As one that falls,
He knows not how, by force demoniac dragged
To earth, or through obstruction fettering up
In chains invisible the power of man,
Who, risen from his trance, gazeth around,
Bewildered with the monstrous agony

He hath endured, and wildly staring sighs;
So stood aghast the sinner when he rose.s

This, I think, will strike the medical reader as a very fine poetic description of an attack of epilepsy; and so, indeed, Benvenuto suggests (Longfellow's Notes). And to the ailment came as soon the plaster."

Thus did appear, coming towards the bellies
Of the two others, a small fiery serpent,
Livid and black as is a peppercorn,
And in that part whereat is first received
Our aliment [the umbilicus] it one of them
transfixed;

Then downward fell in front of him extended,
The one transfixed looked at it, but said naught;
Nay, rather with feet motionless he yawned,
Just as if sleep or fever had assailed him."

"In animals which do not die immediately from the effects of this poison (snake venom) the first signs of nerve poisoning are, drowsiness, incoördination, followed by loss of voluntary motion, convulsions or failure of reflex activity and death.

"From the results of the observations with pure venoms and their globulins and peptones upon respiration, it seems clear the primary action is to cause an increase in the number of respirations, and, secondarily, to diminish the respirations below normal.

"The alterations in the, pulse-rate are dependent chiefly upon two antagonistic factors, which are active at the same time, the one tending to increase the rate and the other to diminish it. The former is found in the increased action of the accelerator centers and the other in a direct action on the heart.

"The variations in arterial pressure are due chiefly to three causes, depression of the vaso-motor centers, depression of the heart, and irritation and consequent constriction or blocking up of the capillaries." 70

"Bite of Australian Species of SnakesConstitutional symptoms appear in from fifteen minutes to two hours. The first symptom is almost invariably a feeling of faintness and an irrestible desire to sleep. On attempting to walk the gait becomes staggering, and the weakness in the legs increases until the patient is unable to stand alone." 71

"Effect on Temperature.-The effects of venoms on body temperature vary. Sometimes a rise is observed, sometimes a fall. In the case of viperine poisoning, together with the intense local edema and extravasation, the temperature is raised." 72

The above quotations vividly demonstrate Dante's knowledge, either from personal observation or from study, of a matter which to-day is the subject of prolonged experimental study, not only in America and Europe, but notably in India.

Though not altogether relevant to the subject in hand, Dante's description of the double transmutation of Guercio Cavalcanti and Buoso degli Abati is so fine that it should not be omitted:

He at the serpent gazed and it at him; One through the wound, the other through the mouth

Smoked violently, and the smoke commingled.
Henceforth be silent, Lucan, where he mentions
Wretched Sabellus and Nasidius,

And wait to hear what now shall be shot forth.
Be silent, Ovid, of Cadmus and Arethusa;
For if him to a snake, her to a fountain,
Converts he fabling, that I grudge him not;
Because two natures never front to front
Has he transmuted, so that both the forms
To interchange their matter ready were.
Together they responded in such wise
That to a fork the serpent cleft his tail,
And eke the wounded drew his feet together.
The legs together with the thighs themselves
Adhered so, that in little time the juncture
No sign whatever made that was apparent.
He with the cloven tail assumed the figure
The other one was losing, and his skin
Became elastic, and the other's hard.

I saw the arms draw inwards at the armpits,
And both feet of the reptile, that were short,

71. Mr. Charles James Martin and Dr. Calmette: A System of Medicine. Edited by Thomas C. Allbutt.

Vol. II, p. 809 et seq.

72. Ibid., p. 826.

Lengthen as much as those contracted were.
Thereafter the hind feet, together twisted,
Became the member that a man conceals,
And of his own the wretch had two created.
While both of them the exhalation veils
With a new color, and engenders hair
On one of them and depilates the other.
The one uprose and down the other fell,
Though turning not away their impious lamps,
Under which each one his muzzle changed;
He who was standing drew it tow'rds the tem-
ples,

And from excess of matter, which came thither,
Issued the ears from out the hollow cheeks;
What did not backward run and was retained
Of that excess made to the face a nose,
And the lips thickened far as was befitting.
He who lay prostrate thrusts his muzzle for-
ward,

And backward draws the ears into his head.
In the same manner as the snail its horns;
And so the tongue, which was entire and apt
For speech before, is cleft, and the bi-forked
In the other closes up, and the smoke ceases.
The soul, which to a reptile had been changed,
Along the valley hissing takes to flight,
And after him the other speaking sputters.
Then did he turn upon him his new shoulders,
And said to the other: "I'll have Buoso run,
Crawling as I have done, along this road.13

But even as Constantine sought out Sylvester
To cure his leprosy, within Soracte,
So this one sought me out as an adept
To cure him of the fever of his pride.'

74

The legend was that in gratitude for a miraculous cure of leprosy effected on him by Pope Sylvester I, Constantine endowed the pontiffs with the government of Rome.

What pain would be if from the hospitals
Of Valdichiana, 'twixt July and September,
And of Maremma and Sardinia

All the diseases in one moat were gathered,
Such was it here, and such a stench came from it
As from putrescent limbs is wont to issue.

I do not think a sadder sight to see
Was in Aegina, the whole people sick,
When was the air so full of pestilence,
The animals, down to the little worm,
All fell ..

Than was it to behold through that dark valley
The spirits languishing in divers heaps.

I saw two sitting leaned against each other,
As leans in heating platter against platter,
From head to foot bespotted o'er with scabs;
And never saw I plied a curry comb
By stable-boy for whom his master waits,
Or him who keeps awake unwillingly,
As every one was plying fast the bite
Of nails upon himself, for the great rage
Of itching which no other succor had.75

"Farther south is the Maremma, a region which, though now worse than a desert, is supposed to have been anciently both fertile and healthy In the

73. Hell, C. XXV.

74. Hell, C. XXVII, Longfellow. 75. Hell, C. XXIX, Longfellow.

9976

The Val di Chiana, near Arezzo, was in
Dante's time marshy and pestilential."
'Twas at the time when Juno was enraged,
For Semele, against the Theban blood,
As she already more than once had shown;
So reft of reason Athamas became,
That, seeing his own wife with children twain
Walking encumbered upon either hand,

He cried: "Spread out the nets, that I may take
The lioness and her whelps upon the passage;"
And then extended his unpitying claws,
Seizing the first, who had the name Learchus,
And whirled him round, and dashed him on a
rock;

And she with the other burden drowned herself;

And at the time when fortune downward hurled
The Trojan's arrogance, that all things dared,
So that the king was with his kingdom crushed,
Hecuba, sad, disconsolate, and captive.
When lifeless she beheld Polyxena
And of her Polydorus on the shore
Of ocean was the dolorous one aware,
Out of her senses like a dog did bark,

So much the anguish had her mind distorted." Athamas, king of Thebes. His madness is thus described by Ovid.79

Now Athamas cries out, his reason fled, "Here, fellow-hunters, let the toils be spread. I saw a lioness in quest of food

With her two young, run roaring in this wood."
Again the fancied savages were seen,

As through his palace still he chased his queen;
Then tore Learchus from her breast; the child
Stretched little arms, and on the father smiled-
A father now no more- who now begun
Around his head to twirl his giddy son,
And, quite insensible to nature's call,
The helpless infant flung against the wall.
The same mad poison in the mother wrought;
Young Melicerta in her arms she caught,
And with disordered tresses, howling, flies.
"O Bacchus! Evoe! Bacchus !" 'loud she cries.
The name of Bacchus Juno laughed to hear,
And said, "Thy foster-god has cost thee dear."
A rock there stood whose sides the beating

The wretched Ino, on destruction bent, Climbed up the cliff-such strength her fury lent;

Thence with her guiltless boy, who wept in vain, At one bold spring she plunged into the main.

Hecuba, wife of Priam of Troy, and mother of Polyxena and Polydorus.' 80 When on the banks her son in ghastly hue Transfixed with Thracian arrows strikes her view,

The matron shrieked; her big swol'n grief surpassed

The power of utterance; she stood aghast;
She had not speech nor tears to give relief;
Excess of woe suppressed the rising grief.
Lifeless as stone, on earth she fixed her eyes,
And then looked up to heaven with wild sur-
prise.

Now she contemplates o'er with sad delight
Her son's pale visage; then her aching sight
Dwells on his wounds; she varies thus by turns,
Till with collected rage at length she burns,
Wild as the mother-lion when among

The haunts of prey she seeks her ravished

young;

Swift flies the ravisher; she marks his trace,
And by the print directs her anxious chase
So Hecuba with mingled grief and rage
Pursues the king, regardless of her age.

Fastens her forky fingers in his eyes;
Tears out the rooted balls; her rage pursues,
And in the hollow orbs her hand imbrues.
The Thracians, fired at this inhuman scene,
With darts and stones assail the frantic queen.
She snarls and growls, nor in an human tone;
Then bites impatient at the bounding stone;
Extends her jaws, as she her voice would raise
To keen invectives in her wonted phrase;
But barks, and thence the yelping brute betrays.

Athamas, the story goes, was driven to madness by the persecutions of Juno. While temporarily insane he seized his son, Learchus, from the mother's arms, and dashed him against a rock; Ino, his wife, threw herself with the other child into the sea. Athamas eventually recovered.

Hecuba was in like manner rendered insane by the cruel death of her children, as related above. The citation of these cases shows Dante's familiarity with their histories, and his clear understanding of their medical features.

I saw one made in fashion of a lute,s
If he had only had the groin cut off
Just at the point at which a man is forked.
The heavy dropsy, that so disproportions
The limbs with humors, which it ill concocts,
That the face corresponds not to the belly,
Compelled him so to hold his lips apart
As does the hectic, who because of thirst
One towards the chin, the other upward turns."
The above not only shows Dante's per-

80. Ovid, XIII, Stanyan's translation. Longfellow's notes, p. 329.

81. The lute of the thirteenth century was shaped like a modern mandolin.

fect knowledge of the doctrines of "Coction and Crises," and its ever-attendant doctrine of the "Four Elements and Four Humors," but also his personal observation of the appearances of dropsy.

"The theory of Coction and Crises regarded disease as an association of phenomena, resulting from the efforts made by the conservative principle of life to effect a coction of the morbific matter in the economy. They thought that it could. not be advantageously expelled until it was properly prepared, that is, until after its elements were separated and united with. the natural humors of the body, so as to form an excrementitious material." 83

It often happened that the vital principle, fatigued and broken down, was unable to effect coction.

And I to him: "Who are the two poor wretches
That smoke like unto a wet hand in winter?"
"One the false woman is who accused Joseph,
The other the false Sinon, Greek of Troy;
From acute fever they send forth such reck."

Recognition of the pathognomonic odors of febrile diseases could only come to Dante as an acute observer of such conditions. Note also his description of tympanites:

And one of them, who felt himself annoyed
At being, peradventure named so darkly,
Smote with his fist upon his hardened paunch,
It gave a sound as if it were a drum.

Sinon, the Greek, and Adamo, the false coiner, hold the following controversy: "Rueful to thee the thirst be wherewith cracks Thy tongue," the Greek said, "and the putrid

water

That hedges so thy paunch before thine eyes."
Then the false-coiner: "So is gaping wide
Thy mouth for speaking evil, as 'tis wont;
Because if I have thirst and humor stuff me,
Thou hast the burning and the head that aches."
The very tongue, whose keen reproof before
Had wounded me, that either cheek was stained,
Now ministered my cure. So have I heard,
Achilles' and his father's javelin caused
Pain first and then the boon of health restored 85

"A Pelion ash which Chiron gave to Achilles' father, cut from the top of Mount Pelion, to be the death of heroes."

" 86

We now had left him, passing on our way,
When I beheld two spirits by the ice
Pent in one hollow, that the head of one
Was cowl unto the other; and as bread

Is ravened up through hunger, the uppermost
Did so apply his fangs to the other's brain,
Where the spine joins it."

While I was still the form of bone and pulp
My mother gave me, the deeds I did
Were not those of a lion, but a fox."

As long as he was in the flesh.
Amid this dread exuberance of woe
Ran naked spirits winged with horrid fear,
Nor hope had they of crevice where to hide,
Or heliotrope to charm them out of view."

The heliotrope of the Middle Ages was a stone, not a flower, to which great virtue was attributed in protecting from the effects of snake poison. It could also render one invisible.

Now though the cold had from my face dislodged

Each feeling, as 't were callous, yet me seemed Some breath of wind I felt."2

Local anesthesia from intense cold. The Poet knew the lack of sensation in callosities. (To be continued.)

3. Fracture of the Tarsal Scaphoid. Fracture of the tarsal bones, while not commonly met with, is nevertheless not. the great rarity that the older text-books would lead us to believe. According to Gurlt's statistics, fractures of the tarsal bones represent 1 per cent. of all fractures. But statistics since the Roentgen era will undoubtedly increase this figure. Trauma to the ankle usually manifests itself in one of three ways.

A gross crushing of the foot, as by a wheel of a railway car or heavy vehicle, may fracture any or all of the tarsal bones.

Direct localized trauma to the tarsal bones is most often the result of falls or jumps, the patient landing on the heel of the foot. Such a force usually spends itself on the os calcis. At the Cincinnati Hospital, where many cases of falls from ladders, scaffolds, etc., are treated, fracture of the os calcis is exceedingly common. The bone may be simply cracked vertically or it may be comminuted in a variety of ways. The result in every case is a dropping downward of the anterior fragment, with a consequent destruction of the normal arch of the foot, traumatic flat foot resulting. Very infrequently the .astragalus may be involved in these injuries, the broken fragment usually springing out of position backward and producing a prominence under the tendo Achillis, the latter condition being practi

1 Eulenberg's Encyclop. 89. Hell, C. XXXII, Cary.

90. Hell, C. XXVII, line 73 et seq., Longfellow.

cally a pathognomonic sign of fracture of the astragalus. The cuboid and cuneiform. bones are rarely involved except in gross crushes. This is due probably to the fact that they are of smaller size and better protected than the other bones, and furthermore do not play such an important part in holding up the arch of the foot or in carrying the weight of the body.

Indirect trauma to the ankle, such as sudden twists and strains, produces most commonly the classical or the modified Potts' fracture. Or the strain may result simply in a tearing of one or more tarsal ligaments.

A rather unusual result of indirect trauma to the ankle is a fracture or fracture-dislocation of the tarsal scaphoid, This bone is well protected against direct trauma, sitting in a niche formed by the astragalus, cuboid and cuneiform bones. Six strong ligaments (four dorsal and two plantar) hold it in place. From its peculiar position as part of a row of closely

connected cuboidal bones whose articulations permit of a certain amount of flexion and extension, it is readily conceivable that indirect trauma or strain may spend itself upon the scaphoid bone, if the limits of the movements of its articulations are overstepped.

If we imagine a row of wooden blocks placed side by side and firmly connected by strips of adhesive plaster, the tarsal articulations will be roughly represented. This row of blocks can be flexed and extended within certain limits, but if we

91. Hell, C. XXIV, lines 89-93, Cary. 92. Hell, XXXIII, Cary.

forcibly bend the row of blocks, either the adhesive strips must break or one or more of the blocks will be crushed and sprung out of position. This is the mechanism of the production of fracture-dislocation of the tarsal scaphoid.

The patient in falling or jumping lands on the tip, ball or dorsum of his toes, resulting in either forcible dorsal extension or plantar flexion of his foot. If extreme plantar flexion occurs, the dorsal ligaments holding the scaphoid bone in place are torn and the scaphoid pops out of position with or without being fractured. The dislocation is dorsal and medium. Nippold2 has compared this dislocation to the method of popping the seed out of a cherry by squeezing it between the fingers.

Fracture of the Tarsal Scaphoid.

If the strain is in the opposite direction, namely, dorsal extension, the bone is tightly squeezed in its compartment. It may pop out, as in the above instance, but it is more likely to be crushed in situ, a "Compressions-Fractur" resulting. One of the small fragments may then be displaced dorsally, producing a fracture-dislocation.

Forty-two cases of fracture of the tarsal scaphoid have been collected by Nippold from the literature. Of the cases in which the etiology of the fracture could be ascertained, 80 per cent. were produced by falls upon the toes, with forcible dorsal extension or plantar flexion; 20 per cent. resulted from direct trauma, as by the passing of a wheel over the foot.

The diagnosis of injury to the tarsal scaphoid may be made with a reasonable degree of certainty when the fracture is accompanied by a dorsal dislocation, either of the entire bone or of one of the fragments. But where the displacement is slight or absent, a positive diagnosis becomes possible only by means of an X-ray examination. The ankle-joint, because of the complex arrangement of its bones, is one of the most difficult parts of the skeleton to examine by means of the X-ray. No less than three views at varying angles must be taken in order to overcome the superimposition of the bones. Very important to remember is the fact that accessory bones are not infrequent in connection with the tarsals. Thus, a small bone, the os intermedium, is frequently found just plantar to the cuboid, while a small accessory bone lying behind the astragalus has given rise to the erroneous term, "Shepard's fracture."

A correct diagnosis of fracture of the scaphoid is imperative from a prognostic point of view. Such fractures, if untreated, may permanently impair the integrity of the ankle. There is a tendency toward dropping of the arch in these fractures, and if this tendency is uncorrected, and the weight of the body placed upon the injured ankle too soon, a progressive traumatic flat-foot may follow. Furthermore, the ankle, because of the great weight it bears, is especially susceptible to chronic hyperplastic changes, which only too often follow such badly healed fractures. Bony outgrowths and spurs may appear upon the bones, with ossification and stiffening of the ligaments and tendons, giving a picture resembling hypertrophic os eo-arthritis. Among the cases collected by Nippold was one of a supposed malingerer, who was trying to avoid German military service. An X-ray picture showed an old fracture of the scaphoid with hypertrophic changes which had stiffened the ankle joint.

The accompanying sketch was taken from a case at the Cincinnati Hospital. The patient presented himself because of a stiff and swollen ankle, supposedly syphilitic, as there were other evidences of syphilis about the patient. The skiagram showed an old fracture of the scaphoid, the dislocated fragment unreduced. The entire ankle was involved in a chronic hyperplastic process.

2 Arch. für Phys. Med., Band 3, Heft 1.