fected by using 1. c. c. of commercial formaldehyde to every 300 c. c. of air; 2. The effect produced in fifteen minutes seems to be equivalent to that produced in twenty-four hours; 3. An increase in the amount of air to each c. c. of formalin is not counterbalanced by an increase in time of exposure; 4. When disinfection was incomplete the bacteria survive only on being soon removed to favorable culture media; 5. The use of the formalin is not detrimental, as far as observed, in any manner to the books, or objectionable to the operator beyond a temporary irritation of the eyes and nose. There are a number of formaldehyde generators on the market, for use of room disinfection. Robinson's lamp was the first of these inventions. A lamp known as "The Primus" and manufactured at 197 Nassau street, N. Y., is now used by the health departments of most of the large cities.

ANGIONEUROTIC EDEMA OF THE TONGUE.

FRANK K. HALLOCK, M.D.,

CROMWELL.

The tongue is a part of the body rarely subjected to the phenomenon of acute, transient and circumscribed swelling, most commonly called angioneurotic edema, The face, hands and feet are most frequently affected, and while the pharynx, with its adjacent mucous membrane spreading up to the nose and down to the larynx, is often involved, the tongue seems to escape. Elliot (1) reports a case of edema, in a man, forty-nine years old, which appeared first in the feet and later affected other parts of the body, notably the face, lips, tongue and throat. Urticarial lesions were associated with these symptoms. Other writers mention that the tongue is sometimes involved, but so far as I know no well-defined case has been reported except that of R. Lewis, Jr. (2). My own case will, therefore, be of interest, not only as being perhaps the second to be fully recorded, but also because it presented the unique characteristic of an edema limited to one side of the tongue.

Reference is made in medical literature to this peculiar type of swelling as early as 1827, but it was not until 1882 that Quincke (3) and his pupil, Dinkelacker (4), gave a systematic account of the disorder. Since then many cases have been reported, and the following list of synonyms will show how it has been regarded by differ ent authors. It has been described under the heading of an acute circumscribed, acute idiopathic, acute noninflammatory, wandering and transient edema, also periodic swelling and urticaria tuberosa, or giant swelling. The term, angioneurotic edema, seems to have found most favor with the majority of writers.

Among the predisposing causes, heredity, hysteric and neurasthenic conditions are the most important. Cases reported by Falcone (5), Strübing (6), and Osler (7), show clearly the effect of hereditary influence. Collins (8), in an excellent article on this subject in Dercum's textbook of Nervous Diseases, 1895, states that he does not consider hysteria to be a common basic accompaniment of this disorder.

Judging from the descriptions of patients by other observers I am inclined to question this assertion. The eight cases which have come under my own observation have all shown, to a greater or less degree, a hysteroneurasthenic foundation.

A variety of exciting causes has been mentioned, such as cold, gastric irritation, puberty, menstruation, menopause, trauma, fright, toxic influence, etc. The effect of cold is well illustrated by Starr's (9) case, and Börner (10) establishes beyond doubt that angioneurosis is very frequently associated with the menstrual and climacteric periods. Simon (11) cites instances of the effect of local irritation similar to that reported by Haynes (12) and this present case of my own in which substances introduced in the mouth, chemically or otherwise, irritate the lingual and buccal nerve filaments, exciting an angineurotic performance in some other part of the body.

Angioneurotic edema occurs at all ages and rather more frequently in females. The earliest case is that reported by Johnston (13) of an infant three months old which was subject to recurrent attacks of redness and swelling in hands and feet for a period of three months. The child was then free from this until its fifth year, when it was again attacked in the hands and afterward in the feet, tip of nose and ears. Küsner (14) reports the case of a female, aged sixty-eight years, and Strübling (6) that of a male seventy years old. These are the oldest cases on record. Seven of my own cases were females, and

all experienced this symptom in middle or early adult

life.

The chief characteristics of this edema are that it develops suddenly, usually without known cause, reaching its maximum in one-half to two hours and then subsides, leaving very little or no trace of its former existence; the swelling may vary in color from pale white to dark red; it does not pit on pressure and there is no fever or inflammatory indication; there is seldom any positive pain connected with it but there is usually a feeling of tension resulting from the pronounced state of the localized congestion; often there is some gastric uneasiness associated with it, but as a rule no other definite constitutional symptoms. When the mucous membrane of the pharynx, larynx and stomach are affected, difficulty in breathing, swallowing and speaking is experienced and vomiting may result. Osler (7) mentions two cases and Krieger (15) reports one in which death occurred from angioneurosis of the larynx.

The majority of writers rely upon the teaching of Cohnheim (16), Rogowicz (17) and subsequent investigators to explain the mechanism of angioneurotic edema.

Briefly stated, it is supposed that either the vaso-constrictors relax from their normal tonicity or there occurs a reflex excitation of the vaso-dilators whereby an increased blood-supply accumulates in the affected areas and as a result of this increased tension a transudate of blood-serum fills the subdermal tissues, producing the circumscribed swelling.

With this brief résumé of the main features of this disorder I will pass on to the consideration of the two cases reported by Lewis (2) and Haynes (12). The swelling of the tongue in Lewis' case occurred in two instances twelve hours after the application of chromic acid to granulations on the upper and posterior portions of the tympanic membrane. The tongue became so con

gested that breathing was difficult; following this a circumscribed edema appeared over the right frontal eminence, over the balls of both thumbs, on the internal malleolus of the ankle-joint and ball of the right foot. In twenty-four hours after the application of the chromic acid all signs of the edema had disappeared. Lewis considers that the edema, so far as the tongue was concerned, arose from the irritation of the chorda tympani nerve in its passage through the ear. He explains the appearance of the tongue-edema twelve hours after the application as due to the slow penetration of the acid through the granulations to the nerve fibre.

Haynes' case is that of an infant nineteen months old of marked neuropathic ancestry; she had a rachitic head with congenital hemi-facial hypertrophy. The child was apparently normal for her age except for the peculiarity that whenever sweet or sour substances were taken in the mouth the flow of saliva increased and the larger side of her face became swollen and red. The edema subsided after the exciting cause was withdrawn. This phenomenon was also sometimes noticed to occur momentarily when she yawned or gaped. The tongue was not affected.

These two cases with my own can be conveniently grouped together for the reason that they supply data for speculation as to the function of the chorda tympani nerve and the mechanism of the angioneurotic process.

The case of unilateral angioneurotic edema of the tongue which I have to present came under observation in the summer of 1896. The patient was a school teacher, twenty-seven years old, female, single, and born in Connecticut. She was admitted to the Sanitorium under the diagnosis of simple neurasthenia with mild hysterical complications. Under the best treatment and routine hygienic living she gained steadily and at the time of the angioneurotic attack she was in a very satisfactory convalescent condition.