although during the periods of excitement there may be maniacal furor with hallucinations which pass away in the stage of relaxation. The temperature is moderately elevated (101° to 103° or higher). This spasmodic stage lasts from one to three days, and the patient may die during this period from exhaustion or from asphyxia. If he lives through this period, the convulsions gradually cease, the power of swallowing returns, and the patient succumbs to exhaustion in. less than twenty-four hours, or he develops ascending paralysis which soon causes cardiac and respiratory failure.

In hydrophobia death is practically inevitable. Almost all cases in which it is alleged that recovery ensued were not true hydrophobia, but hysteria. Wood says that in hysteria, especially among boys, "beast-mimicry" is common, the sufferer snarling like a dog, and in the form known as "spurious hydrophobia," in which there may or may not be convulsion, there are a dread of water, emotional excitement, snarling, and attempts to bite the bystanders (in genuine hydrophobia no attempts are made to bite, and sounds are uttered like those made by a dog).

Lyssa is separated from lockjaw by the spasms of the larynx and the absence of tonic spasms in the former, as contrasted with the spasms of muscles of mastication and the tonic spasms with clonic exacerbations of lockjaw.

Treatment. When a person is bitten by a supposed rabid animal, apply constriction above the wound if possible, excise, and burn with the hot iron. Send the patient to a Pasteur institute at once, that he may be given preventive inoculations of an emulsion made from the dried spinal cords of hydrophobic rabbits (attenuated virus). Pasteur discovered the following remarkable facts: If the virus of a rabid dog (street rabies) be placed beneath the dura of another dog, it always causes hydrophobia in from sixteen to twenty days, and invariably causes death. If the virus is passed through a series of rabbits it gets stronger (laboratory virus), and if inserted beneath the dura of a dog, it causes the disease in from five to six days, and kills in four or five days. The virus can be attenuated by passing through a series of monkeys or by keeping. To get attenuated preparations in a convenient form he made emulsions from the cords of rabbits dead two or three weeks. The emulsion obtained from the rabbit longest dead is the weakest. He injected a dog with emulsions of progressively increasing strength and made it immune to hydrophobia. These emulsions cause the body-cells. to develop antitoxins, which are already in the body when

the street rabies virus begins to develop. The report of the Parisian Pasteur Institute shows that since its foundation there has been a mortality of 0.5 per cent. The lowest estimated number of those attacked by hydrophobia before this method was used was 5 per cent. of those bitten, and all attacked died; hence, the Pasteur treatment shows one-twenty-fifth of the mortality which attends other preventive methods. The value of this plan seems definitely established. Murri, of Bologna, cured a case of hydrophobia by injecting emulsions of cords of rabbits dead six, five, four, and three days respectively. This remedy should be tried. In the paroxysm the treatment in the past was palliative. If we try only palliative methods, keep the patient in a dark, quiet room, relieve thirst by enemata, saturate with morphin, in the paroxysms anesthetize, empty the bowels by enemata, and attend to the bladder.

man.

Glanders, Farcy, or Equinia.-Glanders is an infectious eruptive fever occurring in horses and communicable to If the nodules occur in a horse's nares, we call the disease "glanders;" if beneath his skin, it is termed "farcy." This disease is due to the bacillus of Löffler, and is communicated to man through an abraded surface or a mucous membrane (Osler). The characteristic lesions are infective granulomata, which in the nose form ulcers and under the skin develop abscesses.

Acute and Chronic Glanders.—In acute glanders there is septic inflammation at the point of inoculation; nodules form in the nose, and ulcerate; there is profuse nasal discharge; the glands of the neck enlarge; there are fever and an eruption like small-pox on the face and about the joints (Osler) and severe muscular pain. Acute glanders is always fatal. Chronic glanders lasts for months, is rarely diagnosticated, being mistaken for catarrh, and is often recovered from. Diagnosis is made by injecting a guinea-pig with the nasal

mucus.

Acute and Chronic Farcy.-Acute farcy appears from a skin-inoculation; it begins as an intense inflammation, from which run out inflamed lymphatics that present nodules or "farcy-buds." Abscesses form. There are joint-pain and the constitutional symptoms of sepsis, but no involvement of the nares. Chronic farcy may last for months. In it nodules occur upon the extremities, which nodules break down into abscesses and eventuate in ulcers resembling those of tuberculosis.

Treatment. In treating this disease the point of infection

is at once to be incised and cauterized, dusted with iodoform, and dressed antiseptically. Enlarged glands and swollen. lymphatics are to be painted with iodin and smeared with ichthyol. Bandages are applied to edematous extremities. Ulcers are curetted, touched with pure carbolic acid, dusted with iodoform, and dressed antiseptically. The nose is sprayed at frequent intervals with peroxid of hydrogen, and is frequently syringed with sulphurous acid. The mouth is rinsed repeatedly with solutions of chlorate of potassium. Open the abscesses, swab out with pure carbolic acid, and dress antiseptically. Give stimulants and nourishing diet. Morphin will be necessary for the muscular pain, restlessness, and insomnia. Digitalis is given to stimulate the circulation and kidney secretion. Sulphur iodid, arsenite of strychnin, and bichlorate of potassium have been used. Diseased horses ought at once to be killed and their stalls torn out and purified. A man with chronic glanders should be removed to the seaside. The nasal passages should be kept clean; ulcers must be cauterized and dressed with iodoform gauze. Nutritious foods, tonics, and stimulants are necessary.

Actinomycosis is an infectious disorder characterized by chronic inflammation, and is due to the presence in the tissues of the actinomyces or ray-fungus. This disease occurs in cattle (lumpy jaw) and in pigs, and can be transmitted to man, usually by the food. At the point of inoculation (which is generally about the mouth) arises an infective granuloma, around which inflammation of connective tissue occurs, suppuration eventually taking place. Inoculation in the mouth is by way of an abrasion of mucous membrane or through a carious tooth. Chewing straw which contains the fungi is the most common method of infection. The ray-fungi may pass into the lungs, causing pulmonary actinomycosis; into the intestines, causing intestinal actinomycosis; into the skin, the bones, the subcutaneous tissues, the heart, the brain, the liver, etc. Actinomycosis until very recently was looked. upon as sarcoma.

Cutaneous actinomycosis may be secondary to a visceral area of disease, may be a purely local condition, or may be associated with some adjacent area of bone-infection. The gummatous form of the disease resembles a gummatous syphilitic area, and in it many small purulent pockets open by fistula (Monestié).

In the anthracoid there are no distinct purulent collections, but many fistulæ discharge pus at various points (Monestié). An area of cutaneous anthrax is characterized by the ex

istence of violet, blue, gray, or black maculæ, varying in size from that of a pin's head to that of a bean, the center of each macule being white and containing a minute quantity of pus (Derville).

The pus of actinomycosis contains many sulphur-yellow bodies, visible to the naked eye and composed of fungi. These bodies feel gritty when rubbed between the fingers because of the presence of lime salts.

In actinomycosis of bone the bone enlarges and becomes painful, the parts adjacent are infiltrated and soften, pus forms and reaches the surface through fistulæ, and the skin is often involved secondarily.

In actinomycosis the adjacent lymphatic glands are not involved. The diagnosis must be made from syphilis, sarcoma, and tuberculosis. The microscopic examination of the pus makes the diagnosis.

Treatment.-Free excision if possible; otherwise incision, cauterizing with pure carbolic acid, and packing with iodoform gauze. Give internally large doses of iodid of potassium. This drug alone has cured many cases.

Wounds of Mucous Membranes.—If the surgeon intends to inflict a wound upon a mucous surface, he should see to it that the patient's general condition is good. Thorough asepsis is impossible, and a good result depends largely upon the vital resistance of the tissues. Before operating many surgeons irrigate the part frequently with boric acid, a proceeding of questionable value. When ready to sew up, be sure that all irritant fluids are removed from the wound (saliva in the mouth, etc.). Cleanse the wound with hot normal salt solution. The stitches must include submucous tissue as well as the mucous membrane, and consist of silver wire, silk, or silkworm gut. After sewing up, wash often with salt solution, and follow it by insufflation of iodoform.

In accidental wounds irrigate with salt solution, dust with iodoform, and close as directed above. Corrosive sublimate is so irritant that it does only harm when applied to a mucous membrane.

XVI. SYPHILIS.

Definition.-Syphilis is a chronic infectious, and sometimes hereditary, constitutional disease. Its first lesion is an infecting area or chancre, which is followed by lymphatic enlargements, eruptions upon the skin and mucous membranes, affections of the appendages of the skin (hair and nails),

"chronic inflammation and infiltration of the cellulo-vascular tissue, bones, and periosteum" (White), and, later, often by gummata. This disease is probably due to a microbe, but Lustgarten's bacillus has not been proved to be the one. One fact against its being the cause is its presence in the non-contagious late gummata. White quotes Fenger in his assumption that syphilitic fever is due to absorption of toxins; that the eruptions of skin and mucous membranes in the secondary stage arise from local deposit and multiplication of the virus; that many secondary symptoms result from nutritive derangement caused by tissue-products passing into the circulation; that the virus exists in the body after the cessation of secondary symptoms; and that it may die out or may awaken into activity, producing "reminders."

During the primary and secondary stages fresh poison cannot infect, and this is true for a time after the disappearance of secondary symptoms. Immunity in the primary stage is due to products absorbed from the infected area. Colles's immunity is that acquired by mothers who have borne syphilitic children, but who themselves show no sign of the disProfeta's immunity is the immunity against infection possessed by many healthy children born of syphilitic parents. Tertiary syphilitic lesions are not due to the poison of syphilis, but to tissue-products from the action of that poison, or to nutritive failure as a consequence of the disease. Tertiary syphilis is not transmissible, but it secures immunity.

ease.

Transmission of Syphilis.-This disease can be transmitted (1) by contact with the tissue-elements or virusacquired syphilis; and (2) by hereditary transmission-hereditary syphilis. The poison cannot enter through an intact epidermis or epithelial layer, and abrasion or solution of continuity is requisite for infection. Syphilis is usually, but not always, a venereal disease. It may be caught by infection of the genitals during coition, by infection of the tongue or lips in kissing, by smoking poisoned pipes, by drinking out of infected vessels, or by beastly practices. The initial lesion of syphilis may be found on the finger, penis, eyelid, lip, tongue, cheek, palate, anus, nipple, etc. A person may be a host for syphilis, carry it, give it to another, and yet escape it himself (a surgeon may carry it under his nails, and a woman may have it lodged in her vagina). Syphilis can be transmitted by vaccination with human lymph which contains the pus of a syphilitic eruption or the blood of a syphilitic person. Vaccine lymph, even after passage through a person with pox, will not convey syphilis if it is free from blood