatin is added and warmed
Fig. 604. —
Koch's Cylinder
for Air Analysis.
Fig. 605. — Hesse's Apparatus for Air Analysis.
until the sugar dissolves, after which an Esmarch
roll culture is made in the same tube.
Other workers have filtered the air through liquid
media or through gelatin. The most convenient form
of apparatus of this kind is that of Wurtz, shown in
Fig. 608. A suitable amount of gelatin is placed in
the sterile tube, then a known volume of air is drawn
through, after which the gelatin is solidified over the
inner wall of the tube, thus forming a roll culture.
Examination of Soil. — By means of a small sterile
platinum spoon a definite volume of the soil may be
transferred to a Petri plate, where it is thoroughly
926
mixed with the medium. The colonies which develop
can then be examined. In this way it is possible at
times to demonstrate the presence of the anthrax
bacillus in the soil of an infected locality. The de-
tection of other pathogenic bacteria, as for instance
those of tetanus and malignant edema, can best be
made by introducing a quantity of the soil under the
skin of a guinea-pig or rabbit.
Examination of Water. — This is a very important
procedure, and an enormous amount of work has been
done to perfect the methods of work. The method
followed will necessarily depend upon the immediate
\ i /*
Fig. 606. Fig. 607. Fig. 60S.
Fig. 606.— Petri Sand Filter for Air Analysis.
Fig. 607. — Sedgwick and Tucker's Aerobiocscope.
Fig. 608. — Wurtz's Apparatus for Air Analysis.
object in view. Thus the detection of the cholera,
vibrio is carried out in a different way from that used
for the colon bacillus. The isolation of the cholera
and typhoid organisms from water has already been
described.
The water which is to be tested bacteriologically
must be received into a sterile glass-stoppered bottle,
and should be examined at once. If the examination
is not carried out at once, the bacterial count will
not be reliable. Samples of highly polluted water,
when kept cool for some time, show a marked de-
crease of intestinal organisms. The first step in the
examination is to make gelatin plates. By means of
a sterile pipette 1 c.c. of water is added to a tube of
gelatin, mixed thoroughly, and the gelatin is then
poured out into a Petri plate. In the same way plates
are made with 0.5 c.c. and with one drop of the water.
The gelatin plates are developed at 20° C. for several
liKFEItEXCH IlAXlU'.ooK < >F Till: MEDICAL SCIENCE
K.ii lrrlul\ sis
days. Tin' colonics are thru counted and examined
in the usual way. When only a few colonies are pres-
ent on a plate they can be readily counted with the
eye. When the number is Large special counters are
made use of. That of Wolffhugel (1 ig. 609) is ruled
in squares of one centimeter and fractions thereof.
Another form is that of I.afnr. A very useful and
cheap substitute is mad.' by printing the divided
circle on card paper. To make a count, the number
of colonies in ten or more squares is ascertained, and
the average per square centimeter is obtained. The
ana of the gelatin on the plate is taken and then the
total number of colonies on the plate determined, and
the result is expressed per cubic centimeter of water.
Fig. 609. — Wolffhugel's Colony Counter.
Instead of using Petri plates, the Esmarch roll tube
can be made. To count the colonies in such a tube
Esmarch devised the counter shown in Fig. G10.
When the number of colonies is likely to be ex-
tremely large, as in the examination of pollute,! water.
it is advisable to dilute a portion of the sample with
a known volume of sterile water. If the colonies are
very numerous on a plate, the counting can be carried
out best under a microscope. Ehrlich stops are placed
in the eye-piece or the special Ehrlich ocular may be
used. The size of the opening in the ocular must be
determined by means of a stage micrometer. The
average number of colonies for a given-sized opening
is determined, and from this the total number on the
plate is calculated.
The above method of examination gives approxi-
mately the number of bacteria which are present in a
Fig. 610. — Counter for Esmarch 's Roll-tube Cultures.
water, and to some extent information as to the kind
of bacteria. It is of great value, therefore, in con-
trolling the work done by the water filters. In order
to ascertain the presence of pathogenic and other
bacteria special methods must be resorted to. The
method which has been employed during a number
of years in the Hygienic Laboratory of the University
of .Michigan consists in planting a cubic centimeter
and a drop of the water in tubes of bouillon, which are
then incubated at 39° C. If no growth forms, as
often is the case, pathogenic bacteria may be said to
be excluded. When a growth does form, a portion
(1 e.c.) is injected into a guinea-pig. In ease the
animal dies the heart blood is examined for the kind
of organism present. If no ill effects follow the injec-
Fio. 611 -
1 itation Tube.
tion, the watei maj be aid i<> !»■ free from pathogenic
'Ha.
Sewage contamination Is u ually Indicated by the
presence of colon bacilli and ol tn ptococci.
presence i,t t lie former i • te ted i u bj mean "ft he
Smith fermentation tube (1 is 61 I ater
is added to glui ose bouillon in t In- fermental ion :
which is then set aside at :;? C. The formatio
gas indicates the probable dp sence of tin- colon
Bacillus, while the non-production of gas points to the
ab ence of t his organism. 1 url hi
for indent ifical ton.
Litmus-lactose agar plates should be mad.' directly
from the water and also from the fei atation tube
when gas production is present.
The formation of red colonii
ttive of the colon bacillus,
i i.i organi m ferments lac-
erea tj phoii i like I iactei ia
do not. For the same purpose lac
tose bouillon is some! imes empli 13 ei 1
in the fermenl ation tul ie.
Another procedure is to plant 1 he
water in carbolic bouillon, or in
Parietti's solution, in order to elim-
inate many of the more common
iria.
Neutral red bouillon and agar are
also used for cultivating the sua
pected colon bacillus. The water
may be planted direct, or the red colonies which form
On the plate may be used for inoculation. Some of the
special media such as Endo's fuchsin agar, Harri-
son's oesculin bile salt agar, etc., may be Used', with
good results, by the plating method. Jackson's
lactose bile medium is highly recommended by some
water analysts. The coagulation of milk and the
production of the indol reaction are additional tests
of identification. F. ('.. Now.
Revised by L. W. I'amui.exer.
Bacteriolysis. — Under certain circumstances bac-
teria are dissolved. This process is called bacterioly-
sis and the substances which bring it about are termed
bacteriolysins.
Bacteriolysis may be a sort of self-digestion, brought
about, according to some authorities, by a ferment
contained within the cell, an endotryptase. Bacteri-
olysis occurring in this manner is known as autolysis.
Autolysis takes place only when the conditions are
unfavorable for the growth and development of the
organisms. For instance pneumococci will grow vig-
orously for a time when planted in a suitable medium,
but after a few days they gradually disappear leaving
few or no traces. This disappearance is due to the
fact that the cocci have been injured by the accumu-
lation in the medium of their waste products and
have then undergone lysis. If the temperature
is too high or too low or in the presence of mild
disinfectants such as chloroform, toluol, thymol,
or salicylic acid, autolysis readily occurs. If, how-
ever, the heat is too great or if the disinfectant added is
too strong, such as would be the case with phenol or
corrosive sublimate, then the ferment also is injured
and autolysis is prevented. Even in physiological sail
solution a certain amount of autolysis occurs, due
probably to the insufficiency of food material.
Bacteriolysis may result from the action of added
substances, so-called chemical bacteriolysins. Alka-
lies, antiformin, strong salt solutions, bile salts,
cobra venom, and oleic acid belong to this group of
chemical agents. There is a very great difference in
the way the different organisms read to these lysins.
The pneumococcus yields with comparative ease while
the tubercle bacillus is unaffected even when treated
with strong alkalies or antiformin. The true menin-
gococcus is dissolved by bile and by taurocholic acid
while the Jager meningococcus and the pus cocci are
927
Bacteriolysis
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Bacteriuria
not affected. Glycerin acts upon many bacteria but
not upon the protozoa or the filterable viruses. In
ral spores are the most resistant to bacteriolysis,
with the acid-fast and Gram positive bacteria ranking
next. The Gram negative organisms are the most
susceptible. A notable exception is the pneumococ-
cus which, although Gram positive, is very susceptible
to most bacteriolytic agents.
The reaction of bacteria to the lytic action of the
digestive ferments differs somewhat from both of the
above varieties of bacteriolysis. The living cells are
attacked to a very slight degree if at all. When
killed, the different varieties react in different ways.
The Gram negative bacteria, when killed by a tem-
perature of 75°-S0° C, are readily digested by artificial
gastric juice and even more readily by trypsin.
When killed by the weaker disinfectants such as
chloroform, however, this digestion takes place to a
much less marked degree. The Gram positive bacteria
are much more resistant, many not being attacked
by trypsin, even if they have been killed.
Many normal sera possess a certain amount of
bacteriolytic power which is more or less specific but
which is capable of action on a fairly large number of
organisms. When, however, an animal is inoculated
with bacteria, specific bacteriolysins may be produced
in large quantities. Specific bacteriolysins are anti-
bodies of Ehrlich's third order and are much more com-
plicated than the bodies of the first and second orders.
They are amboceptors, relatively thermostabile and
require the presence of complement for their action.
Their manner of action is analogous to that of all the
cytolysins.
Bacteriolysis was first described by Pfeiffer who
demonstrated the process by the aid of the following
experiment: Two guinea pigs, one normal and one
immunized were injected intraperitoneally with living
cholera vibrios. The peritoneal exudate was with-
drawn from time to time and examined. While
the cholera vibrios in the peritoneal exudate of the
normal animal were unaffected and the animal suc-
cumbed to the infection, those in the exudate of the
immunized animal behaved very differently. They
first began to lose in motility, then broke up into
small granules, and finally disappeared and the animal
recovered. He later found that the same lytic power
was present in the serum of the immunized animal.
Bacteriolysis thus constitutes one of the important
defenses of the body against infection. The process
however is not without danger to the animal. If
there are a large number of bacteria present in the
blood when a dose of bacteriolytic serum is admin-
istered, their sudden lysis may result in the setting
free of a large quantity of endotoxin which may be
powerful enough to cause death even though the in-
fection itself has been cured. At might be supposed
from the behaviour of bacteria to other bacteriolytic
agents, not all the organisms are able to stimulate an
animal to the production of bacteriolysins. For such
as are thus able, however, the bacteriolytic serum con-
stitutes a much more real immunity than the anti-
toxic immunity produced as a result of the inoculation
of other bacteria. It is easily seen that a, serum which
contains merely substances which neutralize bacterial
poisons may leave unharmed in the body the organ-
isms which produced the toxins and these bacteria may
later develop again into virulent forms. Because of
the difficulty in their production, however, bacterioly-
tic sera are not in very general use. The bacterioly-
sis which takes place in serum whether or not it con-
tains specific bacteriolysins, has proven an attractive
subject around which have collected many theories.
TIm' nature of the complement, the role of the leuco-
cyte, the question as to the part played by the lipoids,
all these are closely connected with the main problem,
and about them we know practically nothing. In the
article on Immunity the reader will find a more de-
tailed discussion than is possible here.
Ralph G. Stillman.
Bacteriotropins. — Wright observed that among the
antibodies which were produced by an animal which
had been inoculated with bacteria were some which
rendered the bacteria in question more susceptible
of phagocytosis. These bodies he called opsonins.
He recognized the fact that there were opsonins resi-
dent in normal sera and that they were less specific
than the immune opsonins. Neufeld, however, found
that the immune opsonins were much more thermos-
tabile than the normal opsonins and came to the con-
clusion that they were entirely different substances.
To the immune opsonins he gave the name bacterio-
tropins. Bacteriotropins exert their influence en-
tirely upon the bacteria, for if a bacterial emulsion be
mixed with a serum containing these substances and
then centrifuged to remove the serum the bacteria
will be found to be more readily subject to phagocy-
tosis than organisms not so treated. Their nature is
unknown. There has been an effort to identify them
with the antiaggressins of Bail but not on sound
experimental grounds. Their importance in im-
munity is obvious, as a serum of high bacteriotropic
value would sensitize a large number of organisms
and thus virtually enormously increase the power of
the leucocytes to destroy them. The technique of
determining the bacteriotropic power of a serum is
identical with that of obtaining the opsonic index, for
which the reader is referred to the article on Opsonins.
The relation of these bodies to the other antibodies
will be discussed in detail in the article on Immunity.
Ralph G. Stillman.
Bacterium. — A genus of the family Bacteria* / ,
containing cylindrical rod-shaped or ellipsoidal
organisms, without flagella, sometimes with endo-
spores, and often grouped in zoogleea masses. The
genus is not well defined, many of the species being
classed by some bacteriologists among the bacilli;
Bad. coli, for example, being more commonly called
Bacillus coli communis, and Bad. influenza;, B. in-
fluenza. Bad. termo is a collective term now practi-
cally obsolute, applied to a number of the putre-
factive bacteria.
The term bacteria (the plural form of bacterium)
is also commonly employed in a general sense as
synonymous with Schizomycetes, or the fusion-fungi.
T. L. S.
Bacteriuria. — If a urine is rich in bacterial content
when it is voided, the subject is said to suffer from
bacteriuria. The clinical evidence of this condition
is usually held to be a turbidity which cannot be made
to disappear by filtration, centrifuging, warming, or
the addition of acids or alkalies. The claim has been
made, however, that bacteriuria may be present with
clear urine. Under the microscope a drop of the fluid
is seen to be swarming with bacilli and cocci in a state
of rapid movement. The turbidity can be made to
clear up by agitation with barium carbonate and
filtration through asbestos. The reaction in bacte-
riuria may be acid or alkaline, and the urine rapidly
undergoes either the alkaline or acid fermentation.
The condition is an expression of some purulent affec-
tion at some point in the urogenital tract, of hem-
atogenous infections of the kidneys (scarlatinal neph-
ritis), and certain systemic affections — diabetes, Weil's
disease. The bacterial flora show a wide range, but are
doubtless for the most part saprophytes. E. P.
END OF VOLUME I.
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II I I II
D 000 207 268 4
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1913
v.l
A Reference handbook of the medical
sciences.
MEDICAL SCIENCES LIBRARY
UNIVERSITY OF CALIFORNIA, IRVINE
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