adherent layer of blood. There are also submucous and subserous hemorrhages; the spleen and the mesenteric and lumbar glands are enlarged.

Diagnosis. Much depends, at first, on the knowledge of the possibility of infection, especially in the internal forms. With a well-developed malignant pustule, the central eschar and the surrounding veins and vessels on a red infiltrated base are characteristic. Bacilli may be detected in the fluid from the pustule, or in the blood, expectoration, or urine. But it must be remembered that they are not generally to be found in the blood for some days, though exceedingly numerous in the local sore by the second or third day. The diagnosis may be confirmed by inoculation of a rabbit, guineapig, or mouse with the secretions or with blood. The animal dies within two or three days with dyspnoea, dilated pupils, and, perhaps, convulsions; and the blood contains characteristic bacilli.

Prognosis. This is very unfavorable in cases left without treatment. Treatment. In malignant pustule the most certain cure is to excise the infiltrated part completely, and apply caustic, such as zinc chloride, to the exposed surface. The patient often improves at once, and is soon well. Mr. Davies-Colley, who has treated several cases at Guy's Hospital, finding the bacilli, in the earlier stages, more or less confined to the centre of the pustule, thinks it may not be always necessary to use the caustic after excision. Another treatment, which has been successful in a great many cases, has been the injection of carbolic acid into the tumor. A syringeful (20 or 30 minims) of a 2 per cent. solution of carbolic acid in water is injected into each of four points surrounding the central eschar; and the injections are repeated two or three times a day. In this way sixty or seventy injections have been given in five days, with a good result. Energetic local treatment may still be successful even when there is evidence of general infection having begun. Internal anthrax should be treated with quinine and carbolic acid, stimulants, and suitable nourishing food.

FOOT-AND-MOUTH DISEASE.

This disease, sometimes called aphtha epizootica, is common in cattle and sheep, and is occasionally transmitted to man. The typical feature of the disease in cattle is the formation of vesicles and bullæ on the mucous membrane of the mouth, lips and tongue. The affected parts become swollen, and the saliva dribbles away. The vesicles break, leaving a gray layer covering the base. Vesicles also appear on the feet, around the border of the hoofs, and they become pustular and produce crusts. In cows, vesicles form also on the udders and teats. There is a moderate degree of pyrexia. The disease lasts about a fortnight, and generally ends in recovery; except in calves, of which 50 to 75 per cent. die. It is thought that this is

due to the milk drawn from the diseased cow irritating the bowel as well as conveying the virus.

The disease appears to be conveyed to man by direct inoculation, and by drinking milk from an infected cow.

The incubation is from three to five days. Slight pyrexia and loss of appetite first occur, then vesicles are observed in the mouth, on the lips, tongue, fauces and hard palate. They reach the size of peas, become opaque, break, and form shallow ulcers, with a dark-red base. The lips become swollen, and saliva and mucus are more abundant than normal. Mastication, swallowing, and talking are somewhat painful. There may be some diarrhoea and abdominal pain.

Sometimes vesicles form on the fingers, especially about the nails; they become pustular, and run together; and similar vesicles have been described as occurring on the toes, and on the nipples of women. The duration is from ten days to a fortnight, and the disease is rarely fatal.

Treatment.-Solutions of borax may be used to the mouth, and painful ulcers should be touched with solid silver nitrate. Zinc or lead ointments or lotions should be applied to the eruption on the fingers and toes.

ACTINOMYCOSIS.

Actinomycosis is due to the entrance into the body of a vegetable parasite, the Actinomyces or Ray-fungus. The disease has only been recently recognized, though no doubt cases have occurred frequently before, and have been probably mistaken for scrofula or tubercle. In 1877, Israel, of Berlin, described the first cases in man, and in 1878, Ponfick showed the identity of the human cases with a similar affection occurring in cattle. In England, cases have been submitted to the Pathological Society ("Transactions," 1885), and to the Medical and Chirurgical Society ("Transactions," 1886 and 1889).

The actinomyces is a fungus that is visible to the naked eye as a yellow, glistening, spherical, granular mass, mostly about one-fortieth of an inch in diameter, but sometimes as much as one-tenth of an inch; and consisting, under the microscope, of a central mass of closely-woven mycelial threads, from which proceed radially, in every direction, multitudes of threads, some of which divide dichotomously, all finally terminating in club-shaped extremities. Nothing is known as to how the fungus gets into the body, for although it occurs in domestic animals, none of the patients in hitherto recorded cases have had to do with diseased animals, so that it is probable that man and animals get it from some common source, such, for instance, as their vegetable food. It finds an entrance either by the mouth, the respiratory passages, or the intestine; and local lesions occur in different parts

of the body, which consist mainly of inflammatory changes, of more or less intensity, set up around the fungus-granules, so as to form slowly-growing tumors, which ultimately suppurate, break down, and discharge.

Section

in early stages shows: in the centre the radiating structure of the fungus; immediately around it a thick layer of leucocytes, among which some of the club-shaped ends of the threads are embedded; and a layer of fibroid connective tissue, forming the periphery of the tumor. From the continued growth and multiplication of the fungus at one spot-as, for instance, in the liver-large tumors may be formed, three or more inches in diameter, consisting of a kind of cavernous tissue, the trabecule of which are fibroid tissue, while the spaces either correspond to the fungus and leucocytes, as above described, or contain pus, in which the yellow granular masses of fungus lie loose.

Symptoms and Course.-Clinically, in man, the disease has been described as it invades (1) the mouth, (2) the respiratory organs, and (3) the intestinal canal.

1. In the first case, a tumor is generally first noticed under the skin over the lower jaw, or on the edge of the jaw. It is hard, does not affect the skin, is chronic in its course, varies in size from time to time, and tends to migrate gradually from the edge of the jaw down to the neck, leaving, for a time, a narrow band of firm tissue in its track. The tumor may shrink up in part, the inflammatory tissue cicatrizing, but newer portions continue to form, and ultimately the skin becomes involved, obscure fluctuation is felt, and it opens, discharging a thin, sero-purulent, odorless fluid containing the characteristic granules. A sinus is formed which rarely closes, but continues patent with slight discharge.

There is evidence to show that in these cases the fungus has entered by a carious tooth, and this is held to explain the occurrence of the tumors in connection more frequently with the lower than the upper jaw, and with the back part rather than the front part of the lower jaw. In one case the tumor formed in the substance of the lower jaw and expanded the bone.

Invasion by the upper jaw results in tumors of the cheek or temple; and an extension to the base of the skull or the mediastinum by means of the pharynx, is a possibility which makes the implication of the upper jaw more serious than that of the lower.

2. In actinomycosis affecting the lungs, the symptoms may be bronchitic or pneumonic. In a case of the former kind there was a close resemblance to putrid bronchitis, the sputum separating into two layers (not into three, as in fœtid bronchitis), the upper clear, and the lower turbid; the latter contained the ray-fungus. When the lung substance is affected, pneumonia occurs in patches, the patients cough and lose flesh, and the expectoration is either thick, and muco-purulent, containing the typical granules, or it may be viscid, translucent, and rusty, like pneumonic sputa. There is often a

certain resemblance to phthisis, but the posterior and lateral portions of the lungs are involved, not the apices; and the sputum is, of course, free from tubercle-bacilli. If the inflammatory lesions reach the surface they set up pleurisy, or pericarditis. Effusion takes place, or the lung becomes adherent to the chest wall, which then becomes involved, and ultimately soft, diffused, inflammatory swellings appear on the chest, which may soften down, break, and discharge purulent fluid containing the fungus. From the lung, also, the inflammatory track of the fungus may stretch through the diaphragm into the abdomen, or behind the diaphragm to the psoas and iliacus muscles. These processes are commonly very slow, and are accompanied with varying amounts of fever in different cases.

3. In a case of intestinal actinomycosis, the mucous membrane presented on its surface patches of whitish material, covered with yellow and brown granules. The patches were about two-fifths of an inch in diameter and onefifth of an inch thick, and adhered firmly to the membrane. The disease may also cause swellings in the substance of the intestinal wall, from which it may perforate into the peritoneal cavity, or, by means of adhesions, invade the abdominal wall at almost any point. The liver is often secondarily infected in intestinal cases, and then contains large masses or even prominent tumors, having the structure above described.

Treatment.-A successful issue can only be looked for, at present, in the first series of cases; complete extirpation of the growth, or scraping out the resulting abscess or sinus, so as to completely remove all fungus-granules, has cured some cases.

DISEASES OF THE NERVOUS SYSTEM.

Under this heading we have to deal with disorders of the brain, spinal cord, and nerves-disorders which manifest themselves through the functions of motion, sensation, the special senses, and the intellect and emotions. In no other department of medicine is a knowledge of anatomy and physiology more essential than in this. I must assume that the reader is familiar with these subjects. The nervous system not only controls the motion of the external muscles of the body, and becomes the recipient of all external sensations, whether of touch, sight, hearing, taste, or smell, but it also silently and unobtrusively ministers to the requirements of our internal organs, controlling their blood supply, their secretions, the contraction and dilatation of their ducts, and the size of the muscular sacs. The general principle on which these functions are performed is that of the so-called reflex action. By means of fibres contained in nerve-trunks (afferent nerves), certain sensations of change are conveyed to gray matter containing ganglion cells, and from these orders to act are transmitted to the periphery. The sensations of change are-phenomena of touch, sight, smell, hearing, want of oxygen, etc., etc., according as the skin, eyes, nose, ears, or lungs are affected. The orders to act consist of muscular movements, glandular secretions, contraction of arteries, etc. The whole of the nervous system is mapped out in the most complicated manner-a mapping out which we, even yet, only imperfectly know-into areas, each of which has a special connection with particular functions or particular parts of the body. Thus the spinal cord is connected from above downward successively with the muscles of the arms, trunk, and legs, as well as with the viscera contained in the chest, abdomen, and pelvis. And the brain, in a much less simple manner, has some areas, which are respectively connected with the movements of the arm, leg, head, and face; some which are related to sight, hearing, and the other senses; and some, much less definitely localized, which are the seat of the regular operations of the intellect and less orderly Occurrences known as emotions.

Even these higher cerebral functions work in health more or less by means of reflex action-that is to say, probably no change takes place in any nerve cell spontaneously, but it must be started by an impression conveyed from elsewhere along one of its communicating fibres. Thought leads