Calcareous degeneration is seen in the ovary, and Peterman speaks of a stone in the ovary. Uterine calculi are described by Cuevas and Harlow; the latter mentions that the calculus he saw was egg-shaped. There is an old chronicle of a stone taken from the womb of a woman near Trent, Somersetshire, at Easter, 1666, that weighed four ounces. The Ephemerides speaks of a calculus coming away with the menstrual fluid.

Stones in the heart are mentioned by medical writers, and it is said that two stones as large as almonds were found in the heart of the Earl of Balcarres.

Morand speaks of a calculus ejected from the mouth by a woman.

An old record says that stones in the brain sometimes are the cause of convulsions. D'Hericourt reports the case of a girl who died after six months' suffering, whose pineal gland was found petrified, and the incredible size of a chicken's egg. Blasius, Diemerbroeck, and the Ephemerides, speak of stones in the location of the pineal gland.

Salivary calculi are well known; they may lodge in any of the buccal ducts. There is a record of the case of a man of thirty-seven who suffered great pain and profuse salivation. It was found that he had a stone as large as a pigeon's egg under his tongue.

Umbilical calculi are sometimes seen, and Deani reports such a case. There is a French record of a case of exstrophy of the umbilicus, attended with abnormal concretions.

Aetius, Marcellus Donatus, Scaliger, and Schenck mention calculi of the eyelids.

There are some extraordinary cases of retention and suppression of urine on record. Actual retention of urine, that is, urinary secretion passed into the bladder, but retention in the latter viscus by inanition, stricture, or other obstruction, naturally cannot continue any great length of time without mechanically rupturing the vesical walls; but suppression of urine or absolute anuria may last an astonishingly extended period. Of the cases of retention of urine, Fereol mentions that of a man of forty-nine who suffered absolute retention of urine for eight days, caused by the obstruction of a uric acid calculus. Cunyghame reports a ease of mechanic obstruction of the flow of urine for eleven days. Trapenard speaks of retention of urine for seven days. Among the older writers Bartholinus mentions ischuria lasting fourteen days; Cornarius, fourteen days; Rhoclius, fifteen days; the Ephemerides, ten, eleven, and twelve days. Croom notes a case of retention of urine from laceration of the vagina during first coitus. Foucard reports a case of retention of urine in a young girl of nineteen, due to accumulation of the menstrual fluid behind an imperforate hymen.

The accumulation of urine in cases of ischuria is sometimes quite excessive. De Vilde speaks of 16 pints being drawn off. Mazoni cites a case in which 15 pounds of urine were retained; and Wilson mentions 16 pounds of urine being drawn off. Frank reports instances in which both 12 and 30 pounds of urine were evacuated. There is a record at the beginning of this century in which it is stated that 31 pounds of urine were evacuated in a case of ischuria.

Following some toxic or thermic disturbance, or in diseased kidneys, suppression of urine is quite frequently noticed. The older writers report some remarkable instances: Haller mentions a case lasting twenty-two weeks; Domonceau, six months; and Marcellus Donatus, six months.

Whitelaw describes a boy of eight who, after an attack of scarlet fever, did not pass a single drop of urine from December 7th to December 20th when two ounces issued, after vesication over the kidneys. On January 2d two ounces more were evacuated, and no more was passed until the bowel acted regularly. On January 5th a whole pint of urine passed; after that the kidneys acted normally and the boy recovered. It would be no exaggeration to state that this case lasted from December 5th to January 5th, for the evacuations during this period were so slight as to be hardly worthy of mention.

Lemery reports observation of a monk who during eight years vomited periodically instead of urinating in a natural way. Five hours before vomiting he experienced a strong pain in the kidneys. The vomitus was of dark-red color, and had the odor of urine. He ate little, but drank wine copiously, and stated that the vomiting was salutary to him, as he suffered more when he missed it.

Bryce records a case of anuria of seventeen days' standing. Butler speaks of an individual with a single kidney who suffered suppression of urine for thirteen days, caused by occlusion of the ureter by an inspissated thrombus. Dubuc observed a case of anuria which continued for seventeen days before the fatal issue. Fontaine reports a case of suppression of urine for twenty-five days. Nunneley showed the kidneys of a woman who did not secrete any urine for a period of twelve days, and during this time she had not exhibited any of the usual symptoms of uremia. Peebles mentions a case of suspension of the functions of the kidneys more than once for five weeks, the patient exhibiting neither coma, stupor, nor vomiting. Oke speaks of total suppression of urine during seven days, with complete recovery; and Paxon mentions a case in a child that recovered after five days' suppression. Russell reports a case of complete obstructive suppression for twenty days followed by complete recovery. Scott and Shroff mention recovery after nine days' suppression.

The most persistent constipation may exist for weeks, or even months, with fair health. The fact seemed to be a subject of much interest to the older writers. De Cabalis mentions constipation lasting thirty-seven days; Caldani, sixty-five days; Lecheverel, thirty-four days; and Pomma, eight months; Sylvaticus, thirty months; Baillie, fifteen weeks; Blanchard, six weeks; Smetius, five mouths; Trioen, three months; Devilliers, two years; and Gignony, seven years. Riverius mentions death following constipation of one month, and says that the intestines were completely filled. Moosman mentions death from the same cause in sixty days. Frank speaks of constipation from intestinal obstructions lasting for three weeks, and Manget mentions a similar case lasting three months.

Early in the century Revolat reported in Marseilles an observation of an eminently nervous subject addicted to frequent abuse as regards diet, who had not had the slightest evacuation from the bowel for six months. A cure was effected in this case by tonics, temperance, regulation of the diet, etc. In Tome xv of the Commentaries of Leipzig there is an account of a man who always had his stercoral evacuations on Wednesdays, and who suffered no evil consequences from this abnormality. This state of affairs had existed from childhood, and, as the evacuations were abundant and connected, no morbific change or malformation seemed present. The other excretions were slightly in excess of the ordinary amount. There are many cases of constipation on record lasting longer than this, but none with the same periodicity and without change in the excrement. Tommassini records the history of a man of thirty, living an ordinary life, who became each year more constipated. Between the ages of twenty and twenty-four the evacuations were gradually reduced to one in eight or ten days, and at the age of twenty-six, to one every twenty-two days. His leanness increased in proportion to his constipation, and at thirty his appetite was so good that he ate as much as two men. His thirst was intense, but he secreted urine natural in quantity and quality. Nothing seemed to benefit him, and purgatives only augmented his trouble. His feces came in small, hard balls. His tongue was always in good condition, the abdomen not enlarged, the pulse and temperature normal.

Emily Plumley was born on June 11,1850, with an imperforate anus, and lived one hundred and two days without an evacuation. During the whole period there was little nausea and occasional regurgitation of the mother's milk, due to over-feeding. Cripps mentions a man of forty-two with stricture of the rectum, who suffered complete intestinal obstruction for two months, during which time he vomited only once or twice. His appetite was good, but he avoided solid food. He recovered after the performance of proctotomy.

Fleck reports the case of a Dutchman who, during the last two years, by some peculiar innervation of the intestine, had only five or six bowel movements a year. In the intervals the patient passed small quantities of hard feces once in eight or ten days, but the amount was so small that they constituted no more than the feces of one meal. Two or three days before the principal evacuation began the patient became ill and felt uncomfortable in the back; after sharp attacks of colic he would pass hard and large quantities of offensive feces. He would then feel better for two or three hours, when there would be a repetition of the symptoms, and so on until he had four or five motions that day. The following day he would have a slight diarrhea and then the bowels would return to the former condition. The principal fecal accumulations were in the ascending and transverse colon and not only could be felt but seen through the abdominal wall. The patient was well nourished and had tried every remedy without success. Finally he went to Marienbad where he drank freely of the waters and took the baths until the bowel movements occurred once in two or three days.

There is a record of a man who stated that for two years he had not passed his stool by the anus, but that at six o'clock each evening he voided feces by the mouth. His statement was corroborated by observation. At times the evacuation took place without effort, but was occasionally attended with slight pain in the esophagus and slight convulsions. Several hours before the evacuation the abdomen was hard and distended, which appearance vanished in the evening. In this case there was a history of an injury in the upper iliac region.

The first accurate ideas in reference to elephantiasis arabum are given by Rhazes, Haly-Abas, and Avicenna, and it is possibly on this account that the disease received the name elephantiasis arabum. The disease was afterward noticed by Forestus, Mercurialis, Kaempfer, Ludoff, and others. In 1719 Prosper Alpinus wrote of it in Egypt, and the medical officers of the French army that invaded Egypt became familiar with it; since then the disease has been well known.

Alard relates as a case of elephantiasis that of a lady of Berlin, mentioned in the Ephemerides of 1694, who had an abdominal tumor the lower part of which reached to the knees. In this case the tumor was situated in the skin and no vestige of disease was found in the abdominal cavity and no sensible alteration had taken place in the veins. Delpech quotes a similar case of elephantiasis in the walls of the abdomen in a young woman of twenty-four, born at Toulouse.

Lymphedema, or elephantiasis arabum, is a condition in which, in the substance of a limb or a part, there is diffused dilatation of the lymphatics, with lymphostasis. Such a condition results when there is obstruction of so large a number of the ducts converging to the root of the extremity or part that but little relief through collateral trunks is possible. The affected part becomes swollen and hardened, and sometimes attains an enormous size. It is neither reducible by position nor pressure. There is a corresponding dilatation and multiplication of the blood-vessels with the connective-tissue hypertrophy. The muscles waste, the skin becomes coarse and hypertrophied. The swollen limb presents immense lobulated masses, heaped up at different parts, separated from one another by deep sulci, which are especially marked at the flexures of the joints. Although elephantiasis is met with in all climates, it is more common in the tropics, and its occurrence has been repeatedly demonstrated in these localities to be dependent on the presence in the lymphatics of the filaria sanguinis hominis. The accompanying illustration shows the condition of the limb of a girl of twenty-one, the subject of lymphedema, five years after the inception of the disease. The changes in the limb were as yet moderate. The photograph from which the cut was made was taken in 1875 At the present time (seventeen years later) the case presents the typical condition of the worst form of elephantiasis. Repeated attacks of lymphangitis have occurred during this period, each producing an aggravation of the previous condition. The leg below the knee has become enormously deformed by the production of the elephantoid masses; the outer side of the thigh remains healthy, but the skin of the inner side has developed so as to form a very large and pendant lobulated mass. A similar condition has begun to develop in the other leg, which is row about in the condition of the first, as shown in the figure. Figure 273 represents this disease in its most aggravated form, a condition rarely observed in this country. As an example of the change in the weight of a person after the inception of this disease, we cite a case reported by Griffiths. The patient was a woman of fifty-two who, five years previous, weighed 148 pounds. The elephantoid change was below the waist, yet at the time of report the woman weighed 387 pounds. There was little thickening of the skin. The circumference of the calf was 28 inches; of the thigh, 38 inches; and of the abdomen, 80 inches; while that of the arm was only 15 inches.

The condition commonly known as "Barbadoes leg" is a form of elephantiasis deriving its name from its relative frequency in Barbadoes.

Figure 275 represents a well-known exhibitionist who, from all appearances, is suffering from an elephantoid hypertrophy of the lower extremities, due to a lymphedema. Quite a number of similar exhibitionists have been shown in recent years, the most celebrated of whom was Falmy Mills, one of whose feet alone was extensively involved, and was perhaps the largest foot ever seen.

Elephantiasis seldom attacks the upper extremities. Of the older cases Rayer reports four collected by Alard. In one case the hard and permanent swelling of the arm occurred after the application of a blister; in another the arm increased so that it weighed more than 200 Genoese pounds, 40 of which consisted of serum. The swellings of the arm and forearm resembled a distended bladder. The arteries, veins, and nerves had not undergone any alteration, but the lymphatics were very much dilated and loaded with lymph.

The third case was from Fabricius Hildanus, and the fourth from Hendy. Figure 276 represents a remarkable elephantoid change in the hand of an elderly German woman. Unfortunately there is no medical description of the case on record, but the photograph is deemed worthy of reproduction.

Terry describes a French mulatto girl of eleven whose left hand was enormously increased in weight and consistency, the chief enlargement being in the middle finger, which was 6 1/2 inches long, and 5 1/2 inches about the nail, and 8 1/2 around the base of the finger. The index finger was two inches thick and four inches long, twisted and drawn, while the other fingers were dwarfed. The elephantiasis in this case slowly and gradually increased in size until the hand weighed 3 1/2 pounds. The skin of the affected finger, contrary to the general appearance of a part affected with elephantiasis, was of normal color, smooth, shiny, showed no sensibility, and the muscles had undergone fatty degeneration. It was successfully amputated in August, 1894. The accompanying illustration shows a dorsal view of the affected hand.

Magalhaes of Rio Janeiro reports a very interesting case of elephantiasis of the scalp, representing dermatolysis, in which the fold of hypertrophied skin fell over the face like the hide of an elephant, somewhat similar in appearance to the "elephant-man." Figure 279 represents a somewhat similar hypertrophic condition of the scalp and face reported in the Photographic Review of Medicine and Surgery, 1870.

Elephantiasis of the face sometimes only attacks it on one side. Such a case was reported by Alard, in which the elephantiasis seems to have been complicated with eczema of the ear. Willier, also quoted by Alard, describes a remarkable case of elephantiasis of the face. After a debauch this patient experienced violent pain in the left cheek below the zygomatic arch; this soon extended under the chin, and the submaxillary glands enlarged and became painful; the face swelled and became erythematous, and the patient experienced nausea and slight chills. At the end of six months there was another attack, after which the patient perceived that the face continued puffed. This attack was followed by several others, the face growing larger and larger. In similar cases tumefaction assumes enormous proportions, and Schenck speaks of a man whose head exceeded that of an ox in size, the lower part of the face being entirely covered with the nose, which had to be raised to enable its unhappy owner to breathe.

Rayer cites two instances in which elephantiasis of the breast enlarged these organs to such a degree that they hung to the knees. Salmuth speaks of a woman whose breasts increased to such a size that they hung down to her knees. At the same time she had in both axillae glandular tumors as large as the head of a fetus. Borellus also quotes the case of a woman whose breasts became so large that it was necessary to support them by straps, which passed over the shoulders and neck.

Elephantiasis is occasionally seen in the genital regions of the female, but more often in the scrotum of the male, in which location it produces enormous tumors, which sometimes reach to the ground and become so heavy as to prevent locomotion. This condition is curious in the fact that these immense tumors have been successfully removed, the testicles and penis, which had long since ceased to be distinguished, saved, and their function restored. Alibert mentions a patient who was operated upon by Clot-Bey, whose scrotum when removed weighed 110 pounds; the man had two children after the disease had continued for thirteen years, but before it had obtained its monstrous development—a proof that the functions of the testicles had not been affected by the disease.

There are several old accounts of scrotal tumors which have evidently been elephantoid in conformation. In the Ephemerides in 1692 there was mentioned a tumor of the scrotum weighing 200 pounds. In the West Indies it was reported that rats have been known to feed on these enormous tumors, while the deserted subjects lay in a most helpless condition. Larrey mentioned a case of elephantiasis of the scrotum in which the tumor weighed over 200 pounds. Sir Astley Cooper removed a tumor of 56 pounds weight from a Chinese laborer. It extended from beneath the umbilicus to the anterior border of the anus; it had begun in the prepuce ten years previously. Clot-Bey removed an elephantoid tumor of the scrotum weighing 80 pounds, performing castration at the same time. Alleyne reports a case of elephantiasis, in which he successfully removed a tumor of the integuments of the scrotum and penis weighing 134 pounds.

Bicet mentions a curious instance of elephantiasis of the penis and scrotum which had existed for five years. The subject was in great mental misery and alarm at his unsightly condition. The parts of generation were completely buried in the huge mass. An operation was performed in which all of the diseased structures that had totally unmanned him were removed, the true organs of generation escaping inviolate. Thebaud mentions a tumor of the scrotum, the result of elephantiasis, which weighed 63 1/2 pounds. The weight was ascertained by placing the tumor on the scales, and directing the patient to squat over them without resting any weight of the body on the scales. This man could readily feel his penis, although his surgeons could not do so. The bladder was under perfect control, the urine flowing over a channel on the exterior of the scrotum, extending 18 inches from the meatus. Despite his infirmity this patient had perfect sexual desire, and occasional erections and emissions. A very interesting operation was performed with a good recovery.

Partridge reports an enormous scrotal tumor which was removed from a Hindoo of fifty-five, with subsequent recovery of the subject. The tumor weighed 111 1/2 pounds. The ingenious technic of this operation is well worth perusal by those interested. Goodman successfully removed an elephantiasis of the scrotum from a native Fiji of forty-five. The tumor weighed 42 pounds, without taking into consideration the weight of the fluid which escaped in abundance during the operation and also after the operation, but before it was weighed. Van Buren and Keyes mention a tumor of the scrotum of this nature weighing 165 pounds. Quoted by Russell, Hendy describes the case of a negro who had successive attacks of glandular swelling of the scrotum, until finally the scrotum was two feet long and six feet in circumference. It is mentioned that mortification of the part caused this patient's ultimate death.

Figure 281 is taken from a photograph loaned to the authors by Dr. James Thorington. The patient was a native of Fiji, and was successfully operated on, with preservation of the testes. The tumor, on removal, weighed 120 pounds.

W. R. Browne, Surgeon-General, reports from the Madras General Hospital an operation on a patient of thirty-five with elephantoid scrotum of six years' duration. The proportions of the scrotum were as follows: Horizontally the circumference was six feet 6 1/2 inches, and vertically the circumference was six feet ten inches. The penis was wholly hidden, and the urine passed from an opening two feet 5 1/2 inches from the pubis. The man had complete control of his bladder, but was unable to walk. The operation for removal occupied one hour and twenty minutes, and the tumor removed weighed 124 3/4 pounds. Little blood was lost on account of an elastic cord tied about the neck of the tumor, and secured by successful removal of a scrotal tumor weighing 56 pounds.

Fenger describes a case of the foregoing nature in a German of twenty-three, a resident of Chicago. The growth had commenced eight years previously, and had progressively increased. There was no pain or active inflammation, and although the patient had to have especially constructed trousers he never ceased his occupation as a driver. The scrotum was represented by a hairless tumor weighing 22 pounds, and hanging one inch below the knees. No testicles or penis could be made out. Fenger removed the tumor, and the man was greatly improved in health. There was still swelling of the inguinal glands on both sides, but otherwise the operation was very successful. The man's mental condition also greatly improved. Fenger also calls especial attention to the importance of preserving the penis and testes in the operation, as although these parts may apparently be obliterated their functions are undisturbed.

The statistics of this major operation show a surprisingly small mortality. Fayrer operated on 28 patients with 22 recoveries and six deaths, one from shock and five from pyemia The same surgeon collected 193 cases, and found the general mortality to be 18 per cent. According to Ashhurst, Turner, who practiced as a medical missionary in the Samoan Islands, claims to have operated 136 times with only two deaths. McLeod, Fayrer's successor in India, reported 129 cases with 23 deaths.

Early in this century Rayer described a case of elephantiasis in a boy of seventeen who, after several attacks of erysipelas, showed marked diminution of the elephantoid change; the fact shows the antagonism of the streptococcus erysipelatis to hypertrophic and malignant processes.

Acromegaly is a term introduced by Marie, and signifies large extremities. It is characterized by an abnormally large development of the extremities and of the features of the face,—the bony as well as the soft parts. In a well-marked case the hands and feet are greatly enlarged, but not otherwise deformed, and the normal functions are not disturbed. The hypertrophy involves all the tissues, giving a curious spade-like appearance to the hands. The feet are similarly enlarged, although the big toe may be relatively much larger. The nails also become broad and large. The face increases in volume and becomes elongated, in consequence of the hypertrophy of the superior and inferior maxillary bones. The latter often projects beyond the upper teeth. The teeth become separated, and the soft parts increase in size. The nose is large and broad, and the skin of the eyelids and ears is enormously hypertrophied. The tongue is greatly hypertrophied. The disease is of long duration, and late in the history the bones of the spine and thorax may acquire great deformity. As we know little of the influences and sources governing nutrition, the pathology and etiology of acromegaly are obscure. Marie regards the disease as a systemic dystrophy analogous to myxedema, due to a morbid condition of the pituitary body, just as myxedema is due to disease of the thyroid. In several of the cases reported the squint and optic atrophy and the amblyopia have pointed to the pituitary body as the seat of a new growth of hypertrophy. Pershing shows a case of this nature. The enlargement of the face and extremities was characteristic, and the cerebral and ocular symptoms pointed to the pituitary body as the seat of the lesion. Unverricht, Thomas, and Ransom report cases in which the ocular lesions, indicative of pituitary trouble, were quite prominent. Of 22 cases collected by Tamburini 19 showed some change in the pituitary body, and in the remaining three cases either the diagnosis was uncertain or the disease was of very short duration. Linsmayer reported a case in which there was a softened adenoma in the pituitary body, and the thymus was absent.

Hersman reports an interesting case of progressive enlargement of the hands in a clergyman of fifty. Since youth he had suffered with pains in the joints. About three years before the time of report he noticed enlargement of the phalangeal joint of the third finger of the right hand. A short time later the whole hand became gradually involved and the skin assumed a darker hue. Sensation and temperature remained normal in both hands; acromegaly was excluded on account of the absence of similar changes elsewhere. Hersman remarks that the change was probably due to increase in growth of the fibrous elements of the subcutaneous lesions about the tendons, caused by rheumatic poison. Figure 283 shows the palmer and dorsal surfaces of both hands.

Chiromegaly is a term that has been applied by Charcot and Brissaud to the pseudoacromegaly that sometimes occurs in syringomyelia. Most of the cases that have been reported as a combination of these two diseases are now thought to be only a syringomyelia. A recent case is reported by Marie. In this connection it is interesting to notice a case of what might be called acute symptomatic transitory pseudoacromegaly, reported by Potovski: In an insane woman, and without ascertainable cause, there appeared an enlargement of the ankles, wrists, and shoulders, and later of the muscles, with superficial trophic disturbances that gradually disappeared. The author excludes syphilis, tuberculosis, rheumatism, gout, hemophilia, etc., and considers it to have been a trophic affection of cerebral origin. Cases of pneumonia osteoarthropathy simulating acromegaly have been reported by Korn and Murray.

Megalocephaly, or as it was called by Virchow, leontiasis ossea, is due to a hypertrophic process in the bones of the cranium. The cases studied by Virchow were diffuse hyperostoses of the cranium. Starr describes what he supposes to be a case of this disease, and proposes the title megalocephaly as preferable to Virchow's term, because the soft parts are also included in the hypertrophic process. A woman of fifty-two, married but having no children, and of negative family history, six years before the time of report showed the first symptoms of the affection, which began with formication in the finger-tips. This gradually extended to the shoulders, and was attended with some uncertainty of tactile sense and clumsiness of movement, but actual anesthesia had never been demonstrated. This numbness had not invaded the trunk or lower extremities, although there was slight uncertainty in the gait. There had been a slowly progressing enlargement of the head, face, and neck, affecting the bone, skin, and subcutaneous tissues, the first to the greatest degree. The circumference of the neck was 16 inches; the horizontal circumference of the head was 24 inches; from ear to ear, over the vertex, 16 inches; and from the root of the nose to the occipital protuberance, 16 inches. The cervical vertebrae were involved, and the woman had lost five inches in height. It may be mentioned here that Brissaud and Meige noticed the same loss in height, only more pronounced, in a case of gigantism, the loss being more than 15 inches. In Starr's case the tongue was normal and there was no swelling of the thyroid.

Cretinism is an endemic disease among mountainous people who drink largely of lime water, and is characterized by a condition of physical, physiologic, and mental degeneracy and nondevelopment, and possibly goiter. The subjects of this disease seldom reach five feet in height, and usually not more than four. The word cretin is derived from the Latin creatura. They are found all over the world. In Switzerland it is estimated that in some cantons there is one cretin to every 25 inhabitants. In Styria, the Tyrol, and along the Rhine cretins are quite common, and not long since cases existed in Derbyshire. These creatures have been allowed to marry and generate, and thus extend their species. In "Le Medicin de Campagne," Balzac has given a vivid picture of the awe and respect in which they were held and the way in which they were allowed to propagate. Speaking of the endemic cretins, Beaupre says: "I see a head of unusual form and size, a squat and bloated figure, a stupid look, bleared, hollow, and heavy eyes, thick, projecting eyelids, and a flat nose. His face is of a leaden hue, his skin dirty, flabby, covered with tetters, and his thick tongue hangs down over his moist, livid lips; his mouth, always open and full of saliva, shows teeth going to decay. His chest is narrow, his back curved, his breath asthmatic, his limbs short, misshapen, without power. The knees are thick and inclined inward, the feet flat. The large head droops listlessly on the breast; the abdomen is like a bag." The cretin is generally deaf and dumb, or only able to give a hoarse cry. He is indifferent to heat and cold, and even to the most revolting odors. The general opinion has always been that the sexual desire and genital organs are fully developed.

A quotation under our observation credits Colonel Sykes with the following statistics of cretinism, which show how in some locations it may be a decided factor of population. In December, 1845, in a population of 2,558,349 souls (the locality not mentioned), there were 18,462 people with simple goiter. Of the cretins without goiter there were 2089. Of cretins with goiter there were 3909; and cretins in which goiter was not stated 962, making a total of 6960. Of these 2185 had mere animal instincts; 3531 possessed very small intellectual faculties; 196 were almost without any; 1048 not classified. Of this number 2483 were born of healthy and sane fathers; 2285 from healthy mothers; 961 from goitrous fathers; 1267 from goitrous mothers; 49 from cretin fathers; 41 from cretin mothers; 106 from cretin fathers with goiter; 66 from cretin mothers with goiter; 438 fathers and 405 mothers were not specified.

Sporadic cretinism, or congenital myzedema, is characterized by a congenital absence of the thyroid, diminutiveness of size, thickness of neck, shortness of arms and legs, prominence of the abdomen, large size of the face, thickness of the lips, large and protruding tongue, and imbecility or idiocy. It is popularly believed that coitus during intoxication is the cause of this condition. Osler was able to collect 11 or 12 cases in this country. The diagnosis is all-important, as the treatment by the thyroid extract produces the most noteworthy results. There are several remarkable recoveries on record, but possibly the most wonderful is the case of J. P. West of Bellaire, Ohio, the portraits of which are reproduced in Plate 11. At seventeen months the child presented the typical appearance of a sporadic cretin. The astonishing results of six months' treatment with thyroid extract are shown in the second figure. After a year's treatment the child presents the appearance of a healthy and well-nourished little girl.

Myxedema proper is a constitutional condition due to the loss of the function of the thyroid gland. The disease was first described by Sir William Gull as a cretinoid change, and later by William Ord of London, who suggested the name. It is characterized clinically by a myxedematous condition of the subcutaneous tissues and mental failure, and anatomically by atrophy of the thyroid gland. The symptoms of myxedema, as given by Ord, are marked increase in the general bulk of the body, a firm, inelastic swelling of the skin, which does not pit on pressure; dryness and roughness which tend, with swelling, to obliterate the lines of expression in the face; imperfect nutrition of the hair; local tumefaction of the skin and subcutaneous tissues, particularly in the supraclavicular region. The physiognomy is remarkably altered; the features are coarse and broad, the lips thick, the nostrils broad and thick, and the mouth enlarged. There is a striking slowness of thought and of movement; the memory fails, and conditions leading to incipient dementia intervene. The functions of the thoracic and abdominal organs seem to be normal, and death is generally due to some intercurrent disease, possibly tuberculosis. A condition akin to myxedema occurs after operative removal of the thyroid gland.

In a most interesting lecture Brissaud shows the intimate relation between myxedema, endemic cretinism, sporadic cretinism, or myxedematous idiocy, and infantilism. He considers that they are all dependent upon an inherited or acquired deficiency or disease of the thyroid gland, and he presents cases illustrating each affection. Figure 285 shows a case of myxedema, one of myxedema in a case of arrested development—a transition case between myxedema of the adult and sporadic cretinism—and a typical case of sporadic cretinism.

Cagots are an outcast race or clan of dwarfs in the region of the Pyrenees, and formerly in Brittany, whose existence has been a scientific problem since the sixteenth century, at which period they were known as Cagots, Gahets, Gafets, Agotacs, in France; Agotes or Gafos, in Spain; and Cacous, in Lower Brittany. Cagot meant the dog of a Goth; they were of supposed Gothic origin by some, and of Tartar origin by others. These people were formerly supposed to have been the descendants of lepers, or to have been the victims of leprosy themselves. From the descriptions there is a decided difference between the Cagots and the cretins. In a recent issue of Cosmos a writer describes Cagots as follows:—

"They inhabit the valley of the Ribas in the northwestern part of the Spanish province now called Gerona. They never exceed 51 1/2 inches in height, and have short, ill-formed legs, great bellies, small eyes, flat noses, and pale, unwholesome complexions. They are usually stupid, often to the verge of idiocy, and much subject to goiter and scrofulous affections. The chief town of the Ribas Valley is Ribas, a place of 1500 inhabitants, about 800 feet above sea-level. The mountains rise about the town to a height of from 6000 to 8000 feet, and command an amazingly beautiful panorama of mountain, plain, and river, with Spanish cities visible upon the one side and French upon the other. The region is rich, both agriculturally and minerally, and is famous for its medicinal springs. In this paradise dwell the dwarfs, perhaps as degraded a race of men and women as may be found in any civilized community. They are almost without education, and inhabit wretched huts when they have any shelter. The most intelligent are employed as shepherds, and in summer they live for months at an elevation of more than 6000 feet without shelter. Here they see no human creature save some of their own kind, often idiots, who are sent up every fifteen or twenty days with a supply of food.

"It is said that formal marriage is almost unknown among them. The women in some instances are employed in the village of Ribas as nurses for children, and as such are found tender and faithful. Before communication throughout the region was as easy as it is now, it was thought lucky to have one of these dwarfs in a family, and the dwarfs were hired out and even sold to be used in beggary in neighboring cities. There are somewhat similar dwarfs in other valleys of the Pyrenees, but the number is decreasing, and those of the Ribas Valley are reduced to a few individuals."

Hiccough is a symptom due to intermittent, sudden contraction of the diaphragm. Obstinate cases are most peculiar, and sometimes exhaust the physician's skill. Symes divides these cases into four groups:—

(1) Inflammatory, seen particularly in inflammatory diseases of the viscera or abdominal membranes, and in severe cases of typhoid fever.

(2) Irritative, as in direct stimulus of the diaphragm in swallowing some very hot substance; local disease of the esophagus near the diaphragm, and in many conditions of gastric and intestinal disorder, more particularly those associated with flatus.

(3) Specific or idiopathic, in which there are no evident causes present; it is sometimes seen in cases of nephritis and diabetes.

(4) Neurotic, in which the primary cause is in the nervous system,—hysteria, epilepsy, shock, or cerebral tumors.

The obstinacy of continued hiccough has long been discussed. Osler calls to mind that in Plato's "Symposium" the physician, Eryximachus, recommended to Aristophanes, who had hiccough from eating too much, either to hold his breath or to gargle with a little water; but if it still continued, "tickle your nose with something and sneeze, and if you sneeze once or twice even the most violent hiccough is sure to go." The attack must have been a severe one, as it is stated subsequently that the hiccough did not disappear until Aristophanes had excited the sneezing.

Among the older medical writers Weber speaks of singultus lasting for five days; Tulpius, for twelve days; Eller and Schenck, for three months; Taranget, for eight months; and Bartholinus, for four years.

At the present day it is not uncommon to read in the newspapers accounts of prolonged hiccoughing. These cases are not mythical, and are paralleled by a number of instances in reliable medical literature. The cause is not always discernible, and cases sometimes resist all treatment.

Holston reports a case of chronic singultus of seven years' standing. It had followed an attack of whooping-cough, and was finally cured apparently by the administration of strychnin. Cowan speaks of a shoemaker of twenty-two who experienced an attack of constant singultus for a week, and then intermittent attacks for six years. Cowan also mentions instances of prolonged hiccough related by Heberden, Good, Hoffman, and Wartmouth. Barrett is accredited with reporting a case of persistent hiccough in a man of thirty-five. Rowland speaks of a man of thirty-five who hiccoughed for twelve years. The paroxysms were almost constant, and occurred once or twice a minute during the hours when the man was not sleeping. There was no noise with the cough. There is another case related in the same journal of a man who died on the fourth day of an attack of singultus, probably due to abscess of the diaphragm, which no remedy would relieve. Moore records a case of a child, injured when young, who hiccoughed until about twenty years of age (the age at the time of report). Foot mentions a lad of fifteen who, except when asleep, hiccoughed incessantly for twenty-two weeks, and who suffered two similar, but less severe, attacks in the summer of 1879, and again in 1880. The disease was supposed to be due to the habit of pressing the chest against the desk when at school. Dexter reports a case of long-continued singultus in an Irish girl of eighteen, ascribed to habitual masturbation. There was no intermission in the paroxysm, which increased in force until general convulsions ensued. The patient said that the paroxysm could be stopped by firm pressure on the upper part of the external genital organs. Dexter applied firm pressure on her clitoris, and the convulsions subsided, and the patient fell asleep. They could be excited by firm pressure on the lower vertebrae. Corson speaks of a man of fifty-seven who, after exposure to cold, suffered exhausting hiccough for nine days; and also records the case of an Irish servant who suffered hiccough for four months; the cause was ascribed to fright. Stevenson cites a fatal instance of hiccough in a stone-mason of forty-four who suffered continuously from May 14th to May 28th. The only remedy that seemed to have any effect in this case was castor-oil in strong purgative doses.

Willard speaks of a man of thirty-four who began to hiccough after an attack of pneumonia, and continued for eighty-six hours. The treatment consisted of the application of belladonna and cantharides plasters, bismuth, and lime-water, camphor, and salts of white hellebore inhaled through the nose in finest powder. Two other cases are mentioned by the same author. Gapper describes the case of a young man who was seized with loud and distressing hiccough that never ceased for a minute during eighty hours. Two ounces of laudanum were administered in the three days without any decided effect, producing only slight languor.

Ranney reports the case of an unmarried woman of forty-four who suffered from paroxysms of hiccough that persisted for four years. A peculiarity of this attack was that it invariably followed movements of the upper extremities. Tenderness and hyperesthesia over the spinous processes of the 4th, 5th, and 6th cervical vertebrae led to the application of the thermocautery, which, in conjunction with the administration of ergot and bromide, was attended with marked benefit, though not by complete cure. Barlow mentions a man with a rheumatic affection of the shoulder who hiccoughed when he moved his joints. Barlow also recites a case of hiccough which was caused by pressure on the cicatrix of a wound in the left hand.

Beilby reports a peculiar case in a girl of seventeen who suffered an anomalous affection of the respiratory muscle, producing a sound like a cough, but shriller, almost resembling a howl. It was repeated every five or six seconds during the whole of the waking moments, and subsided during sleep. Under rest and free purgation the patient recovered, but the paroxysms continued during prolonged intervals, and in the last six years they only lasted from twenty-four to forty-eight hours.

Parker reports four rebellious cases of singultus successfully treated by dry cups applied to the abdomen. In each case it was necessary to repeat the operation after two hours, but recovery was then rapid. Tatevosoff reports a brilliant cure in a patient with chronic chest trouble, by the use of common snuff, enough being given several times to induce lively sneezing. Griswold records a successful treatment of one case in a man of fifty, occurring after a debauch, by the administration of glonoin, 1/150 of a grain every three hours. Heidenhain records a very severe and prolonged case caused, as shown later at the operation and postmortem examination, by carcinoma of the pancreas. The spasms were greatly relieved by cocain administered by the mouth, as much as 15 grains being given in twelve hours. Laborde and Lepine report the case of a young girl who was relieved of an obstinate case of hiccough lasting four days by traction on her tongue. After the tongue had been held out of the mouth for a few minutes the hiccoughs ceased. Laborde referred to two cases of a similar character reported by Viand.

Anomalous Sneezing.—In the olden times sneezing was considered a good omen, and was regarded as a sacred sign by nearly all of the ancient peoples. This feeling of reverence was already ancient in the days of Homer. Aristotle inquired into the nature and origin of the superstition, somewhat profanely wondering why sneezing had been deified rather than coughing. The Greeks traced the origin of the sacred regard for sneezing to the days of Prometheus, who blessed his man of clay when he sneezed. According to Seguin the rabbinical account says that only through Jacob's struggle with the angel did sneezing cease to be an act fatal to man. Not only in Greece and Rome was sneezing revered, but also by races in Asia and Africa, and even by the Mexicans of remote times. Xenophon speaks of the reverence as to sneezing, in the court of the King of Persia. In Mesopotamia and some of the African towns the populace rejoiced when the monarch sneezed. In the present day we frequently hear "God bless you" addressed to persons who have just sneezed, a perpetuation of a custom quite universal in the time of Gregory the Great, in whose time, at a certain season, the air was filled with an unwholesome vapor or malaria which so affected the people that those who sneezed were at once stricken with death-agonies. In this strait the pontiff is said to have devised a form of prayer to be uttered when the paroxysm was seen to be coming on, and which, it was hoped, would avert the stroke of the death-angel.

There are some curious cases of anomalous sneezing on record, some of which are possibly due to affections akin to our present "hay fever," while others are due to causes beyond our comprehension. The Ephemerides records a paroxysm of continual sneezing lasting thirty days. Bonet, Lancisi, Fabricius Hildanus, and other older observers speak of sneezing to death. Morgagni mentions death from congestion of the vasa cerebri caused by sneezing. The Ephemerides records an instance of prolonged sneezing which was distinctly hereditary.

Ellison makes an inquiry for treatment of a case of sneezing in a white child of ten. The sneezing started without apparent cause and would continue 20 or 30 times, or until the child was exhausted, and then stop for a half or one minute, only to relapse again. Beilby speaks of a boy of thirteen who suffered constant sneezing (from one to six times a minute) for one month. Only during sleep was there any relief. The patient recovered under treatment consisting of active leeching, purgation, and blisters applied behind the ear, together with the application of olive oil to the nostrils.

Lee reports a remarkable case of yawning followed by sneezing in a girl of fifteen who, just before, had a tooth removed without difficulty. Half an hour afterward yawning began and continued for five weeks continuously. There was no pain, no illness, and she seemed amused at her condition. There was no derangement of the sexual or other organs and no account of an hysteric spasm. Potassium bromid and belladonna were administered for a few days with negative results, when the attacks of yawning suddenly turned to sneezing. One paroxysm followed another with scarcely an interval for speech. She was chloroformed once and the sneezing ceased, but was more violent on recovery therefrom. Ammonium bromid in half-drachm doses, with rest in bed for psychologic reasons, checked the sneezing. Woakes presented a paper on what he designated "ear-sneezing," due to the caking of cerumen in one ear. Irritation of the auricular branch of the vagus was produced, whence an impression was propagated to the lungs through the pulmonary branches of the vagus. Yawning was caused through implication of the third division of the 5th nerve, sneezing following from reflex implication of the spinal nerves of respiration, the lungs being full of air at the time of yawning. Woakes also speaks of "ear-giddiness" and offers a new associate symptom—superficial congestion of the hands and forearm.

A case of anomalous sneezing immediately prior to sexual intercourse is mentioned on page 511.

Hemophilia is an hereditary, constitutional fault, characterized by a tendency to uncontrollable bleeding, either spontaneous or from slight wounds. It is sometimes associated with a form of arthritis (Ogler). This hemorrhagic diathesis has been known for many years; and the fact that there were some persons who showed a peculiar tendency to bleed after wounds of a trifling nature is recorded in some of the earliest medical literature. Only recently, however, through the writings of Buel, Otto, Hay, Coates, and others, has the hereditary nature of the malady and its curious mode of transmission through the female line been known. As a rule the mother of a hemophile is not a "bleeder" herself, but is the daughter of one. The daughters of a hemophile, though healthy and free from any tendency themselves, are almost certain to transmit the disposition to the male offspring. The condition generally appears after some slight injury in the first two years of life; but must be distinguished from the hemorrhagic affections of the new-born, which will be discussed later. The social condition of the family does not alter the predisposition; the old Duke of Albany was a "bleeder"; and bleeder families are numerous, healthy looking, and have fine, soft skins.

The duration of this tendency, and its perpetuation in a family, is remarkable. The Appleton-Swain family of Reading, Mass., has shown examples for two centuries. Osler has been advised of instances already occurring in the seventh generation. Kolster has investigated hemophilia in women, and reports a case of bleeding in the daughter of a hemophilic woman. He also analyzes 50 genealogic trees of hemophilic families, and remarks that Nasse's law of transmission does not hold true. In 14 cases the transmission was direct from the father to the child, and in 11 cases it was direct from the mother to the infant.

The hemorrhagic symptoms of bleeders may be divided into external bleedings, either spontaneous or traumatic; interstitial bleedings, petechiae, and ecchymoses; and the joint-affections. The external bleedings are seldom spontaneous, and generally follow cuts, bruises, scratches, and often result seriously. A minor operation on a hemophile may end in death; so slight an operation as drawing a tooth has been followed by the most disastrous consequences.

Armstrong, Blagden, and Roberts, have seen fatal hemorrhage after the extraction of teeth. MacCormac observed five bleeders at St. Thomas Hospital, London, and remarks that one of these persons bled twelve days after a tooth-extraction. Buchanan and Clay cite similar instances. Cousins mentions an individual of hemorrhagic diathesis who succumbed to extensive extravasation of blood at the base of the brain, following a slight fall during an epileptic convulsion. Dunlape reports a case of hemorrhagic diathesis, following suppression of the catamenia, attended by vicarious hemorrhage from the gums, which terminated fatally. Erichsenf cites an instance of extravasation of blood into the calf of the leg of an individual of hemophilic tendencies. A cavity was opened, which extended from above the knee to the heel; the clots were removed, and cautery applied to check the bleeding. There was extension of the blood-cavity to the thigh, with edema and incipient gangrene, necessitating amputation of the thigh, with a fatal termination.

Mackenzie reports an instance of hemophilic purpura of the retina, followed by death. Harkin gives an account of vicarious bleeding from the under lip in a woman of thirty-eight. The hemorrhage occurred at every meal and lasted ten minutes. There is no evidence that the woman was of hemophilic descent.

Of 334 cases of bleeding in hemophilia collected by Grandidier, 169 were from the nose, 43 from the mouth, 15 from the stomach, 36 from the bowels, 16 from the urethra, 17 from the lungs, and a few from the skin of the head, eyelids, scrotum, navel, tongue, finger-tips, vulva, and external ear. Osler remarks that Professor Agnew knew of a case of a bleeder who had always bled from cuts and bruises above the neck, never from those below. The joint-affections closely resemble acute rheumatism. Bleeders do not necessarily die of their early bleedings, some living to old age. Oliver Appleton, the first reported American bleeder, died at an advanced age, owing to hemorrhage from a bed-sore and from the urethra. Fortunately the functions of menstruation and parturition are not seriously interfered with in hemophilia. Menstruation is never so excessive as to be fatal. Grandidier states that of 152 boy subjects 81 died before the termination of the seventh year. Hemophilia is rarely fatal in the first year.

Of the hemorrhagic diseases of the new-born three are worthy of note. In syphilis haemorrhagica neonatorum the child may be born healthy, or just after birth there may appear extensive cutaneous extravasations with bleeding from the mucous surfaces and from the navel; the child may become deeply jaundiced. Postmortem examination shows extensive extravasations into the internal viscera, and also organic syphilitic lesions.

Winckel's disease, or epidemic hemoglobinuria, is a very fatal affection, sometimes epidemic in lying-in institutions; it develops about the fourth day after birth. The principal symptom is hematogenous icterus with cyanosis,—the urine contains blood and blood-coloring matter. Some cases have shown in a marked degree acute fatty degeneration of the internal organs—Buhl's disease.

Apart from the common visceral hemorrhages, the results of injuries at birth, bleeding from one or more of the surfaces is a not uncommon event in the new-born, particularly in hospital-practice. According to Osler Townsend reports 45 cases in 6700 deliveries, the hemorrhage being both general and from the navel alone. Bleeding also occurs from the bowels, stomach, and mouth, generally beginning in the first week, but in rare instances it is delayed to the second or third. Out of 50 cases collected by Townsend 31 died and 19 recovered. The nature of the disease is unknown, and postmortem examination reveals no pathologic changes, although the general and not local nature of the affection, its self-limited character, the presence of fever, and the greater prevalence of the disease in hospitals, suggest an infectious origin (Townsend). Kent a speaks of a new-born infant dying of spontaneous hemorrhage from about the hips.

Infantile scurvy, or Barlow's disease, has lately attracted marked attention, and is interesting for the numerous extravasations and spontaneous hemorrhages which are associated with it. A most interesting collection of specimens taken from the victims of Barlow's disease were shown in London in 1895.

In an article on the successful preventive treatment of tetanus neonatorum, or the "scourge of St. Kilda," of the new-born, Turner says the first mention of trismus nascentium or tetanus neonatorum was made by Rev. Kenneth Macaulay in 1764, after a visit to the island of St. Kilda in 1758. This gentleman states that the infants of this island give up nursing on the fourth or fifth day after birth; on the seventh day their gums are so clinched together that it is impossible to get anything down their throats; soon after this they are seized with convulsive fits and die on the eighth day. So general was this trouble on the island of St. Kilda that the mothers never thought of making any preparation for the coming baby, and it was wrapped in a dirty piece of blanket till the ninth or tenth day, when, if the child survived, the affection of the mother asserted itself. This lax method of caring for the infant, the neglect to dress the cord, and the unsanitary condition of the dwellings, make it extremely probable that the infection was through the umbilical cord. All cases in which treatment was properly carried out by competent nurses have survived. This treatment consisted in dressing the cord with iodoform powder and antiseptic wool, the breast-feeding of the baby from the first, and the administration of one-grain doses of potassium bromid at short intervals. The infant death-rate on the island of St. Kilda has, consequently, been much reduced. The author suggests the use of a new iodin-preparation called loretin for dressing the cord. The powder is free from odor and is nonpoisonous.

Human Parasites.—Worms in the human body are of interest on account of the immense length some species attain, the anomalous symptoms which they cause, or because of their anomalous location and issue. According to modern writers the famous Viennese collection of helminths contains chains of tenia saginata 24 feet long. The older reports, according to which the taenia solium (i.e., generally the taenia saginata) grew to such lengths as 40, 50, 60, and even as much as 800 yards, are generally regarded as erroneous. The observers have apparently taken the total of all the fragments of the worm or worms evacuated at any time and added them, thus obtaining results so colossal that it would be impossible for such an immense mass to be contained in any human intestine.

The name solium has no relation to the Latin solus, or solium. It is quite possible for a number of tapeworms to exist simultaneously in the human body. Palm mentions the fact of four tapeworms existing in one person; and Mongeal has made observations of a number of cases in which several teniae existed simultaneously in the stomach. David speaks of the expulsion of five teniae by the ingestion of a quantity of sweet wine. Cobbold reports the case of four simultaneous tapeworms; and Aguiel describes the case of a man of twenty-four who expelled a mass weighing a kilogram, 34.5 meters long, consisting of several different worms. Garfinkel mentions a case which has been extensively quoted, of a peasant who voided 238 feet of tapeworms, 12 heads being found. Laveran reports a case in which 23 teniae were expelled in the same day. Greenhow mentions the occurrence of two teniae mediocanellata.

The size of a tapeworm in a small child is sometimes quite surprising. Even the new-born have exhibited signs of teniae, and Haussmann has discussed this subject. Armor speaks of a fully-matured tapeworm being expelled from a child five days old. Kennedy reports cases in which tapeworms have been expelled from infants five, and five and one-half months old. Heisberg gives an account of a tapeworm eight feet in length which came from a child of two. Twiggs describes a case in which a tapeworm 36 feet long was expelled from a child of four; and Fabre mentions the expulsion of eight teniae from a child. Occasionally the tapeworm is expelled from the mouth. Such cases are mentioned by Hitch and Martel. White speaks of a tapeworm which was discharged from the stomach after the use of an emetic. Lile mentions the removal of a tapeworm which had been in the bowel twenty-four years.

The peculiar effects of a tapeworm are exaggerated appetite and thirst, nausea, headaches, vertigo, ocular symptoms, cardiac palpitation, and Mursinna has even observed a case of trismus, or lockjaw, due to taenia solium. Fereol speaks of a case of vertigo, accompanied with epileptic convulsions, which was caused by teniae. On the administration of kousso three heads were expelled simultaneously. There is a record of an instance of cardiac pulsation rising to 240 per minute, which ceased upon the expulsion of a large tapeworm. It is quite possible for the presence of a tapeworm to indirectly produce death. Garroway describes a case in which death was apparently imminent from the presence of a tapeworm. Kisel has recorded a fatal case of anemia, in a child of six, dependent on teniae.

The number of ascarides or round-worms in one subject is sometimes enormous. Victor speaks of 129 round-worms being discharged from a child in the short space of five days. Pole mentions the expulsion of 441 lumbricoid worms in thirty-four days, and Fauconneau-Dufresne has reported a most remarkable case in which 5000 ascarides were discharged in less than three years, mostly by vomiting. The patient made an ultimate recovery.

There are many instances in which the lumbricoid worms have pierced the intestinal tract and made their way to other viscera, sometimes leading to an anomalous exit. There are several cases on record in which the lumbricoid worms have been found in the bladder. Pare speaks of a case of this kind during a long illness; and there is mention of a man who voided a worm half a yard long from his bladder after suppression of urine. The Ephemerides contains a curious case in which a stone was formed in the bladder, having for its nucleus a worm. Fontanelle presented to the Royal Academy of Medicine of Paris several yards of tapeworm passed from the urethra of a man of fifty-three. The following is a quotation from the British Medical Journal: "I have at present a patient passing in his urine a worm-like body, not unlike a tapeworm as far as the segments and general appearance are concerned, the length of each segment being about 1/4 inch, the breadth rather less; sometimes 1 1/2 segments are joined together. The worm is serrated on the one side, each segment having 1 1/2 cusps. The urine pale, faintly acid at first, within the last week became almost neutral. There was considerable vesical irritation for the first week, with abundant mucus in the urine, specific gravity was 1010; there were no albumin nor tube-casts nor uric acid in the urinary sediments. Later there were pus-cells and abundant pus. Tenderness existed behind the prostate and along the course of left ureter. Temperature of patient oscillated from 97.5 degrees to 103.2 degrees F. There was no history at any time of recto-vesical fistula. Can anyone suggest the name, etc., of this helminth?"

Other cases of worms in the bladder are mentioned in Chapter XIII

Mitra speaks of the passage of round-worms through the umbilicus of an adult; and there is a case mentioned in which round-worms about seven inches long were voided from the navel of a young child. Borgeois speaks of a lumbricoid worm found in the biliary passages, and another in the air passages.

Turnbull has recorded two cases of perforation of the tympanic membrane from lumbricoides. Dagan speaks of the issue of a lumbricoid from the external auditory meatus. Laughton reports an instance of lumbricoid in the nose. Rake speaks of asphyxia from a round-worm. Morland mentions the ejection of numerous lumbricoid worms from the mouth.

Worms have been found in the heart; and it is quite possible that in cases of trichinosis, specimens of the trichinae may be discovered anywhere in the line of cardiac or lymphatic circulation. Quoted by Fournier, Lapeyronnie has seen worms in the pericardial sac, and also in the ventricle. There is an old record of a person dying of intestinal worms, one of which was found in the left ventricle. Castro and Vidal speak of worms in the aorta. Rake reports a case of sudden death from round-worm; and Brown has noted a similar instance.

The echinococcus is a tiny cestode which is the factor in the production of the well-known hydatid cysts which may be found in any part of the body. Delafield and Prudden report the only instance of multilocular echinococcus seen in this country. Their patient was a German who had been in this country five years. There are only about 100 of these cases on record, most of them being in Bavaria and Switzerland.

The filaria sanguinis hominis is a small worm of the nematode species, the adult form of which lives in the lymphatics, and either the adult or the prematurely discharged ova (Manson) block the lymph-channels, producing the conditions of hematochyluria, elephantiasis, and lymph-scrotum. The Dracunculus medinensis or Guinea-worm is a widely-spread parasite in parts of Africa and the West Indies. According to Osler several cases have occurred in the United States. Jarvis reports a case in a post-chaplain who had lived at Fortress Monroe, Va., for thirty years. Van Harlingen's patient, a man of forty-seven, had never lived out of Philadelphia, so that the worm must be included among the parasites infesting this country.

In February, 1896, Henry of Philadelphia showed microscopic slides containing blood which was infested with numbers of living and active filaria embryos. The blood was taken from a colored woman at the Woman's Hospital, who developed hematochyluria after labor. Henry believed that the woman had contracted the disease during her residence in the Southern States.

Curran gives quite an exhaustive article on the disease called in olden times "eaten of worms,"—a most loathsome malady. Herod the Great, the Emperor Galerius, and Philip II of Spain perished from it. In speaking of the Emperor Galerius, Dean Milman, in his "History of Latin Christianity," says, "a deep and fetid ulcer preyed on the lower parts of his body and ate them away into a mass of living corruption." Gibbon, in his "Decline and Fall," also says that "his (Galerius's) death was caused by a very painful and lingering disorder. His body, swelled by an intemperate course of life to an unwieldy corpulence, was covered with ulcers and devoured by immense swarms of those insects who have given their names to this most loathsome disease." It is also said that the African Vandal King, the Arian Huneric, died of the disease. Antiochus, surnamed the "Madman," was also afflicted with it; and Josephus makes mention of it as afflicting the body of Herod the Great. The so-called "King Pym" died of this "morbus pedicularis," but as prejudice and passion militated against him during his life and after his death, this fact is probably more rumor than verity. A case is spoken of by Curran, which was seen by an army-surgeon in a very aged woman in the remote parts of Ireland, and another in a female in a dissecting-room in Dublin. The tissues were permeated with lice which emerged through rents and fissures in the body.

Instances of the larvae of the estrus or the bot-fly in the skin are not uncommon. In this country Allen removed such larvae from the skin of the neck, head, and arm of a boy of twelve. Bethune, Delavigne, Howship, Jacobs, Jannuzzi and others, report similar cases. These flesh-flies are called creophilae, and the condition they produce is called myiosis. According to Osler, in parts of Central America, the eggs of a bot-fly, called the dermatobia, are not infrequently deposited in the skin, and produce a swelling very like the ordinary boil. Matas has described a case in which the estrus larvae were found in the gluteal region. Finlayson of Glasgow has recently reported an interesting case in a physician who, after protracted constipation and pain in the back and sides, passed large numbers of the larvae of the flower-fly, anthomyia canicularis, and there are other instances of myiosis interna from swallowing the larvae of the common house-fly.

There are forms of nasal disorder caused by larvae, which some native surgeons in India regard as a chronic and malignant ulceration of the mucous membranes of the nose and adjacent sinuses in the debilitated and the scrofulous. Worms lodging in the cribriform plate of the ethmoid feed on the soft tissues of that region. Eventually their ravages destroy the olfactory nerves, with subsequent loss of the sense of smell, and they finally eat away the bridge of the nose. The head of the victim droops, and he complains of crawling of worms in the interior of the nose. The eyelids swell so that the patient cannot see, and a deformity arises which exceeds that produced by syphilis. Lyons says that it is one of the most loathsome diseases that comes under the observation of medical men. He describes the disease as "essentially a scrofulous inflammation of the Schneiderian membrane, ... which finally attacks the bones." Flies deposit their ova in the nasal discharges, and from their infection maggots eventually arise. In Sanskrit peenash signifies disease of the nose, and is the Indian term for the disease caused by the deposition of larvae in the nose. It is supposed to be more common in South America than in India.